PMHx: previous CVA; Dyslipidemia; HTN; COPD; OA; cancer

(laryngeal squamous cell carcinoma); PUD

FH: cancer (unspecified); hypertension (unspecified);
Lifestyle: cigarette smoker (unspecified pack/years); no EtOH use;
Dyslipidemia (hypercholesterolemia)
no drug use; no known allergies
Hypertension Dyslipidemia (specifically
hypercholesterolemia) can cause plaque
deposits in vessel walls. This causes a
HTN is one of the biggest risk factors for narrowing of the lumen and can impede
stoke. Continual elevated BP can cause adequate blood flow to cerebral tissue.
vessel stenosis. This decreases the
amount of adequate perfusion to the
tissue. Medications for this
Medications for this condition (name,
condition (name, route,
route, dose, action) dose, action)
No medications indicated for HTN No medications indicated
specifically for dysilipidemia
Lovenox: 40mg; Subcutaneous; accelerate formation of A. S. 64yo male
anti-thrombin III-thrombin complex; prophylactic use to
prevent DVT
specifically
ASA: 325mg; Oral: inhibit prostaglandin and interfere
with clotting
Plavix: 75mg; Oral: impede platelet aggregation
Left-sided ischemic
Stroke

Pertinent Physical Examination findings: Medications for this condition (name, route, dose,
- A & O x 4; mild transient confusion; no cranial nerve deficits noted; calm, cooperativce
action)
- No Foley; urine clear, yellow/amber; no odor
- 20G left AC; saline lock; patent; no S&Sx of infection, infiltration; clean, dry, & intact Lovenox: 40mg; Subcutaneous; accelerate
- 20G right AC; saline lock; patent; no S & Sx of infection, infiltration; clean, dry, intact Pathograph of this condition formation of anti-thrombin III-thrombin complex;
- NSR; HR 66; RR12; 92% Ox on room air; BP 132/76; prophylactic use to prevent DVT
- No complaints of pain (with pg# from Lewis): An ischemic stroke is the Protonix: 40mg; Oral: PPI for prevention of ulcers
- Last BM undocumented; patient doesnt remember when last BM occurred
- Abdomen firm, non-tender, slightly distended; normo-active bowel sounds result of inadequate blood flow to the cerebral ASA: 325mg; Oral: inhibit prostaglandin and
interfere with clotting
- Generalized weakness in all extremities; purposeful movement in all extremities
- Radial and dorsalis pedis pulses 2+ bilaterally; capillary refill <2 seconds in all extremities bilaterally tissue as a result of partial or complete artery Plavix: 75mg; Oral: impede platelet aggregation
- Mildly productive cough; scant amounts of semi-thick white/clear secretions Metoclopramide: 5mg; Oral; stimulate upper GI
- Ambulation with one-person assistance; well tolerated; occlusion. These strokes can be further identified as tract motility and blocks dopamine at
- Bed alarm in place and on; wheels locked
thrombotic or embolic. Hypertension is the leading chemoreceptor trigger zone
risk factor.
(Lewis, 2014, 1388-1391)
Lewis, S., Bucher, L., Dirksen, S., Harding, M. and Heitkemper, M.
Priority Nursing Diagnosis (3 parts): Impaired cerebral perfusion (2014). Stroke, In Mosby(Eds.), Medical-Surgical Nursing:
related to ischemic stroke as evidence by changes in motor response, Assessment and Management of Clinical Problems (pp 1388-
speech abnormalities, and dysphagia. 1411). St. Louis, MO Psychosocial / Spiritual
Measurable outcome w/ timeframe: Patient maintains optimal Elsevier, Inc.
perfusion as evidence by Glasgow coma scale greater than 13, issues and discharge needs
absence of new neurological deficits, and stable BP by 1400 on 4/19.
Nursing interventions you used with rationales: Residual cognitive deficits after stroke; coping with appearance (ex: facial droop) after stroke;
1) Administer anticoagulants and antiplatelet drugs Given to coping with loss of independence (even if not forever, still can be a hard loss); advance directive;
reduce clot formation and prevent extension of existing clots. Anticipated patient teaching required: encourage family interaction and aid; encourage independence in safe manner (ex: help with
2) Monitor vital signs as needed frequent assessment is essential. diet/exercise to decrease HTN; stroke ambulating); social needs (ex: help with insurance0; encourage community outreach with church,
other groups
Normotensive state desired to promote effective cerebral perfusion. disease process; medications (uses &
3) Raise head of bed no higher than 30 degrees Current evidence side effects); safety concerns; rehab
suggests that elevating head of the bed reduces ICP by increasing post stroke;
cerebral venous outflow. This position may also reduce verebral Recent laboratory/diagnostic tests results
perfusion and contribute to increased risk for cerebral infarction. with significance (i.e. why are they
Evaluation: Patient met desired outcomes by 1400 on 4/19.
Gulanick, Meg & Myers, Judith (2014). Stroke (Eds.), Nursing Care Plans: Diagnosis, high/low?)
Interventions, and Outcomes (pp. 564-566). Philadelphia,PA: Elsevier, Inc.
Glucose: 114 high; increased due to
increased stress response
Negative Toxicology no external forces
cause current neurological symptoms
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