CASE 29

Trinity University of AsiaSt. Luke’s College of

NursingE. Rodriguez Sr. Avenue, Cathedral Heights,

Quezon City, Philippines

Case 29-2015: A 38-Year-Old Pregnant Woman with Headache and Visual Symptoms

A Case Study

Presented to Mr. Dennis Abellera

Submitted by:

Group 3 – 4NU01

CABRAL, Nolan B.

CAMPOS, Angela A.

CARABIO, Jesica Vanesa N.

FINDLEY, John Paul E.

October 9, 2015

II. Patient’s Profile

A. DEMOGRAPHIC DATA

Name: N/A

Address: N/A

Age: 38 years old

Gender: Female

Date and Time of Admission: N/A

Diagnosis: Embolic Stroke 2° Loffler’s Endocarditis

B. Chief Complaint:

Sudden panic attack followed by narrowing of vision

C. Present History of Illness:

Eleven days priror to admission, patient was rushed to emergency department and the

labor and delivery unit because of neck and pain, occipital headache, vomiting and

elevated temperature of 38.9°c. Urinalysis was done and revealed traces of ketones, 1+

albumin and 2+ urobilimogen. Patient vital signs were normal and patient was

discharged home. On the day of admission, the patient felt onset of panic attacked

followed by tunnel vision. Patient began to hyperventilate and her vision went black

from the periphery to the center. The symptoms lasted about 2 minutes and followed

by spots in her visual fields, headache, neck pain that radiated to her arms, nausea and

dizziness.

D. Past Medical History:

At 17 years old, the patient had presented 20 weeks of gestation with sepsis and still

born fetus. Patient also had a history of anemia, bipolar disorder, panic attakces related

to syncope, chronic pelvic pain, ovarian cysts, asthma and seasonal allergic rhinitis

E. Family History of Illness

Patient’s mother had breast cancer and died at her 50’s

F. Social History

Patient does not smoke, drink alcohol or use recreational and illicit drugs.

G. Allergies

Patient allergic to:

Loperamide

Morphine

Meperidine hydrochloride

Contrast material

H. Physical Assessment

Upon assessment patient’s back was tender, her abdomen was gravid, soft and non-

tender with active fetal movements.

IV. LABORATORY PROCEDURES

Abnormal Results

Lower than normal range

Hematocrito Insufficient fluid intake and possible DM or bleeding

Hemoglobino Insufficient iron intake or bleeding

Lymphocytes

o Chronic infection Monocytes

o Chronic infection HDL

o Unhealthy diet Functional Protein S

o Risk for clotting disorder/thrombus and embolus Free protein S antigen

o Risk for clotting disorder/thrombus and embolusElevated Lab Results

Eosinophilso Parasitic infection

Alkaline Phosphataseo Liver damage

Aspartate aminotransferaseo Liver damage

Lactate dehydrogenaseo Suggests myocardial damage

C-reactive proteino Indicative of infection

Fibrinogeno Risk for thrombus/embolus

Triglycerideso Not enough exercise/unhealthy diet

Cholesterolo Not enough exercise/unhealthy diet

Cardiac Risk Ratioo Risk for cardiac problems such as stroke

Medical Diagnostics Done

Urinalysis CBC Glucose-tolerance test MRI

Transthoracic echocardiogram

Bone Marrow Biopsy

Management

- Urinalysis- Urine culture- Ultrasonography of legs- Neurologic examinations- Mri of the head- Magnetic resonance angiograohy and venography- ECG- Holter monitoring- Lumbar puncture- Blood tests- Ophthalmology consulted- Ultrasound examinations done- Tissue Doppler echocardiography done- Hepatitis screening- Thranthoracic echocardiography- ELISA test done- Serologic tests- Bone marrow biopsy and stool examination

VIII. DRUG STUDY

NAME ACTION INDICATION & CONTRAINDICATION

SIDE EFFECTS & ADVERSE

EFFECTS

NURSING CONSIDERATIONS

GENERIC NAME:

Hydromorphone

BRAND NAME:

Dilaudid

Classifications: NARCOTIC ANALGESIC ANTITUSSIVE

Potent opiate receptor agonist that does not alter pain threshold but changes the perception of pain in the CNS. An effective narcotic analgesic that controls mild to moderate pain. Also has antitussive properties.

INDICATION:

Relief of moderate to severe pain.

CONTRAINDICATION:

Intolerance to opiate agonists;; acute or severe asthma; hypercapnia; bronchial asthma. analgesia; upper airway obstruction, GI obstruction; ilieus; severe respiratory depression;

ADVERSE EFFECTS

GI: Nausea, vomiting, constipation.

CNS: Euphoria, dizziness, sedation, drowsiness.

CV: Hypotension, bradycardia or tachycardia.

Respiratory: Respiratory depression.

Note baseline respiratory rate, rhythm, and depth and size of pupils before administration. Respirations of 12/min or less and mitosis are signs of toxicity. Withhold drug and promptly notify doctor.

Monitor vital signs at regular in- tervals. Drug-induced respiratory depression may occur even with small doses and increases progressively with higher doses.

Assess effectiveness of pain relief 30 min after medication administration.

Assess effectiveness of cough. Drug depresses cough and sigh reflexes and may induce atelectasis, especially in postoperative patients and those with pulmonary disease.


SIDE EFFECTS & ADVERSE

EFFECTS


GENERIC NAME:

Prochlorperazine

BRAND NAME:

Compazin

CLASSIFICATION:

ANTIPSYCHOTIC, ANTIEMETIC

Strong antipsychotic effects thought to be due to blockade of postsyn-aptic dopamine receptors in the brain. Antiemetic effect is produced by suppression of the chemore- ceptor trigger zone (CTZ). Effec tive antipsychotic and antiemetic properties.

INDICATIONS:

Management of manifestations of psychotic disorders, of excessive anxiety, tension, and agitation, and to control severe nausea and vomiting.

CONTRAINDICATIONS:

Hyper- sensitivity to phenothiazines; bone marrow depression; blood dyscrasias, jaundice; comatose or severely depressed states; dementia-related psychosis in elderly; children weigh- ing less than 9 kg (20 lb) or younger than 2 y of age; pediatric surgery; short-term vomiting in children or vomiting of unknown etiology; Reye’s syndrome or other enceph lopathies; history of dyskineticreac-

Drowsiness, dizziness, extrapyramidal reactions (akathisia, ystonia, or parkinsonism), persistent tardive dyskinesia, acute catatonia.

CV: Hypotension. GI: Cholestatic jaundice.

Skin: Contact dermatitis, photosensitivity. Endocrine: Galactorrhea, amenorrhea.

Special Senses: Blurred vision.

Position carefully to prevent aspiration of vomitus; may have depressed cough reflex.

Keep in mind that the antiemetic effect may mask toxicity of other drugs or make it difficult to diag- nose conditions with a primary symptom of nausea.

Note signs of increasing of patient’s temperature: Red, dry, hot skin; full bounding pulse; dilated pupils; dyspnea; confusion; temperature over 40.6° C (105° F); elevated BP. Exposure to high environ- mental temperature places this patient at risk for heat stroke.

Monitorlabtests:PeriodicCBCwith differential in long-term therapy.

tions or epilepsy

NAME ACTION INDICATION & CONTRAINDICAT

ION

SIDE EFFECTS & ADVERSE EFFECTS


GENERIC NAME:

Cyclobenzaprine

BRAND NAME:

Amrix

Relieves skeletal muscle spasm of local origin without interfering with muscle function. Believed to act primarily within CNS at brain stem. Depresses tonic somatic mo-

INDICATION: Short-term adjunct to rest and physical therapy for relief of muscle spasm associated with acute musculoskeletal condi tions. Not effective in treatment of spasticity associated with cerebral palsy or cerebral

Body as a Whole: Edema of tongue and face, sweating, myalgia, hepatitis, alopecia. Shares toxic potential of tricyclic antidepressants.

CV: Tachycardia, syncope, palpitation, vasodilation, chest pain, orthostatic hypotension, dyspnea; with high doses, possibility of

o Supervision of ambulation may be indicated, especially in the older adult because of risk of drowsiness and dizziness.

o Stop drug if signs of hypersensitivity (e.g., pruritus, urticaria, rash) appear.

CLASSIFICATION:

CENTRAL ACTING SKELETAL MUSCLE RELAXANT, ANTI SPASMODIC

tor activity, although both gamma and alpha motor neurons are af fected. Relieves muscle spasm asso ciated with acute, painful musculo-skeletal conditions.

or cord disease.

CONTRAINDICATION: Acute recovery phase of MI, cardiac arrhythmias, heart block or conduction disturbances, QT prolongation; CHF, hyperthyroidism; closed- angle glaucoma, increased intrao ular pressure; moderate or severe hepatic impairment; MAOI ther

severe arrhythmias.

GI: Dry mouth, indigestion, unpleasant taste, coated tongue, tongue discoloration, vomiting, anorexia, abdominal pain, flatulence, diarrhea, paralytic ileus.

CNS: Drowsiness, dizziness, weakness, fatigue, asthenia, paresthesias,

Skin: Pruritus, urticaria, skin rash.

Urogenital: Increased or decreased libido, impotence.

o Dry mouth may be relieved by increasing total fluid intake (if not contraindicated).




GENERIC NAME:

Diphenhydramine

BRAND NAME:

Benadryl

CLASSIFICATION:

Centrally Acting Cholinergic Antagonist; Antihistamine

Diphenhydramine competes for H1- receptor sites on effector cells, thus blocking histamine release. Effects in parkinsonism and drug-induced extrapyramidal symptoms are apparently related to its ability to suppress central cholinergic activity and to prolong action of dopamine by inhibiting its reuptake and storage. Has antihistamine, anti- vertigo, antiemetic, antianaphylactic, antitussive, antidyskinetic, and sedative-hypnotic effects.

INDICATION:

Temporary symptomatic relief of various allergic conditions and to treat or prevent motion sickness, vertigo, and reactions to blood or plasma in susceptible patients. Also used in anaphylaxis as adjunct to epinephrine and other standard measures after acute symptoms have been controlled; in treatment of parkinsonism and drug-induced extrapyramidal reactions; as a nonnarcotic cough suppressant; as a sedative-hypnotic; and for treatment of intractable insomnia.

CONDRAINDICATION:

Hyper- sensitivity to antihistamines of similar structure; lower respiratory tract symptoms (including acute asthma); narrow-angle glaucoma; prostatic hy- pertrophy, bladder neck obstruction; GI obstruction

CNS: Drowsiness, dizziness, headache, fatigue, disturbed coordination, tingling, heaviness and weakness of hands, tremors, euphoria, nervousness, restlessness, insomnia; confusion: Excitement, fever.

CV: Palpitation, tachycardia, mild hypotension or hypertension, cardiovascular collapse.

Special Senses: Tinnitus, vertigo, dry nose, throat, nasal stuffiness; blurred vision, diplopia, photosensitivity, dry eyes.

GI: Dry mouth, nausea, epigastric distress, anorexia, vomiting,

Monitor cardiovascular status especially with preexisting cardiovascular disease.

Monitor for adverse effects especially in children and the older adult.

Supervise ambulation and institute falls precautions as necessary. Drowsiness is most prominent during the first few days of therapy and often disappears with continued therapy. Older adults are especially likely to manifest dizziness, sedation, and hypotension.

or stenosis; constipation, or diarrhea.

Urogenital: Urinary frequency or retention, dysuria.

Respiratory: Thick- ened bronchial secretions, wheezing,

NAME ACTION INDICATION & CONTRAINDICATIO

N



GENERIC NAME:

Oxycodone

BRAND NAME:

Oxycontin

Semisynthetic derivative of an opi- um agonist that binds with stereo- specific receptors in various sites of CNS to alter both perception of pain and emotional

INDICATION:

Relief of moderate to mod- erately severe pain, neuralgia. Re- lieves postoperative, postextractional, postpartum pain.

CNS: Euphoria, dysphoria, lightheaded- ness, dizziness, sedation. GI: An- orexia, nausea, vomiting, constipation, jaundice, hepatotoxicity (combinations containing acetami- nophen). Respiratory: Shortness of

o Monitor respiratory status. With- hold drug and notify prescriber if respiratory depression occurs.

o Monitorpatientsresponseclosely, especially to sustained-release preparations.

o Consultprescriberifnauseacontinues after first few days of

response to pain. Active against moderate to moder- ately severe pain. Appears to be more effective in relief of acute than long-standing pain.

CONTRAINDICATION:

Hyper- sensitivity to oxycodone and prin- ciple drugs with which it is com- bined; bronchial asthma

breath, respiratory depression. Skin: Pruritus, skin rash. CV: Brady- cardia. Body as a Whole: Unusual bleeding or bruising. Urogenital: Dysuria, frequency of urination, urinary retention.

therapy.o Note: Light-headedness,

dizzi-ness, sedation, or fainting appear to be more prominent in ambulatory than in non ambulatory patients and may be alleviated if patient lies down.

o Evaluatepatient’s continuedneed for oxycodone preparations. Psychic and physical dependence and tolerance may develop with repeated use. The potential for drug abuse is high.

o Beawarethatseriousoverdosage of any oxycodone preparation presents problems associated with a narcotic overdose (respiratory depression, circulatory collapse, extreme somnolence progressing to stupor or coma).

Nursing Care Plan:

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective:

Gimacing of the face

rapid breathing

Subjective:

-verbalized high levels of pain (7/10)

-verbalization of increased pain with movement

Acute back pain related to increased weight

Short Term:Reduce pain level of patient to level of 5 within 1 hour of nursing interventions

Long Term:

Educate patient with health teaching regarding generalized pain and more specifically how to deal with back pain within stay at hospital

Monitored patient for changes in pain level

Limited physical activity and encouraged bed rest

Monitored vital signs, with emphasis on blood pressure

Any neurological changes or exacerbations should be controlled as much as possible and can be indicative of a worsening condition

Excessive physical activity may exacerbate symptoms of pain

Vital Signs provide an objective overall measurement of the

Goal Met

Encouraged deep breathing exercises

Encouraged techniques in diversion of focus

Increased fluid intake

patient’s status. Blood pressure can be used as an objective gauge of patient’s pain

Deep beathing exercises can help lower pain levels and provide a distraction to the pain

Other diversion methods may be used to take patient’s focus away from the pain

Increased fluids can promote

Dependent

Administered oxygen as prescribed

Administered medications as prescribed

proper blood flow and can help decrease pain

Oxygen may be necessary to help counteract alterations in breathing due to pain

Medications may be necessary for palliative care


Objective:

Gimacing of the face

rapid breathing

Guarding of head

Subjective:

-verbalized high levels of pain (9/10)

-verbalization of increased pain in lighted areas and excess noise

Acute pain related to headache

Short Term:Reduce pain level of patient to level of 6 within 1 hour of nursing interventions

Long Term:

Educate patient with health teaching regarding generalized pain and more specifically headaches within stay at hospital

Monitored patient for neurological changes

Monitored vital signs, with emphasis on blood pressure

Monitored input and output

Any neurological changes or exacerbations should be controlled as much as possible and can be indicative of a worsening condition

Vital Signs provide an objective overall measurement of the patient’s status. Blood pressure can be used as an objective gauge of patient’s pain

Ineffective

Goal Met

Encouraged deep breathing exercises

Encouraged techniques in diversion of focus


Dependent

Administered

input and output can cause lots of pain and overall problems that can lead to pain

Deep beathing exercises can help lower pain levels and provide a distraction to the pain

Other diversion methods may be used to take patient’s focus away from the pain

Increased fluids can promote

oxygen as prescribed


proper blood flow and can help decrease pain

Oxygen may be necessary to help alleviate headache

Medications may be necessary for palliative care


Objective:

Hematocrit: 33.3

Hemoglobin: 10.6

Eosinophils: 33

Subjective:

Verbalized feelings of dizziness, changes in visual sensation and headache

Disturbed sensory perception (visual) related to changes in functioning of organs secondary to parasitic infection

Short Term:

Provide environment that limits the chance of fall within 45 minutes of admission

Long Term:

Health teaching regarding how to limit the chances of reoccurrence of symptoms.

Independent

Monitored vital signs, especially BP

Raised side rails

Provided quiet, peaceful environment

Limited

Vital signs help the health team by giving objective means of assessing the state of the patient

Side rails need to be raised in order to prevent the patient from falls

Quiet and peaceful environments will limit the amount of presenting symptoms and provide a healing atmosphere

Physical

Goal Met.

physical activity

Increased

fluid intake

Limited contract with visitors

Dependent

Provide assistive aids as prescribed

exertion may exacerbate symptoms and lead to further injury

Increased fluid intake will encourage proper blood flow and help prevent further incidences

Excessive visitors can exacerbate symptoms

Assistive aids, such as slip resistant socks and a room with extra side rails may be

Administer medications as prescribed

needed to help prevent further injury to the patient

Medications may be needed to provide palliative care


Objective:

Hematocrit: 33.3

Hemoglobin: 10.6

Subjective:

Verbalized feelings of vertigo, diplopia and floaters

Risk for fall related to changed in visual perception

Short Term

Provide safe environment that helps to prevent falls within 45 minutes of nursing intervention

Long Term:

Prevent any fall incidents during stay in hospital

Limited amount of activity

Raised the side rails

Provided quiet peaceful environment


Limited amount of

Excessive walking can lead to fall with an abnormal state of vision

Raised side rails will protect the patient from falling out of bed

A peaceful environment may help the patient heal faster

Increased fluid intake can promote better blood flow

Excessive visitors may

Goal Met

visitors

Dependent


exacerbate symptoms and prevent optimum healing environment

Medications may be necessary to provide palliative care


Objective:

Hemoglobin: 10.6

Risk for bleed related to reduced iron intake and anemia

Short Term:

Provide safe environment to prevent any bleeding episodes within 45 minutes of nursing intervention

Long Term:

Prevent any bleed from occurring during stay in hospital

Avoid contact with sharp objects

Provide extra padding for corners and other areas that may cause bleeding

Increase amount of protein and other iron rich foods

Dependent

Administer medications as prescribed

Administer oxygen as prescribed

Sharp objects can break the skin and cause bleeds

Corners are very common causes of injury, especially is patients who are sensory impaired

Increased iron intake will facilitate the body with the requirements to increase hemoglobin

Decreased hemoglobin can lead to low O2 saturation and oxygen may

Goal partially met

be needed to counteract the side effects of insufficient iron

CASE 29

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