Relevant data from personal problems:

Sudden osnet of Right side weakness, right side facial droop, difficulty speaking
These are neuro changes that may reflect a CVA. In absent of a trauma, can be
due to cerebral ischemia or emboli or bleeding. All s/s on the right side indicate the
left side of the brain that was affected

Increased agitation and confusion during transport
Increase in s/s indicate worsening of dx process

Time spent in transport, took 30 minutes to get to ED
With neuro s/s it is important for rapid interventions to limit possible
damages

Relevant data from social history:
Nicotine patch use recently
May be causing some physiological changes such as increase in BP
Pain in right foot recently
Needs to be assessed
Unable to answer wifes questions, appears frustrated
He cant use words or speech to express himself= expressive aphasia
May indicate Brocas area in frontal lobe damage

Pharm classification:
1. NSAID
2. NSAID
3. ACE inhibitor
4. Antihyperlipidemic
5. Hypoglycemia/ insulin
6. Nicotine replacement

Expected outcomes:
1. reduce inflammation
2. prevent thrombus formation, reduce risk of CV disease r/t clots
3. decrease BP
4. increased good HDL cholesterol and lower LDL
5. prevent hyperglycemia
6. continue not smoking cigarettes
PMH that started first:
DM type 2 that has been poorly controlled
Risk factor for clots, CV disease. Poor control may have lead to the need to
manage high triglycerides and cholesterol
Arthritis

PMH that followed:
Smoking
Increases complications of DM, CV and vascular changes
Hyperlipidemia
Can lead to atherosclerosis, causing plaque buildup in arteries leading to
obstruction in flow and CVA/stroke, risk for plaque break off into emboli, CV dx
HTN
Can be caused by atherosclerosis and narrowed arteries, smoking

Relevant VS data:
Pulse 118 bpm and irregular
Tachycardic and irregular pulse can lead to stroke (embolism stroke)
198/94 BP
elevated BP occurs after stroke or CVA. Persistent HTN can decrease cerebral
blood flow and perfusion to brain
99% O2 sat
adequate oxygenation yet pt is still agitated = not due to hypoxia, possibly
more neuro issue

relevant assessment data:
anxious
contributes to elevated BP.
Irregular heart sounds
May have preceded stroke event. Assess irregularity to prevent further
events/complications from occurring

Confusion, agitation, anxious and restless, difficulty speaking, facial droop.
Neuro abnormalities. Right sided manifestations of left cerebral damage

Telemetry strip interpretation: A-fib with rapid ventricular response (>100 bpm)
Significance: a-fib increases risk for strokes/embolic strokes (blood clot break and
travel to brain)

Clinical reasoning:
1. acute stroke/CVA in left hemisphere.
2. A-fib increases risk for clot formation r/t atrial quivering and incomplete
ejection fo blood. Clot within left ventricle can enter blood stream and be
sent through the aorta into the brain blocking blood flow causing cerebral
ischemia and stroke. A stroke due to an embolism is abrupt in onsent.
3. Ineffective tissue perfusion: cerebral r/t obstruction or decreased perusion
to brain tissue s/t embolism, stroke
Risk for falls
Nursing interventions:
1. send to radiology
determine extent/severity of damage
outcome: pt received radiology scan
2. neuro check q 15 minutes
assess changed in mental status
outcome: no change in mental status
3. BP q15 mintues
HTN can decrease cerebral perfusion and further complicate dx
Outcome: BP less than 140/90
4. place on cardiac monitor
assess for a-fib, ireegulairty, pulse rate that requires intervention
outcome: HR less than 100 bpm
5. maintain side rails up
pt confused, at risk for falls, maintain safety is priorty, risk for seizure
activity s/t stroke,
outcome: pt remains free of falls, injury or seizure

neurological system is highest priority

decreased perfusion to brain, HTN and tachycardia may lead to increased ICP and
seziures. Seizures along with increased confusion puts pt at risk for injury,
aspiration, etc

neuro assessments, CV, respiratory, LOC

medical mgmt. rationales:
1. IV access to regulate BP
a. IV is established, maintains patency
2. labetolol in BB to vasodilate and lower BP. Affects afterload
a. BP 140/90, systolic BP <160
3. Haldol decreases agitation and confusion without excessive sedation by
altering dopamine uptake in the brain
a. Decreased agitation, restlessness, confusion
4. CT scan to assess damage and confirm stroke
a. Identify damage and dx; determine trmt
5. cardiac monitoring to asses for a-fib and HR
a. HR <100 bpm
6. NPO to prevent aspiration in patients with facial paralysis, stroke event
causing limited swalloing ability, and decreased LOC
a. Pt will not aspirate
7. thrombolytic therapy to prevent embolism, dissolve present clots
a. pt doesnt not experience embolism, no bleeding or bruising
complications s/t to therapy

order of priortity:
1. CT diagnosis and determine trmt
2. IV- to administer medications, lower HTN to maintain cerebral perfusion
3. tPA IV medciation to limite brain tissue/neuronal damage
4. labetolol- lower BP
5. cardiac monitor-monitor to irregularities, a-fib
6. Haldol- agitation after vitals stable

MOA:
Labetolol: selective Beta 1 inhibition so cardiac dilation without
bronchoconstriction causing decrease in BP and HR
4mL/ 2minutes= 0.5mL Q 15 seconds
assessments: basleine HR and BP prior, hold if HR ,60, SBP <90, monitor for
hypotension, liver fxn, CV fxn tests

Haldol: reduces doampine ptake in brain and decrese neuron firing to
dompaminergic receptors causing mild sedative effects and relief of
manic/hyperctive symptoms
0.5mL/1 minute= 0.1mL q15 seconds
monitor for hypotension, changes in LOC, activity, may cause QT
prolongation, CV monitoring

relevant labs:
CBC. CBC ordered to assess patients overall serum compositions. Risk for infxn,
tissue perfusion, bleeding risk, risk for clots, etc
Trend: all WNL

Education:
1. discharge: DM control, glucose monitoring, dietary and activity modifications
to prevent furhter CVA due to atherosclerosis
BP control to maintain brain perfusion. Reduce salt, encourage fluids,
medication compliance, smoking cessation
2. quiz pt on food choices, demonstrate insulin administration, verbalize back
need for modifications, demonstrate how to self check BP