CVA- Stroke care information please HELP!

Nursing Students Student Assist

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we have to do a group project on a cva patient- this is all made up and we plan on doing a skit i am attaching some information below if there is anything that doesnt make sense please let me know thank you sooooooo much for your help!

chief complaint- headache and left sided weakness

pmh-hypertension, obesity, diabetes, family history of stroke, smoker and has past history of atherosclerosis

medications- currently on medication for hypertension bisoprolol- zebeta and diuretic furosemide- lasix

age/gender 65 year old hispanic male

allergies- none

vital signs temp 99.0, b/p 140/85, pulse 96, resp 16

assessment & ros

mental- patient is confused and drowsy

communication- patient is experiencing expressive language deficit where patient can understand what others say but cannot or does not respond approximately

nurse should use simple one step commands and can also incorporate the use of gestures, written questions or pictures

swallowing- patient demonstrates a decreased gag reflex

motor and sensory function- patient has decreased sensation and weakness on left side of body

vision and perceptual deficit- patient does not notice presence of others standing to left side

patients awareness to left side is diminished

patient favors right side of body and continuously looks to right side even when noises and movement occur to left side of patient

bowel/ bladder function patient has suffered from mild constipation and has normal bladder function

provide a short descriptive type paragraph describing your patient pathophysiology, signs & symptoms, medical management, nursing management, medications (include why the patient is receiving the medications), diagnostic labs and tests.

paragraph for physiology, nursing management, medications, tests, labs, medical management

cva stands for cerebrovascular disease also referred to as a stroke. there are two types of strokes 1) ischemic which is called by a thrombosis or embolism 2) hemorrhage which is a direct result of a vessel wall rupture and bleeding into the brain. the signs, symptoms and tests done on our patent points to an ischemic stroke to the left side of the brain. the thrombus that caused the stroke could either be caused over time or as a result of an embolus formed in another part of the body which made its way to the brain which in turn hinders blood circulation to critical areas of the brain resulting in symptoms such as headache, slurred speech, weakness on one side of the body, drowsiness and confusion all of which the patient experienced. the doctor will order several diagnostic tests to pin point the location of the clot as well as medications to help break down the clot and restore blood flow to the area of the brain affected. the nurse should evaluate the patents vital signs, administer oxygen as ordered, evaluate pupils, document vision, test gag reflex, and administer medications as ordered. the nurse should also try to make the patient's environment as comfortable and safe as possible to reduce the risk of further injury due to confusion, anxiety and physical weakness the patient experiences. this patient will be receiving the following medications as ordered by the doctor, anti-platelet agents such as clopidogrel (plavix) or if not already on an aspirin regime he will order 81 mg of aspirin. the doctor will order the following tests, ct scan, mri, pet scan and an x-ray of the brain. the following diagnostic tests that are pertinent to this patient include cbc and platelet counts.

nursing diagnosis for our patient- we have to come up with 10

ineffective cerebral tissue perfusion related to interruption of blood flow as evidenced by changes in motor and sensory responses.

impaired physical mobility related to left side weakness as evidenced by decreased muscle strength

impaired verbal communication related to neuromuscular impairment as evidenced by patient not able to speak

disturbed sensory perception related to altered sensory reception as evidenced by altered vision and perceptual field

self care deficit related to loss of muscle coordination as evidenced by impaired ability to perform adl's

ineffective coping related to cognitive perceptual changes as evidenced by inability to meet basic needs and role expectations

risk for aspiration related to impaired/decreased gag reflex

risk for injury related to muscle and weakness

knowledge deficit related to misinformation as evidenced by patient statements

impaired social interaction related to limited communication as evidenced by slurred speech

anxiety related to change in health status as evidenced by inability to meet role expectations

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Specializes in med/surg, telemetry, IV therapy, mgmt.

has the patient's hypertension been resolved? it usually isn't after a stroke. after a stroke it is still present and needs to be addressed. the hypertension, obesity and atherosclerosis are still present. you have medication treating the hypertension. what about the obesity and atherosclerosis? even if the doctor isn't treating them, what can the nurse do? what about the smoking? i saw the deficient knowledge diagnosis that had no subject and wondered what you had planned for it. read the information on the "life after stroke" page of the national stoke association that i gave you a link to below. it gives you a lot of info that should help you with your diagnoses and interventions for your presentation.

your nursing diagnoses required corrections, reshuffling of the way they were prioritized and i added two more based on assessment information that you did not include in diagnosing. where possible, i've included weblinks to nursing diagnoses pages with information on the nanda taxonomy, outcomes and some suggestions for interventions:

  1. ineffective cerebral tissue perfusion related to interruption of blood flow as evidenced by confusion and drowsiness, decreased sensation and weakness on left side of body

[*]constipation r/t diuretics and decreased motility of gi track aeb "mild constipation"

[*]impaired physical mobility related to neuromuscular impairment and decreased muscle strength as evidenced by [need evidence to support this]

[*]"bathing/hygiene, dressing/grooming, feeding, toileting" self care deficit related to neuromuscular impairment as evidenced by impaired ability to perform adl's [should list specific inabilities in performing adls]

[*]unilateral neglect r/t left hemiplegia from cva of the right hemisphere aeb favors right side of body and continuously looks to right side even when noises and movement occur to left side of patient, does not notice presence of others standing to left side

[*]impaired verbal communication related to neuromuscular impairment as evidenced by ability to understand what others say but cannot speak

[*]disturbed visual sensory perception related to altered sensory reception as evidenced by altered vision and perceptual field [what kind of a symptom is "altered vision and perceptual field"?]

[*]anxiety related to change in health status as evidenced by restlessness, intention tremor of left hand, and inability to focus attention

[*]ineffective coping related to situational crisis and uncertainty as evidenced by change in usual communication patterns and inability to meet role expectations

[*]knowledge deficit [of what? a specific subject must be identified] related to misinformation [misinformation means the patient was given false information that must now be corrected; is that what you really mean to say?] as evidenced by ???

[*]impaired social interaction related to communication barrier and limited physical mobility as evidenced by slurred speech, inability to communicate ideas and unsuccessful interactive behavior with others

[*]risk for aspiration related to impaired/decreased gag reflex

[*]risk for falls related to muscle and weakness

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