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ASSESSMENT AND PLANNING GUIDE FOR USE IN THE HOSPITAL

The following information should be included daily as it applies to your patient.

Demographic Data Date of Admission Vital Signs

39 y/o African American male 10/28/18 BP: 115/60. Pain: 2

P: 91

T: 98.2.

RR: 22

SP02: 95

Significant Past Medical History Allergies/Reactions

HTN, Hyperlipemia, Diabetes NKA

Reason for Hospitalization and Current Diagnosis

Current Diagnosis: Acute Embolic Stroke, Cerebral Edema, R Hemiparesis, Pneumonia

Reason for hospitalization: 38 y/o male with a history of HTN presented with onset Right Sided Weakness and confusion at 11pm on 10-27-18 when he went to sleep. He woke up at 3am and he was talking gibberish to his fiancé. He went back to sleep and 2 hours later his symptoms had worsened. On 10-28-18, EMS was called by his fiancé and he was taken to the ER. His fiancé said he had taken “something” possibly cocaine. Patient was diagnosed with Acute Embolic Stroke, Cerebral Edema, R Hemiparesis and recently Pnuemonia.

Describe the pathophysiology including signs, symptoms and incidence; and compare with patient findings:

· Acute Embolic Stroke:

Pathophysiology: Occurs when a blood clot that forms somewhere elsewhere in the body breaks loose and then travels to the brain through the bloodstream. The clot can lodge in an artery and blocks the flow of blood.

Common symptoms: Difficulty speaking or understanding words, numbness and tingling, temporary paralysis, blurred vision or blindness, slurred speech, dizziness, feeling faint, difficulty swallowing, nausea, sleepiness. Embolic stroke doesn’t cause any unique symptoms

Muscular symptoms: Difficulty with coordination, stiff muscles, feelings of weakness on one side or all of the body.

Cognitive symptoms : Mental confusion, an altered level of consciousness, visual agnosia

Patient Findings: Patient presented with R hemiparesis, facial drooping, slurred speech, difficulty swallowing.

· Cerebral Edema

Pathophysiology: It’s a life threatening condition that causes fluid to develop in the brain. 

This fluid increases the pressure inside of the skull causing intracranial pressure (ICP). Increased ICP can reduce brain blood flow and decrease the oxygen your brain receives. The brain needs an uninterrupted flow of oxygen to function properly. 

Symptoms: Headache, dizziness, nausea, lack of coordination, numbness, mood changes, memory loss, difficulty speaking, incontinence, change in consciousness, seizures, weakness in extremities

Patient Findings: Patient presented with difficulty speaking, incontinence, change in consciousness, weakness in extremities

· Hemiparesis

Pathophysiology: Hemiparesis is weakness on one side of the body. One side can still move but with reduced muscular strength.

Symptoms: Difficulty walking, standing, and maintaining your balance. You may also have numbness or tingling on your weaker side.

Patient findings: Patient has right sided weakness.

· Pneumonia

Pathophysiology: Any infectious organisms that reach the alveoli. Consequently, they may overwhelm the macrophages, resulting in production of a fibrin-rich exudate that fills the infected alveolar spaces. This causes them to stick together causing difficulty of oxygen to filter through. The inflammatory response also results in a proliferation of neutrophils. This can damage lung tissue, leading to fibrosis and pulmonary edema, which also impairs lung expansion.

Symptoms: Chest pain when breathing or coughing, confusion, productive cough, fatigue, fever, sweating, chills, hypothermia, nausea, vomiting, diarrhea, shortness of breath

Medication

Drug/Dose Classification/Action Purpose for use in this patient

1. Acetylsteine 10% Inhalation 2ml Q4H	Mucolytic	Loosen mucus in lungs from pneumonia
2. Albuterol Inhalation 3ml Q4H	Bronchodilators	Open airways and relax muscles
3. Sodium Chloride 3% 3mlQ4H	Mineral	Maintain fluid levels
4. Heparin 5,000 U/ml SubQ Injection Q8H	Anticoagulants	Prevent the blood from clotting to prevent recurrent stroke
5. Metronidazole 500mg Q8H	Antibiotic	Used to treat Pneumonia
6. Atorvastatin 80mg at bedtime	statin	Lowers lipid levels
7. Docusate Sodium 100mg/10ml Q12H	Laxative	Prevent straining or constipation with stools
8. Senna 8.8mg/5ml Q12H	Stimulant laxatives	Prevent straining or constipation with stools
9. Insulin 10 U/ Sliding Scale PRN	Hormone	Regulates blood sugar levels

Intake/Output

Diet________ Enteral Feeding__PEG_ Drainage/Tubes___ _____

Intake: 1440

Output: 1350

Procedures/Surgery: (Describe).

1. Chest Xray 10/29/18: To diagnosis pneumonia

2. CT Head w/o contrast10/28/18: A CT of the brain is a noninvasive diagnostic imaging procedure that uses special X-rays measurements to produce horizontal, or axial, images (often called slices) of the brain. 

3. Transesophageal echocardiogram: is provides images of the internal structures of the heart and its blood vessels using the same ultrasound technology.

4. EKG Tracing11/4/18:  It indicates that the atria are contracting, pumping blood into the ventricles. The QRS complex, normally beginning with a downward deflection, Q; a larger upwards deflection, a peak (R); and then a downwards S wave.

5. Craniotomy11/7/18: surgical removal of part of the bone from the skull to expose the brain

6. Cerebral Angiography 11/4/18: an image that can help find blockages or other abnormalities in the blood vessels of your head and neck.

7. A transthoracic echocardiogram (TTE)11/4/18: is a procedure used to check for problems with the heart. It will also show any problems in the blood vessels near your heart. Sound waves are sent through a handheld device placed on the chest.

Oxygen Therapy Ventilator Setting :(if applicable)

Other Equipment/Lines applicable ( eg PA catheters, A-lines, etc)

Oxygen Therapy Mode: Trach Collar

02 Flow Rate: 5

FIO2: 28

SPO2: 95

RR: 22

Diagnostic Studies/Lab Data

(Identify abnormalities and describe their significance in the patient).

Lab	Value	Normal Range	Significance
1. RBC	3.43 L	4.7-6.1	Anemia
2. HGB	9.2 L	14-18	Anemia
3. HCT	28 L	42-54	Anemia
4. MCH	26.8 L	27-31	Anemia
5. RDW	16.5 H	11.5-14.5	Anemia, B12 deficiency
6. MCV	7.2 L	7.4-10.4	Anemia
7. Platelet	498 H	133-450	Thrombocythemia, Anemia
8. Lymphocyte	11.3L	20-40	Infection
9. Albumin	2.4 L	3.5-5.5	Stroke
10. HDL	39L	40-50	Hyperlipidemia
11. LDL	150 H	70-130	Hyperlipidemia

Treatments

(Provide rational for use)

· PT/OT: Improve movement and swallowing abilities

· NPO until Speech Therapy clears patient: Impaired swallowing

· Aggressive BP control to decrease ICP pressure

· Trach: decrease stress of breathing and decrease aspiration

· Statins to decrease lipid levels

· Anticoagulant to decrease blood clotting, however be cautious for hemorrhage

Response to Illness and Hospitalization

Patient is unable to verbalize response to illness

Physical Assessment findings (ROS)

General appearance:

Patient was laying in bed with legs bent. He had on his hospital gown. No visual distress. Not able to ambulate. Clean appearance

Neuro:

Disoriented x3, GSC 14, flat affect, unequal extremity movement, pupil react to light, opens eyes spontaneously,

HEENT:

Head: L head scar, macrocephaly

Ears: Hearing intact, symmetrical

Nose: No external lesions

Mouth: slight drooping

Teeth: No obvious caries or periodontal disease. No gingival inflammation or significant resorption.

Resp:

Trach collar in place. Crackles assessed in lung fields. Cough present.

Cardio:

No murmur or gallop assessed. No cardiomegaly or thrills present. Normal rate and rhythm

GI:

Incontinent, rounded abdomen. Bowel sounds heard in all 4 quadrants, PEG TUBE

GU:

Abdomen rounded and distended, incontinent

Musculoskeletal:

Right sided weakness. Unable to asses gait. Decreased ROM, abnormal strength and tone on right side of body.

Integumentary:

Skin is of normal racial tone which is consistent with ethnicity. It is dry and smooth. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. He does not have any edema. He has scar on left side of head

Psychiatric

Client does not show any signs of depression or self harm

Discharge Plans

Left carotid terminus dissection

Asprin and statins- Pt will need repeat vessel imaging 6-8 weeks

Goal Systolic BP 110-150

Tolerate trach cholar

Patient will require around the clock care. Referral to a social worker for support options.

Teaching and Health Promotion Needs

Teaching fiancé about Craniotomy procedure

Nursing Diagnoses

(List top 5 in order of priority)

1. Ineffective Cerebral Tissue Perfusion related to blockage of arteries AMB changes in verbal responses, slurred speech, right sided weakness and facial drooping.

2. Ineffective airway clearance related to presence of artificial airway AMB crackles in lower lung fields, productive cough and respiratory rate of 22

3. Impaired Physical Mobility related to right sided weakness AMB difficulty in moving right side of body, limited range of motion and decrease muscle strength.

4. Impaired swallowing related to artificial airway

5. Impaired verbal communication related to right sided weakness AMB patients inability to speak, inability to produce written communication and unable to identify objects.

Nursing Care Plan

(Formulate nursing care plan on 3 of nursing problems (diagnoses) listed, Use 3 nursing care plan forms)

1. Ineffective Cerebral Tissue Perfusion related to blockage of arteries AMB changes in verbal responses, slurred speech, right sided weakness and facial drooping.

2. Ineffective airway clearance related to presence of artificial airway AMB crackles in lower lung fields, cough and respiratory rate of 22

3. Impaired Physical Mobility related to right sided weakness AMB difficulty in moving right side of body, limited range of motion and decrease muscle strength.