Was given a case study from my lecturer to complete a nursing care plan and would just like some help to see if I'm on the right path... Thanks :)
CASE STUDY A 71 year old male was eating breakfast when he had an abrupt onset of visual loss in left eye and weakness in right arm and leg. There is some tingling of the right hand and right corner of mouth. He has difficulty standing and is taken to the emergency room where you are asked to initiate admission. On examining him, you find that his vision has recovered but he has weakness of the right arm involving the triceps, wrist and finger extensors and right leg involving hamstrings (lower leg flexors) and anterior tibial reflex. He also has Babinski's sign.
Sensory examination reveals decreased sensation in right hand and arm and less sensation on the right side of face and leg. He has difficulty identifying objects placed in his hand by sensation alone. The patient has no difficulty understanding speech but speaks infrequently and does so with paucity of otherwise meaningful words.
General examination reveals left carotid bruit and a normal sinus rhythm.
From looking at the symptoms and doing some reading I found that most of the symptoms are present with a TIA. So these are the nursing diagnoses I have (was only required to have one actual and one potential diagnosis but I have two actual diagnoses to be critiqued):
Disturbed sensory perception r/t reduction in cerebral blood flow AEB decreased sensation on right side of face, right arm, hand and leg, decreased ability to identify objects placed in hand and patient's verbalization of abrupt visual loss in left eye and tingling in right hand and right corner of mouth.
Desired outcome: Patient will verbalize increased sensation in right hand, arm, leg and right side of face.
