Nursing Care Plan of a Patient with Embolic CVA
Care Plan Worksheet
Student: Date of Care:
Age/Gender: Rm Number: Code Status: full
Allergy: NKA
Admitting Diagnosis : embolic cerebral vascular accident (CVA), right side
Current Medical/Surgical Diagnosis: chronic left ventricle thrombus on anticoagulant, hypertension, chronic kidney disease stage 3
Past Medical/Surgical History: metastasis of prostate cancer, primary; bone cancer, secondary; cardiomyopathy, a central hypertension, left bundle branch lock, past substance abuse, congestive heart failure; removal of throat abscess (date unknown); tonsillectomy (date unknown)
Family/Cultural/Ethnic Considerations: patient prefers to live alone though has family support from siblings
Summary of Admission History and Progress Notes: 67-year-old male has a history of non-ischemic cardiomyopathy with ejection factor of 24%, chronic left ventricle thrombus on anticoagulant, hypertension, metastasis of prostate cancer, chronic kidney disease stage 3. Patient was admitted to UCSD emergency department on 08/20 after falling down stairs. Patient presented confused but conscious. Upon presentation in the ED he had left face, left arm, and left leg weakness. After MRI and cerebral angiogram, findings were conclusive to a right-sided embolic CVA. Echocardiogram revealed apical ventricular thrombus. Patient presented to ED on Coumadin therapy with INR at 3.1. Patient was not a candidate for thrombolytic therapy. He continued on Coumadin and aspirin 81 milligrams was added. Left-sided weakness resolved within one to two days. Cardiologist at UCSD recommends Cardiac Thrombectomy to prevent further strokes. Neurologist recommends endovascular intervention to prevent future embolic strokes though not during an acute episode. Patient was held at UCSD ED for permissive hypertension during acute stroke. Patient complained of cough with green phlegm over the past few days; chest x-ray findings of no local infiltrate.
Pathophysiology:
Student: Date of Care:
Age/Gender: Rm Number: Code Status: full
Allergy: NKA
Admitting Diagnosis : embolic cerebral vascular accident (CVA), right side
Current Medical/Surgical Diagnosis: chronic left ventricle thrombus on anticoagulant, hypertension, chronic kidney disease stage 3
Past Medical/Surgical History: metastasis of prostate cancer, primary; bone cancer, secondary; cardiomyopathy, a central hypertension, left bundle branch lock, past substance abuse, congestive heart failure; removal of throat abscess (date unknown); tonsillectomy (date unknown)
Family/Cultural/Ethnic Considerations: patient prefers to live alone though has family support from siblings
Summary of Admission History and Progress Notes: 67-year-old male has a history of non-ischemic cardiomyopathy with ejection factor of 24%, chronic left ventricle thrombus on anticoagulant, hypertension, metastasis of prostate cancer, chronic kidney disease stage 3. Patient was admitted to UCSD emergency department on 08/20 after falling down stairs. Patient presented confused but conscious. Upon presentation in the ED he had left face, left arm, and left leg weakness. After MRI and cerebral angiogram, findings were conclusive to a right-sided embolic CVA. Echocardiogram revealed apical ventricular thrombus. Patient presented to ED on Coumadin therapy with INR at 3.1. Patient was not a candidate for thrombolytic therapy. He continued on Coumadin and aspirin 81 milligrams was added. Left-sided weakness resolved within one to two days. Cardiologist at UCSD recommends Cardiac Thrombectomy to prevent further strokes. Neurologist recommends endovascular intervention to prevent future embolic strokes though not during an acute episode. Patient was held at UCSD ED for permissive hypertension during acute stroke. Patient complained of cough with green phlegm over the past few days; chest x-ray findings of no local infiltrate.
Pathophysiology: