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
Sleep and maintain
Breath Eat and drink body wastes body temp Communicate clean
rest Desirable
Normally adequately 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 The skull is Normal
palpation size of the body, normocephalic and
round with symmetrical to the
prominences in the body with
frontal and prominences in the
occipital area, frontal and occipital
symmetrical in all area, symmetrical in
place all place

2. SCALP Inspection White, clean, free White, no masses, Normal

from masses, lumps, scars, and
lumps, scars, and lesions no area of
lesions no areas of tenderness is
tenderness observed.
3. FACE Inspection Oblong or round or Oblong. No facial Not normal-
square, or heart movement is Indicates
shaped,, facial observed. There wereimpairment of
expression that is presence of acne facial nerves
dependent on the around his forehead. which cause
mood or true paralysis.
feelings, no
involuntary muscle,
Symmetric facial
movements.

4. EYES Inspection Parallel and evenly Dilated pupils which -Not Normal-
spaced symmetrical, is black in color and Indicates altered
non- protruding, non reacting to light. level of
pink palpebral He have some consciousness.
conjunctiva, and discharges around
pupils black in color, the lacrimal area.
equal in size, round
and constricts in
response to light.
5. NOSE Inspection Midline Midline Normal
symmetrical and symmetrical and
patent, no patent, no
discharge. discharge. With
presence of
nasogastric tube
insertion on the
right nares.

6. EARS Inspection Parallel Parallel Not normal-

symmetrical, symmetrical, Indicates poor
proportional to the proportional to the personal
size of the head, size of the head, hygiene-
bean-shaped, skin bean-shaped, skin inadequate
is same color as is same color as selfcare
the surrounding the surrounding primarily
color, clean firm color, with dust caused by self
cartilage. accumulation on care deficit.
firm cartilage.
7. MOUTH Inspection Symmetrical, gums Symmetrical, gums Normal
pinkish in color, lips slightly dark in color
margin is with yellowish teeth,
symmetrical, no lips margin is
lesion and symmetrical, no
tenderness, without lesion and
involuntary tenderness, without
movement involuntary
movement

A. SKIN Inspection, Varies from light to With uniform deep Not normal-The
palpation deep brown, from brown skin color client has
ruddy pink to light with slightly elevatedimpaired skin
pink, from yellow temperature. Poor integrity with
overtones to olive, skin integrity and hyperthermia
generally uniform redness on bony and disruptions
skin temperature prominences. on skin integrity.
B. HAIR Inspection Thick, silky, Thick, oily with Normal
resilient, free from traces of white
infestation, evenly hairs evenly
distributed and distributed which
covers whole covers the whole
scalp. scalp and free from
infestation.

C.NAILS Inspection, Convex curvature Long with convex Normal

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

E. LUNGS Auscultation Symmetrical chest Difficulty of Not normal-

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

G.PHERIPERAL Palpation Symmetrical pulse Symmetrical pulse Normal

volume, full volume, full
pulsation 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, audible contour, audible
bowel sounds, no bowel sounds, no
tenderness, liver tenderness, liver
and bladder are and bladder are not
not palpable palpable
J.MALE Inspection Normal pubic hair The genitalia was Not Normal-
GENITALIA distribution is noted not assessed Indicates
and free from because the Urinary
infestation. Penile
relatives refused dysfunction
lesions, masses, or
to do so. The (refer to
discharges are not
present.Testes is patient also has laboratory
symmetric without an indwelling result).
masses or undue catheter.
tenderness. The left
testis may be
slightly larger and
hang lower than the
right testis.Inguinal
or femoral hernias
are not present.
K. UPPER AND Inspection Equal size on both Immobilization of Not normal the
LOWER sides of the body, all the extremities. patient is
EXTREMITIES no contractures, comatose.
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 consideration
Action
Generic name: Inhibits calcium Treatment of Hypersensitivity, Patients Dizziness, flushing, Use caution in
nifedipine ion influx across vasospatic, cardiovascular withdrawn headache, severe aortic stenosis
Brand name: all membrane angina, chronic shock, combination from blockers hypotension or severe hepatic
Calcibloc during cardiac stable angina, with rifampicine while taking peripheral edema, impairment
depolarization, hypertension contraindicated in nifedifine may tachycardia and Assess potential for
Route: oral produces (sustained- unstable angina and experience palpitation interactions with
Dosage: 180mg relaxation of released tablets after resent MI increase angina other
Frequency: once a coronary vascular only. severe hypotension, pharmacological
day smooth muscle with systolic agents or herbal
and peripheral pressure less than 90 products patients is
vascular smooth mmHg taking that may
muscle, dilates decompensate heart increase risk of
coronary arteries, failure pregnancy hypotension and
increase and lactation toxicity
myocardial Monitor blood
oxygen delivery pressure and pulse
in patients with before therapy, during
vasospastic dose
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 consideration
Action
Generic name: Increases the Adjunct in the Hypersensitivity , CNS: headache, Monitor vital signs,
Mannitol osmotic pressure treatment of acuteanuria, dehydration, confusion. urine output, CVP,
Brand name: of the glomerular oliguric renal intracranial bleeding. and pulmonary artery
Osmitrol filtrate, thereby failure, adjunct in EENT: blurred pressure prior to and
inhibiting the treatment of hourly throughout
Route: IV vision, rhinitis
reabsorption of edema, administration.
Dosage: water and redunction of Assess patient for
Adult 0.25-2 g/kg as electrolytes. intraocular CV: transient signs and symptoms
15 to 25% solution pressure, to volume expansion, of dehydration or
over 30 to 60 min. promote the tachycardia, chest signs of fluid over
Children 1-2 g/kg excreation of pain, congestive load.
(30 – 60 g/m2)as a certain toxic heart failure,
Assess patient for
15 to 20 solution substances. pulmonary edema.
anorexia, muscle
0ver 30 – 60% weakness, numbness,
Frequency: GI: thirst, nausea, tingling, confusion
4x daily 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 consideration
Action
Generic name: Inhibits influx of Hypertension, Sick sinus CHF, hepatic Palpitations, Assess cardio
Amlodipine calcium ion chronic stable syndrome; second- impairment, peripheral edema, respiratory status.
across cell angina, or-third- degree caustious use is syncope, Angina pain, B/P
Brand name:
membranes to vasospatic angina artrioventicular required tachycardia, pulse, respiration,
Amvasc, norvasc produce block exept with a bradycardia, ECG
Route: relaxation of functioning arrythmias,
Dosage: coronary vascular pacemaker ventricular Assess hydration and
5 mg smooth muscle asystoles, headache,fluid volume status,
(dilatation of dizziness,
Frequency: input and output ratio,
coronary arteries) lightheadedness, presence of edema,
Once daily decrease fatigue, lethargy, distended neck veins,
peripheral somnolence, luck crackles,
vascular dermatitis,rash adequate pulses and
resistance of pruritus, skin turgor.
smooth muscle uticaria,nausea,
(decrease blood abdominal
pressure) discomfort, cramps,
dyspepsia,
shortness of breath,
and increases dyspnea, Monitor liver function
myocardial wheezing, ALT, AST, bilirubin
oxygen delivery flushing, sexual Monitor if platelet
in patients with difficulties, count is less than
vasospatioc muscle cramps, 150,000/mm, drug is
angina. pain or usually discontinued
inflammation and another drug
started.
 Drug study 4

Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing

Action consideration

Generic name: Inhibits the •Mild to Previous GI: hepatic •Advise patient to
Acetomenophen synthesis of moderate pain hypertensive necrosis take medication
prostaglandin that •Fever Product containing DERM: rash, exactly as directed
Brand name:
may serve as alcohol, aspartame, urticaria. and not to take more
Aminofen mediators of pain than the
saccharin, sugar or
Route: and fever. tartrazine. recommended
IV amount.
Dosage: Therapeutic effects. Severe and
325-1000mg every 4 •Analgesic (due to permanent liver
to 6 hrs needed damage may result
peripheral
prostaglandin from prolonged use
or high doses of
inhibitors)
acetomenophe.
•Antipyresis (lowers
fever); due to Adult should not take
acetomenophen
inhibitors of
longer than 10 days
prostaglandin in the
CNS and children longer
than 5 days unless
No significant anti directed by
inflammatory physician.
properties
•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
ASSESSMENT DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION

Objective cues: Ineffective After four Plan ways on Position head midline To open or After four hours of
airway hours of how to reduce with flexion maintain airway nursing
clearance nursing congestion on appropriate for to the client. intervention the
•Clavicular
related to intervention airway. condition. client air way
•Breaking retained mucus the client To clear airway clearance is
•Rhonchi secretion due to airway Oropharyngial when secretions cleared.
breathing sound absence of clearance will suctioning (as needed) are blocking on
•Increase cough reflex. be cleared. airway.
respiratory rate
of 36 to 38 bpm Scientific
To decrease the
Explanation: Elevate head of the pressure on the
Inability to bed and change diaphragm.
clear secretions position every 2 hrs.
or obstruction
from the To help liquefy
respiratory tract Increased fluid intake secretion
to maintain a at least 3000 ml/day
clear air way.
Auscultate breath To maitain status
souds and assess air and note progress
movement
 Nursing Care Plan Two
ASSESSMENT NURSING OBJECTIVE PLANNING NURSING RATIONALE EVALUATIO
DIAGNOSIS INTERVENTION N
Subjective Cues: Hyperthermia related >after 2 hours of >Plan techniques >Identify under lying >To assess causative >after 2 hours of
>”tatlong araw na to inflammation of nursing in which the cause factors to the clients nursing
siyang nilalagnat” cerebral tissue as interventions the temperature of fever thus formulation intervention the
as verbalized by the evidence by elevated client’s the client will of appropriate nursing client’s
relatives. body temp. temperature will decrease to a intervention. temperature is
Objective Cues: decrease to a normal rage. >Heat loss by decreased to a
normal range. evaporation and normal range
>elevated body Scientific EXP:
conduction
temp of 39˚C Body temperature
elevated above >Promote surface
>flushing skin
normal range, cooling by means of >Heat loss by
>warm to touch tepid sponge bath
because of body’s convection.
>increase RR with a response to >Establish cool
rate of 38 Bpm inflammation from environment by
>diaphoresis hemorrhage that opening air vents and
result from ruptured window panes >to avoid further
cerebral artery. >Advise relatives not increase of clients
to cover the client with temperature.
a blanket, and use less
restrictive clothing’s
> Administer > For immediate
antipyretics through IV alteration of body
as prescribed. temperature
 Nursing Care Plan Three
ASSESSMENT DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION

Objective Cues: >Risk for >After 3 hour s >Plan strategies>Note for general > To assess After two hours
>reddened skin impaired skin of nursing on how to debilitation, reduced aggravating of nursing
>poor skin turgor Integrity related to intervention the eliminate the mobility, changes in factor to skin intervention the
physical client relatives risk for skin and muscle breakdown and possibilities for
>immobility immobilization. will identify risk impaired skin mass, poor make appropriate impaired skin
>friction factors for integrity. nutritional status intervention to it. integrity of the
impaired skin and problems of self client is
Scientific
integrity , care eliminated.
Explanation:
verbalize > Maintain strict
At risk for skin understanding
skin hygiene, using
being potentially of therapy
mild non-detergent > To prevent skin
vulnerable to regimens and
breakdown soap, drying gently irritation
demonstrate and thoroughly. and
because of behaviors and lubricating with
immobilization techniques to
lotion
prevent skin
breakdown.
>Instruct the >To reduce tissue
relative to turn the pressure and
patient every two prevent pressure
hours sore.

> Avoid friction > To prevent a

when changing shearing force on
position the skin.

>Provide protection >To increase

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

>Observe for >Reduces

reddened or likelihood of
blanched areas and progression to skin
give proper 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 motion

E 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 continuity
O 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 is low
D 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.