CASE PRESENTATION

OF
HEMORRHAGIC
STROKE

(Subarachnoid hemorrhage)
Presented By:

GROUP 3
Vernalin Terrado
Lerma Auman
Elenita Molina
Richelle Manlangit
Andres Jose
Bernard Bartolome
Marlen Tigno
Subarachnoid hemorrhage
 INTRODUCTION:

A Stroke, cerebrovascular Accident, or what is now being termed as

“brain attack” is a sudden loss of brain functions resulting from
disruption of blood supply to a part of the brain resulting from
pathologic blood vessels. It denotes an abnormality of the brain. Stroke
can be classified into ischemic and hemorrhagic strokes. Ischemic
stroke can be divided into thrombotic and embolic stroke. Thrombotic
stroke results from the narrowing or occlusion of blood vessels due to
fat deposits while embolic strokes result from the occlusion of a blood
vessel from a blood clot originating from the other parts of the body,
most commonly from the heart.
Hemorrhagic stroke is further classified into intracerebral
hemorrhage and subarachnoid hemorrhage. It results from the
rupture of blood vessels in the brain. Rupture of arterioles
result in bleeding into the parenchyma of the brain, while
rupture of larger arteries or its tributaries result in bleeding in
the subarachnoid space. Normal brain metabolism is impaired
by interruption of blood supply, compression and increased
ICP.

Usually due to rupture of intracranial aneurysm, AV

malformation, Subarachnoid hemorrhage.
Risk factors for hemorrhagic stroke includes age, gender, race,
hypertension, smoking and use of illicit drugs.

A stroke causes a wide variety of neurologic deficit, depending on

thelocation of the lesion,the size of the area of inadequate
perfusion and the amount of severity of blood flow. It may
include vomiting, headache, seizures, hemiplegia and loss of
consciousness. Pressure on the brain tissue from increase
intracranial pressure may cause coma and death.
General Objectives:

The primary concern of this study is to further

enhance the understanding of Cerebrovascular Accident
in congruence with the learned concepts of the Nursing
students.
Objectives of the Study:
This case presentation seeks to provide different
information about the disease to be presented about
the client being considered with the ff. specific
objectives:
1. Give a brief introduction about Cerebrovascular
Accident together with it clinical manifestations.

2. Present a theoretical framework for the study in

relation to a nursing approach applied to a patient
with hemorrhagic stroke.

3. Present the clients demographic and health history with

its Gordons eleven functional health pattern.
4. Present the abnormal results of the physical assessment and
compare it to the normal values or findings.

5. Present the different laboratory test and results done to the client
with its interpretation.

6. Discuss the normal Anatomy and Physiology of Circulatory and

Central Nervous System.

7. Explain the Pathophysiology of Hemorrhagic stroke

8. Identify Nursing Problems related to the situation and
case of the client

9. Discuss the drugs that has been used and prescribed to

the client by a drug analysis.

10. Present a Nursing Care Plan for the prioritized

problems of the client.

11. Show a Discharge Planning that the client may use

upon discharge to the hospital.
Theoretical Framework: Virginia Henderson
Difficulty of Impaired skin Urinary Loss of Poor
Breathing Integrity HPN dysfunction
Hyperthermia
consciousness
immobility Hygiene

Nursing intervention

Sleep and Keep

Move and
Eliminate Maintain rest and body
Breath Eat and drink Sleep and maintain
body wastes body temp Communicate clean
Normally adequately rest Desirable
with and well
postures
others groomed

Improved Health
 Comprehensive History:
Biographic History:
Name : D.A.C
City Address :Blk 14, lot 52 PVR-1, Norzagaray, Bulacan
Provincial Address :Romblon (Visayas)
Age : 53 years old
Gender : Male
Religious Affiliation : Roman Catholic
Marital Status : Married
Occupation : Unemployed (formerly a construction worker)
Source of Information : Daughter
Room & Bed No. : Male Ward Bed #9
Date of Birth : November 18, 1955
Diagnosis : Cerebrovascular Accident (subarachnoid
hemorrhagic)
Physician : Dr. Steve Conneroid
Chief complaint: : Loss of consciousness
Date of admission : January 05, 2009
Present Condition:

Two days prior to admission, the patient experienced high

blood pressure accompanied by low grade fever. At that
time, the client is having an argument with his daughter
that day before the time he was admitted which serves as
a triggering factor of his present illness. Upon admission
her daughter claim that her father experienced severe
headache followed by loss of consciousness. After series of
tests he was diagnosed to have experienced or suffered a
hemorrhagic stroke.
Past Medical History:

Three months prior to admission, the patient

Experienced intermittent flu and Arthritis in both knees.
While on this condition, the patient’s blood
pressure keeps elevating at a range of 150/90 mmHg
To 190/100 mmHg.
The patient also experienced a vehicular accident on
his bicycle two months ago, but no abnormal
manifestation has been observed aside from multiple
superficial wounds.
Family History:

The paternal side of the patient has a history of

pulmonary tuberculosis.

The maternal side of the patient has a history of

hypertension and heart disease.
Activities of daily living

A. Health perception and health management pattern

According to her, her father doesn’t go to the
doctor for consultation on his health status. He
seldom takes any medicine for his common
illnesses though he sometimes takes paracetamol to
relieve fever. She also states that her father is a
heavy alcohol drinker and cigarette smoker.the
patient self perception of health prior and upon
hospitalization is undermined because the patient
is in the state of coma.
B. Nutritional and Metabolic Pattern

Before the patient was hospitalized, he normally

eats fried chicken, especially the skin, chicharon and
processed meats such as tocino and longganisa. He
seldom eat vegetables and fruits. He prefers meat over
fish.
C. Elimination Pattern

Prior to admission the patient has a regular bowel

pattern but after he was hospitalized he was not able to
defecate for 3 days. He urinates 5 to 7 times a day with
a light yellow color before he is admitted, now he has
an indwelling urinary catheter draining dark yellow
urine.
D. Activity-Exercise Pattern

According to the patient’s daughter, her father

spends most of his time gambling or having a drinking
session with neighbors and friends. He doesn’t have a
job and he didn’t mind looking for one. He doesn’t help
in household chores instead he preferred spending his
time watching television.
E. Sleep – Rest Pattern

The patient has a habit of taking short nap in the

afternoon for 2 hours. In the evening he usually retires
at around 2:00am and usually sleeps for 3 hours. This
is primarily due to his fathers’ failing ability to
promote sleep.
F. Cognitive – Perceptual Pattern

The patient can read and write, he doesn’t have

hearing difficulty before he was hospitalized. He
doesn’t wear eyeglasses. His daughter said that her
father still possess a sharp memory and still recalls past
experiences with spontaneity. Her daughter also
reported that her father doesn’t have any speech
problem and has a normal sense of taste and smell
before he was hospitalized.
G. Self – perception and Self – Concept Pattern

According to the daughter her father verbalizes

that his contentment of a well balanced health
condition. Now his self- perception is undermined,
since the client is in the state of coma.
H. Role – Relationship Pattern

Significant people to the client are his family. He is

the head of the family. His daughter stated that the
only problem they have is the hospitalization of her
father because of financial problems that arises from it.
They resolve and manage their problems through
constant communication themselves.
I. Sexually – Reproductive Pattern

His daughter said that her father shows his

affection to his family by constantly kissing and
hugging them. The client has three children: two girls
and a boy.
J. Coping – Stress Tolerance Pattern

Before being hospitalized the client experiences

many stressors are brought about by financial factor
and health problems. They are able to cope up by
constantly cooperating with one another.
K. Value – Belief Pattern

Her father does not hear mass on a regular basis

because he believes that God is always in our hearts
and that we don’t need to go to church just to pray. Yet
he believes that being a Catholic is the best way to be
close to God.
 Physical Assessment:
BP: 160/90 PR: 102 Bpm
Temp: 39˚C RR: 38 Bpm
BODY PARTS TECHNIQUE NORMAL ACTUAL ANALYSIS
USED FINDINGS FINDING
1. SKULL Inspection, Proportional to The skull is Normal
palpation the size of the normocephalic
body, round and symmetrical
with to the body with
prominences in prominences in
the frontal and the frontal and
occipital area, occipital area,
symmetrical in symmetrical in all
all place place
2. SCALP Inspection White, clean, White, no masses, Normal
free from lumps, scars, and
masses, lumps, lesions no area of
scars, and tenderness is
lesions no areas observed.
of tenderness
3. FACE Inspection Oblong or round Oblong. No facial Not normal-
or square, or movement is Indicates
heart shaped,, observed. There impairment of
facial expression were presence of facial nerves
that is dependent acne around his which cause
on the mood or forehead. paralysis.
true feelings, no
involuntary
muscle,
Symmetric facial
movements.
4. EYES Inspection Parallel and Dilated pupils -Not Normal-
evenly spaced which is black in Indicates
symmetrical, non- color and non altered level
protruding, pink reacting to light. of
palpebral He have some consciousness.
conjunctiva, and discharges around
pupils black in the lacrimal area.
color, equal in
size, round and
constricts in
response to light.
5. NOSE Inspection Midline Midline Normal
symmetrical symmetrical
and patent, no and patent, no
discharge. discharge. With
presence of
nasogastric tube
insertion on the
right nares.
6. EARS Inspection Parallel Parallel Not normal-
symmetrical, symmetrical, Indicates
proportional to proportional to poor
the size of the the size of the personal
head, bean- head, bean- hygiene-
shaped, skin is shaped, skin is inadequate
same color as same color as selfcare
the surrounding the surrounding primarily
color, clean color, with dust caused by
firm cartilage. accumulation self care
on firm deficit.
cartilage.
7. MOUTH Inspection Symmetrical, Symmetrical, Normal
gums pinkish in gums slightly
color, lips margin dark in color with
is symmetrical, yellowish teeth,
no lesion and lips margin is
tenderness, symmetrical, no
without lesion and
involuntary tenderness,
movement without
involuntary
movement
A. SKIN Inspection, Varies from light With uniform Not normal-
palpation to deep brown, deep brown skin The client has
from ruddy pink color with slightly impaired skin
to light pink, elevated integrity with
from yellow temperature. hyperthermia
overtones to olive, Poor skin and
generally uniform integrity and disruptions on
skin temperature redness on bony skin integrity.
prominences.
B. HAIR Inspection Thick, silky, Thick, oily with Normal
resilient, free traces of white
from hairs evenly
infestation, distributed
evenly which covers
distributed and the whole scalp
covers whole and free from
scalp. infestation.

C.NAILS Inspection, Convex Long with Normal

palpation curvature convex
smooth texture, curvature
highly vascular smooth texture,
and pink, highly vascular
prompt return with bluish to
of pink less pinkish
than 4 seconds discoloration,
capillary refill is
prompt.
D.NECK Inspection, Symmetrical Symmetrical Normal
REGION palpation and straight, no and straight, no
palpable lumps, palpable lumps,
and supple, and supple,
trachea is on trachea is on
midline of neck, midline of neck,
and spaces are and spaces are
equal on both equal on both
sides. sides.

E. LUNGS Auscultation Symmetrical Difficulty of Not normal-

chest expansion, breathing with Indicates
clear breath breath sounds tachypnea
sounds. (ronchi) audible primarily
even without the due to
use of hypertension
stethoscope .
having the
respiration rate
of 38 Bpm.
F. HEART Auscultation A dynamic Palpitations Not Normal-
pericardium, with elevated indicates
normal rate, heart rate of increase
regular rhythm, 115 bpm. cardiac
no murmur. overload due
to increase
blood
pressure

G.PHERIPER Palpation Symmetrical Symmetrical Normal

AL pulse volume, pulse volume,
full pulsation full pulsation
H. BREAST Inspection, No tenderness, No tenderness, Normal
palpation masses, nodules masses, nodules
and discharge. and discharge.

I. ABDOMEN Inspection, Uniform color, Uniform color, Normal

Auscultation, rounded rounded
Percussion, symmetrical symmetrical
Palpation. contour, contour, audible
audible bowel bowel sounds,
sounds, no no tenderness,
tenderness, liver and
liver and bladder are not
bladder are not palpable
palpable
J.MALE Inspection Normal pubic The genitalia Not Normal-
GENITALIA hair distribution was not Indicates
is noted and free assessed Urinary
from infestation.
because the dysfunction
Penile lesions,
masses, or
relatives (refer to
discharges are refused to do laboratory
not so. The patient result).
present.Testes is also has an
symmetric indwelling
without masses catheter.
or undue
tenderness. The
left testis may be
slightly larger
and hang lower
than the right
testis.Inguinal or
femoral hernias
are not present.
K. UPPER Inspection Equal size on Immobilization Not normal
AND both sides of of all the the patient is
LOWER the body, no extremities. comatose.
EXTREMITI contractures,
ES deformities and
tenderness,
normally firm,
joints move
smoothly.
Laboratory Test:
BLOOD CHEMISTRY
Test Results Normal Values

Glucose HGT 105 75-115mg/dl

Creatinine 1.7 0.6-1.1mg/dl

Sodium 142 135-140mmol/L

Potassium 3.5 3.5-5.3mmol/L

Uric acid 4.5 3.4-7.0mg/dl

Total Cholesterol 250 <200mg/dl

Triglycerides 133 <200mg/dl

HDL 40.8 40-58.7mg/dl

 BLOOD HEMATOLOGY

Results Normal Values

RBC 8.0 4.5-5.8 x 12/L

WBC 15,900 5000-10000/cumm

Hgb 21 14-18 x 12/L

Hct 0.62 0.42-0.52 x 12/L

Platelet count 300000 150000-450000/cumm

Segmenters 0.66 0.50-0.66

Lymphocytes 0.30 0.20-0.40

Monocytes 0.04 0.02-0.08

Anatomy and Physiology Unoxygenated Blood

Blood Circulation: Superior & Inferior Vena cava

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonary trunk & pulmonary

Arteries

LUNGS (process f oxygenation)

 Pulmonary Vein

Left Atrium

Bicuspid valve

Left ventricle

Aortic Valve

Aorta

Systemic Circulation
 BRAIN: Cranial Nerves
1. Olfactory: Smell
2. Optic: Visual fields and ability to see
3. Oculomotor: Eye movements; eyelid opening
4. Trochlear: Eye movements
5. Trigeminal: Facial sensation
6. Abducens: Eye movements
7. Facial: Eyelid closing; facial expression;
taste sensation
8. Auditory/vestibular: Hearing; sense of balance
9. Glossopharyngeal: Taste sensation; swallowing
10. Vagus: Swallowing; taste sensation
11. Accessory: Control of neck and shoulder muscles
12. Hypoglossal: Tongue movement
• Cranial Nerves – There are 12 pairs of nerves that originate from
the brain itself. These nerves are responsible for very specific
activities and are named and numbered as follows:
• Olfactory: Smell
• Optic: Visual fields and ability to see
• Oculomotor: Eye movements; eyelid opening
• Trochlear: Eye movements
• Trigeminal: Facial sensation
• Abducens: Eye movements
• Facial: Eyelid closing; facial expression; taste sensation
• Auditory/vestibular: Hearing; sense of balance
• Glossopharyngeal: Taste sensation; swallowing
• Vagus: Swallowing; taste sensation
• Accessory: Control of neck and shoulder muscles
• Hypoglossal: Tongue movement
Cranial Meninges
BRAIN
BRAIN
Non-modifiable Risk PATHOPHYSIOLOGY Modifiable Risk Factors
Factors >HPN
>Advanced Age >Smoking
>Gender >excessive intake of foods
>Heredity high in fats and cholesterol
Triggering Factors
>Sudden extreme emotion

Cerebral aneurysm Arteriovenous

rupture malformation

Bleeding into the brain tissue

and subarachnoid space

Blood Clots in the

Subarachnoid Space
Blood supply interruption Brain Compression

S/S:
Tissue Necrosis >Severe Headache Increase Intracranial
>Drowsiness Pressure
>Loss of consciousness
Neuronal Death

Regional Paralysis Epileptic Seizure:

increase intraocular
pressure= blindness
Total Paralysis

coma

Death
 Drug study 1

Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing

Action consideration
Generic name: Inhibits Treatment of Hypersensitivity, Patients Dizziness, Use caution in
nifedipine calcium ion vasospatic, cardiovascular withdrawn flushing, severe aortic
Brand name: influx across angina, shock, from headache, stenosis or severe
Calcibloc all membrane chronic stable combination with blockers hypotension hepatic
during angina, rifampicine while taking peripheral impairment
Route: oral cardiac hypertension contraindicated nifedifine edema, Assess potential
Dosage: 180mg depolarization (sustained- in unstable may tachycardia and for interactions
Frequency: once , produces released angina and after experience palpitation with other
a day relaxation of tablets only. resent MI severe increase pharmacological
coronary hypotension, angina agents or herbal
vascular with systolic products patients
smooth pressure less is taking that may
muscle and than 90 mmHg increase risk of
peripheral decompensate hypotension and
vascular heart failure toxicity
smooth pregnancy and Monitor blood
muscle, dilates lactation pressure and
coronary pulse before
arteries, therapy, during
increase
dose
myocardial
oxygen
delivery in
patients with
vasospastic
filtration and
periodically during
therapy monitor
ECG periodically
during prolonged
therapy
Assess therapeutic
effectiveness and
adverse reaction
Assess location,
duration intensity,
precipitating factor
of patients angina
pain
 Drug study 2

Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing

Action consideration
Generic name: Increases the Adjunct in the Hypersensitivity , CNS: headache, Monitor vital
Mannitol osmotic treatment of anuria, confusion. signs, urine
Brand name: pressure of acute oliguric dehydration, output, CVP, and
Osmitrol the renal failure, intracranial EENT: blurred pulmonary artery
Route: IV glomerular adjunct in the bleeding. vision, rhinitis pressure prior to
filtrate, treatment of and hourly
Dosage: thereby edema, throughout
Adult 0.25-2 g/kg inhibiting redunction of CV: transient administration.
as 15 to 25% reabsorption intraocular volume Assess patient for
solution over 30 of water and pressure, to expansion, signs and
to 60 min. electrolytes. promote the tachycardia, symptoms of
Children 1-2 g/kg excreation of chest pain, dehydration or
(30 – 60 g/m2)as certain toxic congestive heart signs of fluid over
a 15 to 20 substances. failure, load.
solution 0ver 30 pulmonary
Assess patient for
– 60% edema.
anorexia, muscle
Frequency: weakness,
4x daily GI: thirst, numbness,
nausea, tingling, confusion
vomiting and excessive
thirst.
GU: renal
failure, urinary
retention.
Monitor neurologic
status and
intracranial
pressure readings
in patient receiving
this medication to
decrease cerebral
edema.
 Drug study 3

Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing

Action consideration
Generic name: Inhibits influx Hypertension, Sick sinus CHF, Palpitations, Assess cardio
Amlodipine of calcium ion chronic stable syndrome; hepatic peripheral respiratory status.
across cell angina, second-or-third- impairment, edema, syncope, Angina pain, B/P
Brand name:
membranes to vasospatic degree caustious tachycardia, pulse, respiration,
Amvasc, norvasc produce angina artrioventicular use is bradycardia, ECG
Route: relaxation of block exept with required arrythmias,
Dosage: coronary a functioning ventricular Assess hydration
5 mg vascular pacemaker asystoles, and fluid volume
smooth headache,
Frequency: status, input and
muscle dizziness,
Once daily output ratio,
(dilatation of lightheadedness, presence of
coronary fatigue,
edema, distended
arteries) lethargy, neck veins, luck
decrease somnolence, crackles, adequate
peripheral dermatitis,rash pulses and skin
vascular pruritus,
turgor.
resistance of uticaria,nausea,
smooth abdominal
muscle discomfort,
(decrease cramps,
blood dyspepsia,
pressure) shortness of
breath,
and increases dyspnea, Monitor liver
myocardial wheezing, function ALT,
oxygen flushing, AST, bilirubin
delivery in sexual Monitor if platelet
patients with difficulties, count is less than
vasospatioc muscle 150,000/mm, drug
angina. cramps, pain is usually
or discontinued and
inflammation another drug
started.
 Drug study 4

Medication Classification/ Indication Contraindication Side Adverse effects Nursing

Action effects consideration

Generic name: Inhibits the •Mild to Previous GI: hepatic •Advise patient to
Acetomenophen synthesis of moderate hypertensive necrosis take medication
Brand name: prostaglandin pain Product DERM: rash, exactly as
that may serve •Fever containing urticaria. directed and not
Aminofen as mediators of to take more than
alcohol,
Route: pain and fever. aspartame, the recommended
IV saccharin, sugar amount.
Dosage: Therapeutic or tartrazine. Severe and
325-1000mg effects. permanent liver
every 4 to 6 hrs •Analgesic (due damage may
needed to peripheral result from
prolonged use or
prostaglandin
inhibitors) high doses of
acetomenophe.
•Antipyresis
(lowers fever); Adult should not
take
due to inhibitors
acetomenophen
of prostaglandin
in the CNS longer than 10
days and children
No significant longer than 5
anti days unless
inflammatory directed by
properties physician.
•Advise the patient to
consult the physician if
discomfort or fever is not
relieved by routine
dosages of this drug or if
fever is greater than 39.5
(103 F) or lasts longer
than 3 days
 Nursing Care Plan One
ASSESSMEN DIAGNOSIS OBJECTI PLANNING INTERVENTION RATIONAL EVALUATION
T VE E
Objective Ineffective After four Plan ways on Position head To open or After four
cues: airway hours of how to midline with flexion maintain hours of
clearance nursing reduce appropriate for airway to the nursing
•Clavicular related to interventio congestion on condition. client. intervention the
retained n the client airway. client air way
•Breaking
mucus airway clearance is
•Rhonchi Oropharyngial To clear
secretion due clearance suctioning (as airway when cleared.
breathing to absence of will be needed) secretions are
sound cough reflex. cleared.
blocking on
•Increase
airway.
respiratory Scientific
rate of 36 to Explanation:
38 bpm Elevate head of the To decrease
Inability to bed and change the pressure
clear position every 2 on the
secretions or hrs. diaphragm.
obstruction
from the
respiratory Increased fluid To help
tract to intake at least 3000 liquefy
maintain a ml/day secretion
clear air
way.
Auscultate breath To maitain
souds and assess status and note
air movement progress
 Nursing Care Plan Two
ASSESSMEN NURSING OBJECTIV PLANNING NURSING RATIONALE EVALUATI
T DIAGNOSIS E INTERVENTION ON
Subjective Cues: Hyperthermia >after 2 >Plan >Identify under >To assess causative >after 2
>”tatlong araw related to hours of techniques in lying cause factors to the clients hours of
na siyang inflammation of nursing which the fever thus nursing
nilalagnat” as cerebral tissue as interventions temperature formulation of intervention
verbalized by evidence by the client’s of the client appropriate nursing the client’s
the relatives. elevated body temperature will decrease intervention. temperature
Objective Cues: temp. will decrease to a normal >Heat loss by is decreased
to a normal rage. evaporation and to a normal
>elevated body range. range
Scientific EXP: >Promote surface conduction
temp of 39˚C
Body temperature cooling by means
>flushing skin of tepid sponge
>warm to touch elevated above >Heat loss by
normal range, bath convection.
>increase RR because of body’s >Establish cool
with a rate of 38 response to environment by
Bpm inflammation opening air vents
>diaphoresis from hemorrhage and window panes >to avoid further
that result from >Advise relatives increase of clients
ruptured cerebral not to cover the temperature.
artery. client with a
blanket, and use
less restrictive
clothing’s
> Administer > For immediate
antipyretics through alteration of body
IV as prescribed. temperature
 Nursing Care Plan Three
ASSESSMEN DIAGNOSIS OBJECTIVE PLANNING INTERVENTIO RATIONALE EVALUATIO
T N N
Objective >Risk for >After 3 >Plan >Note for > To assess After two
Cues: impaired skin hour s of strategies on general aggravating hours of
>reddened Integrity nursing how to debilitation, factor to skin nursing
skin related to intervention eliminate reduced breakdown intervention
>poor skin physical the client the risk for mobility, and make the
immobilization relatives will impaired changes in skin appropriate possibilities
turgor
. identify risk skin and muscle intervention for impaired
>immobility factors for mass, poor to it. skin integrity
integrity.
>friction impaired nutritional status of the client is
Scientific
skin integrity and problems of eliminated.
Explanation:
, verbalize self care
At risk for skin understandin
> Maintain strict
being g of therapy skin hygiene, > To prevent
potentially regimens and using mild non- skin irritation
vulnerable to demonstrate
breakdown detergent soap,
behaviors drying gently
because of and and thoroughly.
immobilization techniques to
and lubricating
prevent skin with lotion
breakdown.
>Instruct the >To reduce
relative to turn tissue pressure
the patient every and prevent
two hours pressure sore.

> Avoid friction > To prevent a

when changing shearing force
position on the skin.

>Provide >To increase

protection by circulation and
use of eliminate
pads,pillows, excessive tissue
foam mattress. pressure.

>Observe for >Reduces

reddened or likelihood of
blanched areas progression to
and give proper skin breakdown.
management if
there is any.
 Discharge Plan

M >Nifedipine must be given 10mg once a day by sublingual as

prescribed.
>Instruct the relative to follow medication regimen.

>Encourage the relative to do some exercises like a passive range of

E motion in affected and unaffected parts of the body of the client.

T > Educate & instruct the family to monitor the blood pressure and
pulse rate before administering medication.
 >Inform the relative the importance of proper hygiene of the patient
from head to toe.
H >regular inspection of the diaper of the patient and change if there a
presence of fecal material, urine or even redness that would lead to skin
rashes.
>Educate and instruct the relatives on how to feed the client through
nasogastric tube.
>Instruct them to turn the client every 2 hrs to avoid pressure sores.

>Inform the family of the patient to have a regular check-up for the
O continuity of treatment.
>Instruct the family of the patient to monitor if there is any sudden
change to the patient and report immediately.

>Instruct the relative to feed the client on time with nutrition food that
D is low in sodium, low in cholesterol, low in fat and give citrus fruits,
moderate in fluid intake and increase fiber diet to improve health.
>Follow the diet prescribed by the doctor.