Ischemic Stroke Case Study Essay
PRACTICAL NURSING PROGRAM
CARE PLAN/CASE STUDY
Student’s Name:
Contact Dates: 11/07/2013
Client’s Initials: FL Room Number: 439 Age: 68 Race: African American Sex: M
Date of Admission: 1/18/2013 Allergies: No known Allergies
Primary Diagnosis
CVA (Ischemic Stroke): Deficient blood flow to the brain from a partial or complete occlusion of an artery. Ischemic strokes are divided into thrombotic and embolic and account for about 80% of all strokes (National Institute of Neurological Disorders and Strokes, n.d.).
Text Client Predisposing 1. Atherosclerosis 3, 4, 8, 9, 11 factors or 2. Heart disease causes 3. HTN
4. Smoking
5. Kidney disease
6. Peripheral vascular …show more content…
disease
7. Diabetes mellitus
8. Obesity
9. High serum cholesterol
10 .Stress
11 .Cocaine use
12. Sedentary lifestyle
Text Client
Signs and 1. Confusion 8
Symptoms 2. Dysarthria: Difficulty speaking or understanding speech 3. Difficulty seeing with one or both eyes 4. Difficulty walking 5. Dizziness, loss of balance or coordination 6. Severe headache with no known cause 7. Fainting or unconsciousness 8. hemiplegia
Client
Treatment 1. Angioplasty 1 & 5
(Medical 2. Surgery
Management) 3. Anticoagulants 4. Anti-platelet drugs 5. In clients with seizures, antiepileptic may be given
Text Client
Nursing Care 1. Encourage active ROM on unaffected side and passive ROM 1-9 on affected side
(Nursing 2. Turn and reposition client every 2 hours
Interventions) 3. Monitor lower extremities for thrombophlebitis
4. Encourage use of unaffected arm for ADLs
5. Have client put clothes on affected side first
6. Resume diet orally only after successful completing a swallowing evaluation
7. Try alternate methods of communication for clients with aphasia and consult with speech pathologist as needed 8. Accept client’s frustration and anger as normal to loss of function 9. Reinforce to client with homonymous hemianopsia to overcome deficit by turning head side to side to fully scan visual field
Secondary Diagnosis
Hypertension: blood pressure higher than 140/90 mm Hg.
DJD: A degeneration or ‘wear and tear’ of articular (joint surface) cartilage usually accompanied by an overgrowth of bone (osteophytes), narrowing of the joint space, sclerosis or hardening of bone at the joint surface, and deformity in joints.
Chronic low back pain s/p motor vehicle accident.
Hyperlipidemia: an increase in the amount of fat in the blood.
Gastroesophageal Reflux disease: a common condition in which the acid from the stomach flows back into the esophagus, causing discomfort and in some instances, damage to the esophageal lining.
PSTD: anxiety disorder that develops after experiencing or seeing a traumatic event.
Reason for admission
Patient is a 67 year old African American male, with a chief complaint of sudden onset of left sided weakness and sensory deficit. As per Neurology discharge note at MCG, It started 1 p.m. on 1/05/2013. He also has a history of seizure on Keppra. National Institutes of Health (NIH) stroke scale (a tool used by healthcare providers to objectively quantify the impairment caused by a stroke) is 12 on admission.
Vital Signs
Temperature 98.4⁰F (36.9⁰C)
Pulse 109
Respiration 16
Blood pressure 147/82
Height- 72 in. (6 ft.)
Weight 291.3 lb. (132.4 kg.)
Progress During Hospitalization
01/05/2013—01/18/2013: CT of head showed old stroke and no acute process. Patient was given Tissue Plasminogen Activator (TPA) for his left-sided weakness under the working diagnosis of right cerebral ischemic stroke. Right after the TPA infusion was completed, the patient had a generalized tonic clonic seizure episode. Stat CT was done which was stable and did not show any hemorrhage in the brain. The patient was started on his home medications for seizure that is Keppra and carbamazepine.
Patient was admitted initially under nero –ICU post TPA.
While in the ICU, the patient remained stable hemodynamically. Over the next couple of days, patient’s left side weakness worsen somewhat and at the time of discharge, his left-sided strength is 1/5 in the upper extremity and 1/5 on the lower extremity. MRI of the brain showed acute ischemic stroke, involving the right posterior temporal, right frontal supramarginal gyrus, posterior third right cortex and right parietal subcortical white matter. Carotid Doppler scan did not show any stenosis. Echocardiogram was normal with no thrombus and normal right ventricle. The patient was started on aspirin 81 mg q daily and statin and his blood pressure was controlled with hydrocholothiazide 12.5 mg daily. For his seizure disorder, the patient remained seizure-free throughout the hospital course and he was continued on Keppra 1500 mg b.i.d and carbamazepine 350 mg b.i.d.
During the hospitalization course, the patient developed acute respiratory failure due to upper airway swelling and had stridor and patient was intubated. Over the next day and a half, the patient remained stable while on the vent and for his upper airway swelling he got racemic mixture and steroid to which he responded well and extubated. Postextubation the patient was doing well on room air, without any desaturation or respiratory distress. Also during the course of the hospitalization, the patient had PEG placement and he has been tolerating his PEG feeds
well.
Past Medical History
Hyperlipidemia
DJD
Gastroesophageal reflux disease
Prostate cancer
Hypertension
Chronic low back pain
PSTD/Depression
Diagnostic precedures
MRI—2013 brain showed acute ischemic stroke, involving the right posterior temporal, right frontal supramarginal gyrus, posterior third right cortex and right parietal subcortical white matter
Echocardiogram – 2013 normal
Carotid Doppler scan – 2013 normal
Past Surgical History
Intubated--2013
PEG placement-- 2013
Discharge Planning and Rehabilitation
Pt will be place at the VA for further rehabilitation for left-sided weakness. PEG will be discontinued and patient will be placed on a regular diet due to a swallowing evaluation that was done on 01/16/2013. Patient will participate in physical therapy on Wednesdays and Thursdays of every week at 1:30.
Diet and rationale
Patient is on a 2 gm Na diet
Rationale: A 2 gm Na diet will help maintain low blood pressure level as well as prevent fluid retention/edema of the lower extremities.
Lab Values Results Units Referred Range GLUCOSE 87 Normal mg/dL 7-106
UREA 15 Normal mg/dL 8-23
CREAT 1.1 Normal mg/dL 0.6-1.2 eGFR 65 High mL/min > = 60
SODIUM 147 H High meq/L 133-145
POTASSIUM 4.1 Normal meq/L 3.3-5.0
CHLORIDE 101.4 Normal meq/L 96-108
CO2 28.0 Normal meq/L 22-29
CALCIUM 9.1 Normal mg/dL 8.6-10.2
WBC 8.1 Normal K/mm3 4.8-10.8
RBC 4.24 L Normal M/mm3 3.8-5.6
HGB 13.2 L Normal g/dL 12.5-16.5
HCT 40.2 Normal % 38-46
MCV 95.0 Normal fl 81-95
MCH 31.1 Normal pg 27-33
MCHC 32.8 Normal g/dL 32-36
RDW 14.2 Normal % 11-15
PLT 120 L Low K/mm3 150-400
* A high glomerular filtration rate (eGFR) may signify kidney disease.
* A low level of platelet blood test (PLT) may indicate certain autoimmune disorders such as thrombocytopenia or lupus. Other indications may be due to medication. For instance, patient is currently on lovenox, which may induce low platelet count. Continue to monitor lab work as suggested by physician.
Discharge Planning and Rehabilitation
Patient was discharged on 03/22/13 home with his wife. He was instructed to clean incision site everyday with mild soap and water and to apply antibiotic ointment (Neosporin) to the area 2 to 3 times a day. Avoid strenuous activity for the first 2 weeks. No jogging, aerobics, or swimming, or lifting more than 15 pounds. Soreness is expected when chewing food. Take Tylenol to help reduce pain; preferably 30 minutes before eating. Patient was also instructed to maintain a steady vitamin K diet while on warfarin. He was given a copy of the vitamin K diet. He was also advised to check incision for signs of infection such as redness, tenderness, swelling, warmth, purulent drainage, and temperature of >102 F. He is to return to the hospital for further evaluation if any of the signs of infection are noted. Patient and wife verbalized understanding and agreed to plan of care. Patient’s condition upon discharge was stable.
References
Ackley, Betty J, and Gail Ladwig. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9e. St. Louis: Mosby, 2011.
http://www.mayoclinic.com/health/transient-ischemic-attack/DS00220/DSECTION=treatments-and-drugs
Christensen, Barbara L, and Elaine Kockrow. Adult Health Nursing, 6e. St. Louis: Mosby, 2011.
Christensen, Barbara L, and Elaine Kockrow. Foundations of Nursing, 6e. St. Louis: Mosby, 2011.
Nix, S. Basic Nutrition and Diet Therapy, 13e. St. Louis: Mosby, 2009.
(Health topics: Stroke,Cerebrovascular accident) http://www.who.int/topics/cerebrovascular_accident/en/ http://en.wikipedia.org/wiki/Tissue_plasminogen_activator#Ischemic_stroke Vallerand, April H, and Cythnia Sanoski. Davis 's Drug Guide for Nurses, 13e. Philadelphia: F.A. Davis Company, 2011.
Venes, Donald. "pp. 1626, 2094." Taber 's Cyclopedic Medical Dictionary. 21e. Philadelphia: F.A. Davis Company, 2009.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient is a 77-year-old Caucasian male who was admitted to VAMC with complaints of facial numbness and a visible firm lump located in front of left ear. A left superficial parotidectomy was performed on 03/19/01 to remove the malignant tumor.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Risk for infection
r/t post operative incision
AEB left superficial parotidectomy, 3 ½ inch incisional wound located on left ear
Patient will be free of infection during my shift 03/22/13.
Monitor vital signs q4h.
Inspect wound area q shift; note characteristics of drainage.
Maintaining aseptic technique when providing wound care (i.e. hand washing, wearing gloves).
Provides baseline for comparison of changes.
Identifying problems early can prevent more serious complications.
Prevents entry of bacteria, reducing risk of nosocomial infections.
Patient meets plan. Patient was free of infection during my shift. Wound area was clean and dry with no drainage noted. Jackson pratt secured and intact with 5 mL of serosanguinous drainage present. Will continue to monitor for signs of infection.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient verbalizes pain of 5 on a scale of 0 out of 10 at incisional area. Patient displays facial grimacing and guarding behavior when getting out of bed.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Alteration in comfort
r/t pain at incision site
AEB reported pain of 5 on a scale of 0-10, facial grimacing, guarding behavior
Patient will report pain of 0 on a scale of 0 to 10 during my shift 03/22/13.
Assess pain level using a scale of 0-10.
Promote adequate rest and sleep.
Administer hydrocodone 5/acetaminophen 500 mg tab po q6h prn for pain due to surgical wound.
Helps identify the intensity of pain.
Helps facilitate pain relief.
Helps control level of pain.
Patient meets plan. Patient reported pain level of 0 on a scale of 0-10. Patient was medicated with hydrocodone 5/acetaminophen 500 mg tab po x 1 during shift. Continue to monitor and/or evaluate patient for pain as needed.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient verbalizes fatigue when ambulating. Requires help from nursing staff and walker to ambulate.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Risk for activity intolerance
r/t generalized weakness
AEB unsteady gait, ambulates with assistance from staff and walker, report of fatigue when ambulating
Patient will demonstrate increased tolerance to activity during my shift 03/22/13.
Encourage adequate rest periods, especially before meals, ADLs, exercise, and ambulation.
Monitor and record patients’ ability to tolerate activity q shift.
Observe and document skin integrity q shift.
Rest between activities provides time for energy conservation and recovery.
Provides a baseline of the patient’s activity level.
Activity intolerance may lead to pressure ulcers.
Patient does not meet plan. Patient verbalized fatigue when ambulating. Gait was unsteady. Patient required assistance from staff with ADLs and when ambulating. Will continue to monitor and assess skin integrity and encourage patient to ambulate.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
A left superficial parotidectomy was performed on 03/19/01 to remove the malignant tumor. Patient verbalized that he was worried of how his family/friends will react when they see him. He also verbalized about his change in body image and how he never would of thought something like this would happen to him.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Disturbed body image
r/t altered body structure (left parotidectomy)
AEB verbalization of change in body image, fear of reaction of others, and negative feelings about body
Patient will verbalize feelings about surgical incision and participate in self-care during my shift 03/22/13.
Encourage patient to verbalize feelings regarding the left parotidectomy.
Provide opportunity for patient to participate in care of surgical incision.
Maintain positive attitude during care activities, avoiding expressions that may cause patient to feel ashamed about one self.
Allows patient to express feelings of anger, depression, and grief over loss.
Participating in self-care helps improve self-confidence and acceptance of situation.
Helps assist patient to accept body changes and feel good about self.
Patient meets plan. Patient verbalized his feelings about surgical incision. He also helped participate in care by putting Neosporin on incision site. Will continue to monitor behavior and help patient adjust to situation.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient has a history of DVT and pulmonary embolism. He complains of dyspnea during shift. Respirations were 22 breaths per minute and sp02 at 89%.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Ineffective tissue profusion
r/t decrease venous blood flow
AEB respirations of 22 breaths per minute, patient verbalizing dyspnea, sp02 at 89%, DVT, pulmonary emboli
Patient will have sp02 of 95% to 100% by the end of my shift 03/22/13.
Monitor vital signs q4h.
Administer oxygen by nasal cannula 2 L.
Administer enoxaparin (Lovenox) inj 40-mg/ 0.4 mL sq BID and/or warfarin na 5 mg tab po q daily at 6 PM except Tuesdays/Thursdays take one and one half tab.
Provides baseline information for comparison of changes.
Helps increase blood supply to the brain and the organs.
Helps prevent further blood clots.
Patient meets plan. Sp02 was 97% during shift. He is encouraged to notify staff when dyspnea occurs. Will continue to monitor patient’s vital sign, administer oxygen, and anticoagulants (warfarin and lovenox) as needed.
MEDICATION (generic/trade) CLASSIFICATION
DOSAGE
ROUTE
FREQUENCY
INDICATIONS
FOR
THIS CLIENT
SIDE
EFFECTS
NURSING IMPLICATIONS
omeprazole
PriLOSEC
antiulcer agents
sennoside
Senokot
Stimulate laxatives 20 mg
PO
QAM
8.6 mg tab
PO
Give at bedtime
Maintenance of GERD.
Treatment of constipation, particularly when associated with: Slow transit time, Constipating drugs, Irritable or spastic bowel syndrome, Neurologic constipation.
Dizziness, drowsiness, fatigue, headache, weakness, abdominal pain, diarrhea, flatulence.
Cramping, diarrhea, nausea, pink-red or brown-black discoloration of urine, electrolyte abnormalities (chronic use or dependence).
Administer before meals, preferably in the morning. Capsules should be swallowed whole; do not crush or chew. Advise patient to avoid alcohol, products containing aspirin or NSAIDs.
Administer with full glass of water. Administer at bedtime for evacuation 6-12 hr. later. Administer on an empty stomach for more rapid results. Shake oral solution well before administering. Granules should be dissolved or mixed in water or other liquid before administration.
MEDICATION (generic/trade) CLASSIFICATION
DOSAGE
ROUTE
FREQUENCY
INDICATIONS
FOR
THIS CLIENT
SIDE
EFFECTS
NURSING IMPLICATIONS
tamsulosin
Flomax
Used to manage BPH in men
simvastatin
Zocor
lipid-lowering agent
0.8 mg cap
PO
QHS
20 mg
PO
QPM
Manage overflow obstruction in male patients with prostate hyperplasia.
Management of dyslipidemia.
Dizziness, .
Abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, RHABDOMYOLYSIS.
Assess BP, pulse, and respirations before and during administration. Assess level of sedation if respiratory rate is
CARE PLAN/CASE STUDY
Student’s Name:
Contact Dates: 11/07/2013
Client’s Initials: FL Room Number: 439 Age: 68 Race: African American Sex: M
Date of Admission: 1/18/2013 Allergies: No known Allergies
Primary Diagnosis
CVA (Ischemic Stroke): Deficient blood flow to the brain from a partial or complete occlusion of an artery. Ischemic strokes are divided into thrombotic and embolic and account for about 80% of all strokes (National Institute of Neurological Disorders and Strokes, n.d.).
Text Client Predisposing 1. Atherosclerosis 3, 4, 8, 9, 11 factors or 2. Heart disease causes 3. HTN
4. Smoking
5. Kidney disease
6. Peripheral vascular …show more content…
disease
7. Diabetes mellitus
8. Obesity
9. High serum cholesterol
10 .Stress
11 .Cocaine use
12. Sedentary lifestyle
Text Client
Signs and 1. Confusion 8
Symptoms 2. Dysarthria: Difficulty speaking or understanding speech 3. Difficulty seeing with one or both eyes 4. Difficulty walking 5. Dizziness, loss of balance or coordination 6. Severe headache with no known cause 7. Fainting or unconsciousness 8. hemiplegia
Client
Treatment 1. Angioplasty 1 & 5
(Medical 2. Surgery
Management) 3. Anticoagulants 4. Anti-platelet drugs 5. In clients with seizures, antiepileptic may be given
Text Client
Nursing Care 1. Encourage active ROM on unaffected side and passive ROM 1-9 on affected side
(Nursing 2. Turn and reposition client every 2 hours
Interventions) 3. Monitor lower extremities for thrombophlebitis
4. Encourage use of unaffected arm for ADLs
5. Have client put clothes on affected side first
6. Resume diet orally only after successful completing a swallowing evaluation
7. Try alternate methods of communication for clients with aphasia and consult with speech pathologist as needed 8. Accept client’s frustration and anger as normal to loss of function 9. Reinforce to client with homonymous hemianopsia to overcome deficit by turning head side to side to fully scan visual field
Secondary Diagnosis
Hypertension: blood pressure higher than 140/90 mm Hg.
DJD: A degeneration or ‘wear and tear’ of articular (joint surface) cartilage usually accompanied by an overgrowth of bone (osteophytes), narrowing of the joint space, sclerosis or hardening of bone at the joint surface, and deformity in joints.
Chronic low back pain s/p motor vehicle accident.
Hyperlipidemia: an increase in the amount of fat in the blood.
Gastroesophageal Reflux disease: a common condition in which the acid from the stomach flows back into the esophagus, causing discomfort and in some instances, damage to the esophageal lining.
PSTD: anxiety disorder that develops after experiencing or seeing a traumatic event.
Reason for admission
Patient is a 67 year old African American male, with a chief complaint of sudden onset of left sided weakness and sensory deficit. As per Neurology discharge note at MCG, It started 1 p.m. on 1/05/2013. He also has a history of seizure on Keppra. National Institutes of Health (NIH) stroke scale (a tool used by healthcare providers to objectively quantify the impairment caused by a stroke) is 12 on admission.
Vital Signs
Temperature 98.4⁰F (36.9⁰C)
Pulse 109
Respiration 16
Blood pressure 147/82
Height- 72 in. (6 ft.)
Weight 291.3 lb. (132.4 kg.)
Progress During Hospitalization
01/05/2013—01/18/2013: CT of head showed old stroke and no acute process. Patient was given Tissue Plasminogen Activator (TPA) for his left-sided weakness under the working diagnosis of right cerebral ischemic stroke. Right after the TPA infusion was completed, the patient had a generalized tonic clonic seizure episode. Stat CT was done which was stable and did not show any hemorrhage in the brain. The patient was started on his home medications for seizure that is Keppra and carbamazepine.
Patient was admitted initially under nero –ICU post TPA.
While in the ICU, the patient remained stable hemodynamically. Over the next couple of days, patient’s left side weakness worsen somewhat and at the time of discharge, his left-sided strength is 1/5 in the upper extremity and 1/5 on the lower extremity. MRI of the brain showed acute ischemic stroke, involving the right posterior temporal, right frontal supramarginal gyrus, posterior third right cortex and right parietal subcortical white matter. Carotid Doppler scan did not show any stenosis. Echocardiogram was normal with no thrombus and normal right ventricle. The patient was started on aspirin 81 mg q daily and statin and his blood pressure was controlled with hydrocholothiazide 12.5 mg daily. For his seizure disorder, the patient remained seizure-free throughout the hospital course and he was continued on Keppra 1500 mg b.i.d and carbamazepine 350 mg b.i.d.
During the hospitalization course, the patient developed acute respiratory failure due to upper airway swelling and had stridor and patient was intubated. Over the next day and a half, the patient remained stable while on the vent and for his upper airway swelling he got racemic mixture and steroid to which he responded well and extubated. Postextubation the patient was doing well on room air, without any desaturation or respiratory distress. Also during the course of the hospitalization, the patient had PEG placement and he has been tolerating his PEG feeds
well.
Past Medical History
Hyperlipidemia
DJD
Gastroesophageal reflux disease
Prostate cancer
Hypertension
Chronic low back pain
PSTD/Depression
Diagnostic precedures
MRI—2013 brain showed acute ischemic stroke, involving the right posterior temporal, right frontal supramarginal gyrus, posterior third right cortex and right parietal subcortical white matter
Echocardiogram – 2013 normal
Carotid Doppler scan – 2013 normal
Past Surgical History
Intubated--2013
PEG placement-- 2013
Discharge Planning and Rehabilitation
Pt will be place at the VA for further rehabilitation for left-sided weakness. PEG will be discontinued and patient will be placed on a regular diet due to a swallowing evaluation that was done on 01/16/2013. Patient will participate in physical therapy on Wednesdays and Thursdays of every week at 1:30.
Diet and rationale
Patient is on a 2 gm Na diet
Rationale: A 2 gm Na diet will help maintain low blood pressure level as well as prevent fluid retention/edema of the lower extremities.
Lab Values Results Units Referred Range GLUCOSE 87 Normal mg/dL 7-106
UREA 15 Normal mg/dL 8-23
CREAT 1.1 Normal mg/dL 0.6-1.2 eGFR 65 High mL/min > = 60
SODIUM 147 H High meq/L 133-145
POTASSIUM 4.1 Normal meq/L 3.3-5.0
CHLORIDE 101.4 Normal meq/L 96-108
CO2 28.0 Normal meq/L 22-29
CALCIUM 9.1 Normal mg/dL 8.6-10.2
WBC 8.1 Normal K/mm3 4.8-10.8
RBC 4.24 L Normal M/mm3 3.8-5.6
HGB 13.2 L Normal g/dL 12.5-16.5
HCT 40.2 Normal % 38-46
MCV 95.0 Normal fl 81-95
MCH 31.1 Normal pg 27-33
MCHC 32.8 Normal g/dL 32-36
RDW 14.2 Normal % 11-15
PLT 120 L Low K/mm3 150-400
* A high glomerular filtration rate (eGFR) may signify kidney disease.
* A low level of platelet blood test (PLT) may indicate certain autoimmune disorders such as thrombocytopenia or lupus. Other indications may be due to medication. For instance, patient is currently on lovenox, which may induce low platelet count. Continue to monitor lab work as suggested by physician.
Discharge Planning and Rehabilitation
Patient was discharged on 03/22/13 home with his wife. He was instructed to clean incision site everyday with mild soap and water and to apply antibiotic ointment (Neosporin) to the area 2 to 3 times a day. Avoid strenuous activity for the first 2 weeks. No jogging, aerobics, or swimming, or lifting more than 15 pounds. Soreness is expected when chewing food. Take Tylenol to help reduce pain; preferably 30 minutes before eating. Patient was also instructed to maintain a steady vitamin K diet while on warfarin. He was given a copy of the vitamin K diet. He was also advised to check incision for signs of infection such as redness, tenderness, swelling, warmth, purulent drainage, and temperature of >102 F. He is to return to the hospital for further evaluation if any of the signs of infection are noted. Patient and wife verbalized understanding and agreed to plan of care. Patient’s condition upon discharge was stable.
References
Ackley, Betty J, and Gail Ladwig. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9e. St. Louis: Mosby, 2011.
http://www.mayoclinic.com/health/transient-ischemic-attack/DS00220/DSECTION=treatments-and-drugs
Christensen, Barbara L, and Elaine Kockrow. Adult Health Nursing, 6e. St. Louis: Mosby, 2011.
Christensen, Barbara L, and Elaine Kockrow. Foundations of Nursing, 6e. St. Louis: Mosby, 2011.
Nix, S. Basic Nutrition and Diet Therapy, 13e. St. Louis: Mosby, 2009.
(Health topics: Stroke,Cerebrovascular accident) http://www.who.int/topics/cerebrovascular_accident/en/ http://en.wikipedia.org/wiki/Tissue_plasminogen_activator#Ischemic_stroke Vallerand, April H, and Cythnia Sanoski. Davis 's Drug Guide for Nurses, 13e. Philadelphia: F.A. Davis Company, 2011.
Venes, Donald. "pp. 1626, 2094." Taber 's Cyclopedic Medical Dictionary. 21e. Philadelphia: F.A. Davis Company, 2009.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient is a 77-year-old Caucasian male who was admitted to VAMC with complaints of facial numbness and a visible firm lump located in front of left ear. A left superficial parotidectomy was performed on 03/19/01 to remove the malignant tumor.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Risk for infection
r/t post operative incision
AEB left superficial parotidectomy, 3 ½ inch incisional wound located on left ear
Patient will be free of infection during my shift 03/22/13.
Monitor vital signs q4h.
Inspect wound area q shift; note characteristics of drainage.
Maintaining aseptic technique when providing wound care (i.e. hand washing, wearing gloves).
Provides baseline for comparison of changes.
Identifying problems early can prevent more serious complications.
Prevents entry of bacteria, reducing risk of nosocomial infections.
Patient meets plan. Patient was free of infection during my shift. Wound area was clean and dry with no drainage noted. Jackson pratt secured and intact with 5 mL of serosanguinous drainage present. Will continue to monitor for signs of infection.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient verbalizes pain of 5 on a scale of 0 out of 10 at incisional area. Patient displays facial grimacing and guarding behavior when getting out of bed.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Alteration in comfort
r/t pain at incision site
AEB reported pain of 5 on a scale of 0-10, facial grimacing, guarding behavior
Patient will report pain of 0 on a scale of 0 to 10 during my shift 03/22/13.
Assess pain level using a scale of 0-10.
Promote adequate rest and sleep.
Administer hydrocodone 5/acetaminophen 500 mg tab po q6h prn for pain due to surgical wound.
Helps identify the intensity of pain.
Helps facilitate pain relief.
Helps control level of pain.
Patient meets plan. Patient reported pain level of 0 on a scale of 0-10. Patient was medicated with hydrocodone 5/acetaminophen 500 mg tab po x 1 during shift. Continue to monitor and/or evaluate patient for pain as needed.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient verbalizes fatigue when ambulating. Requires help from nursing staff and walker to ambulate.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Risk for activity intolerance
r/t generalized weakness
AEB unsteady gait, ambulates with assistance from staff and walker, report of fatigue when ambulating
Patient will demonstrate increased tolerance to activity during my shift 03/22/13.
Encourage adequate rest periods, especially before meals, ADLs, exercise, and ambulation.
Monitor and record patients’ ability to tolerate activity q shift.
Observe and document skin integrity q shift.
Rest between activities provides time for energy conservation and recovery.
Provides a baseline of the patient’s activity level.
Activity intolerance may lead to pressure ulcers.
Patient does not meet plan. Patient verbalized fatigue when ambulating. Gait was unsteady. Patient required assistance from staff with ADLs and when ambulating. Will continue to monitor and assess skin integrity and encourage patient to ambulate.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
A left superficial parotidectomy was performed on 03/19/01 to remove the malignant tumor. Patient verbalized that he was worried of how his family/friends will react when they see him. He also verbalized about his change in body image and how he never would of thought something like this would happen to him.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Disturbed body image
r/t altered body structure (left parotidectomy)
AEB verbalization of change in body image, fear of reaction of others, and negative feelings about body
Patient will verbalize feelings about surgical incision and participate in self-care during my shift 03/22/13.
Encourage patient to verbalize feelings regarding the left parotidectomy.
Provide opportunity for patient to participate in care of surgical incision.
Maintain positive attitude during care activities, avoiding expressions that may cause patient to feel ashamed about one self.
Allows patient to express feelings of anger, depression, and grief over loss.
Participating in self-care helps improve self-confidence and acceptance of situation.
Helps assist patient to accept body changes and feel good about self.
Patient meets plan. Patient verbalized his feelings about surgical incision. He also helped participate in care by putting Neosporin on incision site. Will continue to monitor behavior and help patient adjust to situation.
NURSING
ASSESSMENT
NURSING
DIAGNOSIS
EXPECTED
OUTCOME
IMPLEMENTATION
NURSING
INTERVENTIONS
RATIONALE FOR NURSING INTERVENTIONS
EVALUATION (ACTUAL OUTCOME)
Patient has a history of DVT and pulmonary embolism. He complains of dyspnea during shift. Respirations were 22 breaths per minute and sp02 at 89%.
VS
T: 97.4 °F
P: 79
R: 22
BP: 125/73
Ineffective tissue profusion
r/t decrease venous blood flow
AEB respirations of 22 breaths per minute, patient verbalizing dyspnea, sp02 at 89%, DVT, pulmonary emboli
Patient will have sp02 of 95% to 100% by the end of my shift 03/22/13.
Monitor vital signs q4h.
Administer oxygen by nasal cannula 2 L.
Administer enoxaparin (Lovenox) inj 40-mg/ 0.4 mL sq BID and/or warfarin na 5 mg tab po q daily at 6 PM except Tuesdays/Thursdays take one and one half tab.
Provides baseline information for comparison of changes.
Helps increase blood supply to the brain and the organs.
Helps prevent further blood clots.
Patient meets plan. Sp02 was 97% during shift. He is encouraged to notify staff when dyspnea occurs. Will continue to monitor patient’s vital sign, administer oxygen, and anticoagulants (warfarin and lovenox) as needed.
MEDICATION (generic/trade) CLASSIFICATION
DOSAGE
ROUTE
FREQUENCY
INDICATIONS
FOR
THIS CLIENT
SIDE
EFFECTS
NURSING IMPLICATIONS
omeprazole
PriLOSEC
antiulcer agents
sennoside
Senokot
Stimulate laxatives 20 mg
PO
QAM
8.6 mg tab
PO
Give at bedtime
Maintenance of GERD.
Treatment of constipation, particularly when associated with: Slow transit time, Constipating drugs, Irritable or spastic bowel syndrome, Neurologic constipation.
Dizziness, drowsiness, fatigue, headache, weakness, abdominal pain, diarrhea, flatulence.
Cramping, diarrhea, nausea, pink-red or brown-black discoloration of urine, electrolyte abnormalities (chronic use or dependence).
Administer before meals, preferably in the morning. Capsules should be swallowed whole; do not crush or chew. Advise patient to avoid alcohol, products containing aspirin or NSAIDs.
Administer with full glass of water. Administer at bedtime for evacuation 6-12 hr. later. Administer on an empty stomach for more rapid results. Shake oral solution well before administering. Granules should be dissolved or mixed in water or other liquid before administration.
MEDICATION (generic/trade) CLASSIFICATION
DOSAGE
ROUTE
FREQUENCY
INDICATIONS
FOR
THIS CLIENT
SIDE
EFFECTS
NURSING IMPLICATIONS
tamsulosin
Flomax
Used to manage BPH in men
simvastatin
Zocor
lipid-lowering agent
0.8 mg cap
PO
QHS
20 mg
PO
QPM
Manage overflow obstruction in male patients with prostate hyperplasia.
Management of dyslipidemia.
Dizziness, .
Abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, RHABDOMYOLYSIS.
Assess BP, pulse, and respirations before and during administration. Assess level of sedation if respiratory rate is