Concept Map #2

Cultural considerations, ethnicity, occupation, religion, family support, insurance. Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns, to include the following Social Determinants of Health

*Patient is retired and not employed

*Patient is married and lives with spouse

*patient has received prior health advise and has knowledge on health *Patient is American * Patients preferred language is English.

History of Present Illness (HPI)

The 63year old patient was admitted to Holy Cross Hospital on 22nd

September 2020. The patient has a BMI of 25.2; height of 188.88cm and

weight of 84.37 kg. He had presented with as new onset of right facial

weakness and numbness consistent with stroke. He was checked for

stroke but it was ruled out. Further evaluation of the patient by Dr.

Azaret, a neurologist revealed that he was suffering from lateral

medullary syndrome. He was found to have onset atrial fibrillation on

EKG. He also was found to have an elevated hemoglobin A1c of 6.1

Patient on IRU developed rapid atrial fibrillation accompanied by

significant hypotension.

“Lateral medullary syndrome (LMS), also called Wallenberg syndrome

or posterior inferior cerebellar artery syndrome results from a vascular

event in the lateral part of the medulla oblongata. Lateral medullary syndrome characteristically has varied neurologic manifestations. The

damage is to the inferior cerebellar peduncle and dorsolateral medulla,

descending spinal tract, the nucleus of the trigeminal nerve, nuclei, and

fibers of the vagus nerves and glossopharyngeal, descending sympathetic

tract fibers, spinothalamic tract, and vestibular nuclei.” (Saleem, 2020)

Medical History

Patient has been on medication and medication were reviewed for

contraindication and none were found. Patient has no known allergies.

His family has a history of heart diseases with his father’s heart disease

on set being 60 years and older and his grandfather’s heart disease on set

being between 50 and 60 years old.

Individuals with a family medical history of heart diseases are prone to

heart diseases (Raič, 2017).

Surgical History

Patient has had right hand surgery and an ACL repair of the lower

extremity.

Social History

Patient denies participating in recreational drug use, smoking and alcohol

consumption. Patient has a supportive spouse.

Continuous abuse of drugs and alcohol can contribute to neurological

damage. Patient should be evaluated on lifestyle to ascertain whether it is

responsible for neurological damage (Unsworth & Mathias, 2017).

Chief Complaint

Numbness and weakness on right facial side.

Admitting Diagnosis

Lateral medullary syndrome and significant

four-vessel coronary artery disease

Patient Information (1)

Name: M.S

Age:63

Gender: Male

Code Status: Full code

DPOA: NA

Living Will: Yes

Patient Education (In Pt.) & Discharge Planning (home needs)

• The patient must continue follow up with primary care physician

• Encourage patient to get adequate rest

• Medications to be issued (not lifelong)

• Patient to drink a lot of fluid to prevent electrolyte imbalance

• Home blood pressure monitoring.

• Patient demonstrated understanding of the discharged

• planning explaining back the appropriate diet to follow and

• the lifestyle change he has to make.

• Instruct patient in energy-conserving and energy-efficient behaviors. (American Heart Association, 2019)

Concept Map #1

Student Name: Adidley Garcia

Instructor: Yader Perez

Diagnostic Test/ Lab Results with dates

and Normal Ranges

Test Norms Date

Current

Value

CT scan No

abnormali

ties

identified

10/11/

2020

Left

cerebell

ar

infarct

Hemoglo

bin level

test

13.8 to

17.2

grams per

deciliter

22/09/

2020

6.5

RBC 4-6

million

10/29/

2020

3.67

Hbg 13.5-17.5

(Men)

10/29/

2020

10.3

WBC 5,000-

10,000

10/29/

2020

5.4

Neutrophi

ls %

1,500-

8,000

(1.5-8.0)

10/29/

2020

70.7

Erickson’s Developmental Stage

The patient is 63 years old and fits the integrity vs. despair

stage.

The integrity vs despair stage consists of people who are above

60 years old and they either struggle with regrets or

accomplishments (Gross, 2020). If the patient is accomplished

then he will not have any regrets, however if he is not, he will

have many regrets and this can influence his recovery.

Interventions # 1

• Assess extent of impairment

initially and on a regular basis.

Classify according to 0–4 scale.

• Inspect skin regularly, particularly

over bony prominences. Gently

massage any reddened areas and

provide aids such as sheepskin pads

as necessary.

• Change positions at least every 2 hr

(supine, side lying) and possibly

more often if placed on affected

side

Priority nursing diagnosis #1

Impaired Physical mobility relate

to Neuromuscular involvement:

weakness, paresthesia as

evidenced by impaired

coordination

Vital Signs (4)

Temp:36.6 R: 75 P:  SpO2: 98 at Room Air

Neurological (5)

The patient was awake, alert, and oriented to

person, place and time. There were noted mild right facial weakness,

involuntary movement, gait ataxia

Respiratory (7)

Lung sounds were

diminished at bases

bilaterally. No ralles,

rhonchi or wheezes

were noted.

Priority nursing diagnosis #2

Disturbed Sensory Perception

relate to neurological trauma or

deficit as evidenced by Altered

communication patterns

Outcome/Goal #2

Patient will regain/maintain

usual level of consciousness and

perceptual functioning by the

end of the shift

Outcome/Goal #1

Patient will maintain/increase

strength and function of

affected or compensatory body

part as evidenced by gait by

discharge

Interventions # 2

• Observe behavioral responses:

crying, inappropriate affect,

agitation, hostility, agitation,

hallucination.

• Speak in calm, comforting, quiet voice, using short sentences.

Maintain eye contact.

• Ascertain patient’s perceptions. Reorient patient frequently to

environment, staff, procedures.

Assessment/ Evaluation #1

• Strengths and deficiencies of patient was identified

• Pressure points over bony prominences was inspected and massage as needed

• Position changed every 2 hr.

• Goal was met.

Assessment/ Evaluation #2

• Behavioral response was observed during the chief • Slow tone of the voice and calm speaking was used • Eye contact was maintained • Patient was reoriented frequently • Goal was met

PC Interventions

• Assess type and degree of hemisphere injury the patient exhibits.

• Remind patients who have a dominant (left) hemisphere injury to scan their environment

• Give short, simple messages or questions and step- by-step directions

• Assist patients with eating. Monitor the environment for safety hazards, and remove unsafe objects such as scissors from the bedside

PC Evaluation Plan

• Patient injury was prevented during the shift

• Simple and question and message was given to the patient

• Patient was assisted with eating.

• Goal was met

PC Outcomes/Goal

Patient will interact appropriately

with his or her environment and does

not exhibit evidence of injury caused

by sensory/perceptual deficit.

Potential Complications/ at

risk for

Patient at risk of injury related

to Altered sensory reception

Nutrition/Hydration

(8)

Well-nourished and

well developed.

Rest/ Exercise (11)

Patient is not able to ambulate on his own.

GI (9)

Negative for Abdominal pain, Constipation, Diarrhea, Jaundice, Nausea and Vomiting. Soft no tender or distention

GU (10)

Negative for Dysuria, Hematuria and

Polyuria (Genitourinary). No suprapubic or CVA

tenderness.

Misc. (Ht/Wt)

84.37 kg WT

182 cm Ht

Endocrine (13)

Negative for Cold intolerance, Heat

intolerance, Polydipsia and

Polyphagia.

Cardiovascular (6)

Revealed: normal S1 and S2. The rhythm was regular, and no murmurs, rubs, clicks, or gallops.

Psychosocial (14)

Negative for Anxiety

and Depression.

Appropriate mood and

affected, normal

through process

Integumentary (12)

Skin is dry, warm and intact. No rash and no

cellulitis lesion

Medical Management/

Name Dose RT Freq. MOA RN Considerations Side effects and Adverse effects

Enoxaparin

(LEVENOX)

Patient lack of

mobility while in

hospital,

medication use to

prevent clots.

40 mg sub

Q

Q24

Hr

“Enoxaparin is

used to prevent

and treat harmful

blood clots. This

helps to reduce the

risk of a stroke or

heart attack. This

medication helps

keep your blood

flowing smoothly

by lowering the

activity of clotting

proteins in the

blood. Enoxaparin

is an

anticoagulant, also

known as a "blood

thinner." It is a

type of heparin”.

(WedMD,2020)

Monitor for allergic and low

platelet

Monitor for any sign of bleeding.

“Mild irritation, pain, bruising, redness, and swelling at the injection site may occur. Fatigue

or fever may also occur. If any of these effects persist or worsen, tell your doctor or

pharmacist promptly”. (WedMD,2020)

Oxycodone/

acetaminophen

1

tablet

Oral One

tab

Q6Hr

Used to relieve

pain severe

enough to require

opioid treatment

and when other

pain medicines did

not work well

enough or cannot

be tolerated

-When oxycodone is used for a

long time, it may become habit-

forming, causing mental or

physical dependence.

-Physical dependence may lead to

withdrawal side effects if

treatment is stopped suddenly.

However, severe withdrawal side

effects can usually be prevented

by gradually reducing the dose

over a period of time before

treatment is stopped completely.

-Using narcotics for a long time

can cause severe constipation

Side Effects: Black, tarry stools, chills dark urine, dizziness, fever, headache, itching, skin rash

Adverse effect:

Nausea, vomiting, constipation, lightheadedness, dizziness, or drowsiness may occur. Some of

these side effects may decrease after you have been using this medication for a while. If any of

these effects persist or worsen, tell your doctor or pharmacist promptly

( Mayo Clinic, 2020)

Cyclobenzaprine 10 mg Oral HS Muscle relaxant. It

works by blocking

nerve impulses (or

pain sensations)

that are sent to

your brain.

-Do not use cyclobenzaprine if

patient is taken an MAO

inhibitor in the past 14 days. A

dangerous drug interaction could

occur. MAO inhibitors include

isocarboxazid, linezolid,

phenelzine, rasagiline, selegiline,

and tranylcypromine.

-Signs of an allergic reaction to cyclobenzaprine: hives; difficult breathing; swelling of your

face, lips, tongue, or throat.

Other side effects are: fast or irregular heartbeats; chest pain or pressure, pain spreading to

your jaw or shoulder; or sudden numbness or weakness (especially on one side of the body),

slurred speech, balance problems.

References

Gross, Y. (2020). Erikson's Stages of Psychosocial Development. The Wiley Encyclopedia of Personality and Individual Differences:

Models and Theories, 179-184.

Oxycodone And Acetaminophen (Oral Route) Description and Brand Names. (2020, October 01). Retrieved November 24, 2020,

from https://www.mayoclinic.org/drugs-supplements/oxycodone-and-acetaminophen-oral-route/description/drg-20074000

Raič, M. (2017). Depression and heart diseases: Leading health problems. Psychiatr Danub, 29(Suppl 4), 770-7.

Saleem, F. (2020, October 13). Lateral Medullary Syndrome. Retrieved November 24, 2020, from

https://www.ncbi.nlm.nih.gov/books/NBK551670/

Unsworth, D. J., & Mathias, J. L. (2017). Traumatic brain injury and alcohol/substance abuse: a Bayesian meta-analysis comparing the

outcomes of people with and without a history of abuse. Journal of clinical and experimental neuropsychology, 39(6), 547-

562.

Vera, M., By, -, Vera, M., & Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently

working as a full-time writer and editor for Nurseslabs. During his time as a student. (2020, February 18). 12 Stroke (CVA)

Nursing Diagnosis and Nursing Care Plans. Retrieved November 24, 2020, from https://nurseslabs.com/8-cerebrovascular-

accident-stroke-nursing-care-plans/2/