N301- Nursing Diagnosis and Medication Research

Student Name Linda Laine Shelton Dates of Client Care April 6, 2011 Date Submitted Wednesday, April 6, 2011
Client’s age 83 years old Gender Male Date of Hospital Admission April 1, 2011
Medical Diagnosis/Surgical Procedure: CVA, Aneurysm, Seizure
Medical History : A-Fib, Arthritis, CVA 2009, Dementia, ESRD, High Cholesterol, HTN, Hyperlipidemia, PVD, Hypothyroidism, Lipid Artroplasty,
Laminectomy, Triple Bypass, 80 TURP

1. Clinical Situation: This patient is an 82 year old male with a history of progressive chronic kidney disease stage 5, who has
reached a stage where he needs to initiate hemodialysis. Because of his advanced age and comorbidities, Dr, Satish Bankuru
elected to admit him for catheter placement and initial dialysis. He was admitted as a direct admit to the floor. The patient has
been nonambulatory since a stroke August 2009.

2. Assessment/Collection of Data.

Subjective Data Objective Data

ALLERGIES: PENCILLIN
Stated pain “5 out of 10” scale Diet: Cardiac
IV line/ Lock
Hemodialysis
Fall/Bed Alarm
Dialysis Fistula left arm ( thrill and bruie present)
Temperature 98.1 oral
Pulse 83
Respiration 16
Blood Pressure 111/53
5 out of 10 pain scale
3. Client Assessment:
“Client awake, alert, and oriented x 1, knows name but unaware of time, place and situation. Respirations even and
and unlabored. Temporal pulses + 2 bilaterally. Skin warm, dry, and skin intact. Eyes PERRLA. Both nostrils are patent and
free from discharge. Ears are clean and clear of drainage or cerumen. Mucous membranes are pink, and free from bleeding,
breaks in mucosal integrity, swelling, or drainage. Tone is moist and pink and free from fissures. Several theeth are missing.
Patient wears partial upper and lower dentures. Uvula is in the midline of the posterior throat. Tonsils are pink and free from
discharge, redness, or edema. Carotid pulses +2 bilaterally. Lymph nodes noted. Trachea is in midline. Patient has very limited
ROM in bilaterally upper and lower extremities. Left – sided weakness is evident. Brachial and radial pulses +2 bilaterally. Poor
grip noted in right hand. Very light grip noted in the left hand. Capillary refill under 5 seconds in fingers of both hands. Apical
pulse assessed and found both S1 and S2 present. Lungs clear. Abdomen is free from lesions or drainage. Patient is
incontinent. Femoral pulse +2 bilaterally. Popliteal pulses +2 bilaterally. Capillary refill in bilateral toes under 5 seconds.
Dorsalis pedis pulses and posterior tibial pulses +1 bilaterally.

Therapeutic Communication:
1. Met the patient, let him know my role as student nurse.
2. Acknowledged patient’s pain.
3. Specific and tentative – I consistently assessed vital signs and needs.
4. Asked personal preferences of the patient’s desire, meals, television, etc.
5. Non-verbal communication – kept eye contact, smiling.

4. Physiology of Disease Process.

CVA: Cerebrovascular accident is a sudden neurological incident related to impaired cerebral blood supply, which may be
caused by hemorrhage, embolism, or thrombosis, resulting in ischemia to the brain. A stroke in the dominant right hemisphere
typically causes dysphasia, dysarthria, a decreased awareness of the left-side of the body, left-sided paralysis, impaired
judgement, increased emotional lability, and deficits in handling new spatial judgment. (Gulanick, 2009, p. 552) The brain is very
sensitive to a loss of blood supply. The brain is perfused at the expense of other less vital organs to preserve cerebral
metabolism. If blood flow is not restored, brain tissue sustains irreversible damage or infarction within minutes. The extent of
the infarction depends on the location and size of the occluded artery and the adequacy of collateral circulation to the area it
supplies. (Black, 2009, p. 1846)
Aneurysm: As an aneurysm develops, it often forms a neck with a dome. The arterial internal elastic lamina disappears at the
base of the neck. The media thins, and connective tissues replace smooth muscle cells. At the site of the rupture, the wall thins,
 and the tear that allows bleeding is often no more than 0.5 mm long. It is not possible to predict which aneurysms are likely to
rupture, but limited data suggests that most ruptured aneurysms average 7 mm in diameter. (Black, 2009, p. 970)
Seizure: When the integrity of the neuronal cell membrane is altered, the cell begins firing with increased frequency and
amplitude. When the intensity of the discharges reach the threshold, the neuronal firing spreads to adjacent neurons ultimately
resulting in a seizure. (Black, 2009, p.575)

5. Medications

Medication/Dose/ Why Client is Mechanism of Side Effects Nursing Implications

Classification Action
Route/Frequency Receiving
Produces Anorexia, nausea, Monitor for
Analgesia by vomiting, hepatotoxicity
unknown hepatotoxicity
mechanism

Reduces fever by
Tylenol 650mg by mouth every 6
Analgesic; direct action on
hours PRN Pain
Antipyretic hypothalamus with
(Wilson, 2009, p. 9)
consequent
peripheral
vasodilatation,
sweating, and
dissipation of
heat.
By direct action on Muscle weakness, Monitor BP carefully.
smooth muscles, wasting numbness, Monitor heart rate and
decreases fatigue, abnornal gait, rhythm until drug
Amiodorone(Cordarone)/200mg/ peripheral bradycardia, response has
Antiarrhythmic,
daily/ oral Arrhythmia resistance and hypotension, sinus stabilized. Auscultate
Class III
(Wilson, 2009, p. 73) increases arrest, cardiogenic chest periodically or
coronary blood shock, CHF, when patient complains
flow. arrhythmias of respiratory
symptoms.
 Inhibits platelet Flu-like syndrome, Monitor for and
aggregation by fatigue, pain, back immediately report GI
selectively pain. Chest bleeding. Evaluate
preventing the pain.edema, patients with
Clopidogrel (Plavix) / 75 mg/ oral
binding of hypertension, unexpected fever.
daily Anticoagulant HX of CVA
adenosine dizziness,,rash,
(Wilson, 2009, p.364)
diphosphate to its headache.
platelet receptor. It
prolongs bleeding
time.

6. Priority Nursing Diagnosis.

Nursing Diagnosis : Impaired physical mobility related to CVA as evidenced by left-sided weakness.

Goal: The patient will maintain maximum level of function and risk of complications is reduced by the end of my shift.

Interventions Evidence for Practice Implementation Evaluation

Perform ROM exercises to joints,
unless contraindicated, at
least once every shift.
Progress from passive to
active as tolerated.
(Gulanick, 2007, p.559).
Turn and position patient every 2
hours.
(Gulanick, 2007, p. 561)
Place items within reach of the
unaffected right arm.
(Gulanick, 2007, p. 561)
Goal met.
The patient participated in limited passive
This prevents joint contractures and ROM exercises. Left side had
muscular atrophy. very limited range of passive
ROM exercises.
Goal met.
This prevents skin breakdown by The client was turned and positioned
relieving pressure. every 2 hours.
Goal met.
This promotes patient’s independence. Patient called nurse for needs.