Nursing discharge project ischemic stroke power point due 3/02/21
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dischargeproject.pptxN432 DISCHARGE Cerebral vascular accident (CVA) Clinical Instructor:
Student:
Component 1: Objectives, Clinical Picture.
SITUATION
Diagnosis: Ischemic stroke. Cerebral vascular accident (CVA)
Demographic data: 80-year-old female. Admitted post cardiogenic embolic stroke resulting in contralateral paralysis of the arm, leg, and face.
HISTORY
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Pertinent History: Hypertension, peripheral vascular disease, type 2 diabetes, hyperlipidemia, Kidney injury.
Family History: Father & Sister- Hypertension. Mother- Diabetes.
Lifestyle Practices: Smoking: 3 pack per day smoker. Alcohol Use: 1 12 oz bear per day.
ASSESSMENT
Vital Signs: Temp – 98-degree Fahrenheit, pulse -90, MAP -97 mmHg, BP – 160/75, Resp. 18, O2: 97 % on 2L nasal cannula.
Neuro: Orientation: X4, Sensation: Numbness & weakness to the left leg. Neglect syndrome to left side. Paresthesia. Ataxia. Dysphagia
Cardio/Vasc: Left Anterior Descending Artery Stenosis. ST elevation. Normal S1, S2, no murmurs.
Raspatory: Diminished bilateral breath sounds at the base of the lungs.
Gastrointestinal : Dysphagia, constipation.
Genitourinary: Urinary incontinence.
Musculoskeletal: weakness to the left leg. Hemiplegia. Poor DTR.
I/O: Intake= 2532 mL, Output= 1587 mL.
Foley: Urinary catheter.
IV’s: 0.9% NaCl.
REQUIREMENTS
Isolation: N/A
Fall Risk: Active
Restraints: N/A
Other: Seizure precaution with Na+ = <135 mEq/L
EVALUATE
Tests: ECG, Echocardiogram, Clotting times, Stress test
Labs: BMP, CBC, Lipid panel, BNP test
Other: Hemodynamic monitoring (PAWP, CVP, CO, PAP
Component 1: Concept Map
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| Category 1 | Category 2 | Category 3 | Category 4 | |
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| Item 2 | 3.2 | 5.1 | 4.4 | 3 |
| Item 3 | 2.1 | 1.7 | 2.5 | 2.8 |
| Item 4 | 4.5 | 2.2 | 1.7 | 7 |
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