TMMC

Name:
MOTT COMMUNITY COLLEGE

DIVISION OF HEALTH SCIENCES - NURSING PROGRAMS
CLIENT CARE CLINICAL FOCUS – NRSG 101
Client InitialsNURSING HOME Age 73 Gender FEMALE Room # 55B

Dates of Care
Admitting Diagnosis (es): Cardiovascular Accident (CVA), Alzheimer Disease, Multiple

coloissis
Past Medical History: Cerebrovascular Accident or stroke, Alzheimer’s Disease, Hypothyroidism,
Multiple scoliosis, Idiopathic Scoliosis, chronic neck pain, Hypotension , Dry Eye Syndrome,
Constipation, Mycotic toe nails ____
Allergies: Beef Fragrance, Novocain, penicillin, Synthroid, Wheat, Tetanus, immune-globulin,
procain.
________________________________________________________________________________________
NANDA Definition: Chronic confusion- An irreversible, long-standing and/or progressive
deterioration of intellect and personality characterized by decreased ability to interpret environmental
stimuli, decreased capacity for intellectual thought process and manifested by disturbances of memory,
orientation, and behavior.
NANDA Definition: Impaired Mobility- Limitation in independent, purposeful physical movement of the
body or of one or more extremities.
NANDA Definition: Chronic pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage (International Association for the Study of
Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated
or predictable end and a duration of greater than 6 months.
1. Define the client’s current medical diagnosis (es) and/or surgical

procedure (s).
` Cerebrovascular Accident or Stroke :(also called brain attack) results from sudden
interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than
24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood
vessel by cerebral thrombosis or embolism or hemorrhage (leakage of blood from a vessel causes
compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the dura
(extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within
the brain substance itself (intracerebral). Disruption of the blood supply to brain. Neuralgic Deficit
/opt/scribd/conversion/tmp/scratch3625/58313318.doc Page 1 of 11
middle cerebral artery (MCA) is most common affected. The second most frequently affected is the
internal carotid artery. Cerebrovascular accident may be caused by any of three mechanisms.
• Ceebral Thrombosis – blockage in the thrombus (clot) that has built up on the wall of the brain artery.
• Cerebral Embolism – blockage by an embolus (usually a clot) swept into the artery in the brain.
• Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface of the brain
Alzheimer’s Disease: is a progressive neurodegenerative

disorder that many experts believe first manifests clinically as mild
cognitive impairment (MCI).7,8 This subtle memory loss is
followed by progressive deterioration in executive function,
language skills, and ability to perform activities of daily living.
Psychiatric symptoms, such as depression, apathy, and emotional
lability, are common.9 Agitation, psychosis, wandering, physical
aggression, and other behavioral disturbances occurring later in the
course of Alzheimer’s disease are associated with significant
caregiver distress and often lead to institutionalization
Multiple Sclerosis Overview
Multiple sclerosis affects the brain and spinal cord. Early symptoms of multiple sclerosis include weakness, tingling,
numbness, and blurred vision. Other possible warning signs are muscle stiffness, thinking problems, and urinary
problems. A multiple sclerosis diagnosis is made by the history of symptoms and a neurological exam, often with the
help of tests such as an MRI or a spinal tap. Multiple sclerosis (MS) is a progressive disease that attacks the central
nervous system (CNS) and affects multiple systems of the body through attacks on the nervous system. MS affects individuals
of all races and socioeconomic groups and is seen all over the world. It is most common in white women of northern European
descent.
1. Based upon readings, list the signs and symptoms for a client with this medical
diagnosis (es) and/or post-operative observations for the surgical procedure (s). At
the end of the time you care for this client, highlight or star (*) the signs and
symptoms you have observed in this client.
Cerebrovascular Accident: Alzheimer’s Disease

Headache Inability to learn new mental task
Dizziness and confusion Loss of judgment, reason, and cognitive abilities
Slurred speech or loss of speech Aphasia (loss of ability in comprehension of language)
Difficulty of swallowing spoken or written.
Delusions
Loss of inhibitions and belligerence
Social withdrawal
Visual hallucinations
Apraxia (inability to perform physical tasks
such as dressing, eating)
Multiple Sclerosis
Weight changes
Verbal or coded report or observed evidence of protective behavior,
guarding behavior, facial mask, irritability, self-focusing, restlessness, depression
Atrophy of involved muscle group Changes in sleep pattern, Fatigue
Fear of rein-jury reduced interaction with people Altered ability to continue previous activities
Sympathetic mediated responses (e.g., temperature, cold, changes of body position,
hypersensitivity)Anorexia Related Factors: Chronic physical or psychosocial disability
Expected Outcomes Patient verbalizes acceptable level of pain relief and ability to engage in desired
activities.
Reference (s) of the above:

www.chestjournal.chestpubs.org/content/125/3/935
www1.us.elsevierhealth.com
www.webmd.com/multiple-sclerosis
• List the CBC, electrolytes, and one other laboratory test for your client.
Dat Lab Normal Client Reason for Test Nursing Interventions for abnormal
e Range Results results
(Include notification of health team
members.)
WBC
RBC
HGB
HCT
PLAT
Na
CO2
Cl
BUN
Cr
Glucos
e
PT
PTT
INR
• List any diagnostic tests ordered for your client (i.e. X-ray, MRI, or CT).
Date Test Client Results Reason for Test Preparation Pre- &
Post-
• Describe the anticipated nursing interventions and rationales to be used in the
care of a client with this medical diagnosis and/or surgical procedure (s).
Remember to include teaching and discharge planning, when appropriate. Include
care of invasive lines and treatments such as wound care.
Intervention Rationale (Scientific Explanation)
1, The prone position has been recommended to improve
1. Turn patient to prone or semiprone position once ventilation-perfusion relationships in the dorsal lung
daily unless contraindicated. segments.
2. Perform passive or active assistive ROM exercises to

all extremities. 2. Exercise promotes increased venous return, prevents
stiffness, and maintains muscle strength and endurance.
3. Use prophylactic antipressure devices as appropriate.

Immobility, which leads to pressure, shear, and 3. Advanced age; the normal loss of elasticity; inadequate
friction, is the factor most likely to put an individual nutrition; environmental moisture, especially from
at risk for altered skin integrity. incontinence; and vascular insufficiency potentiate the
effects of pressure and hasten the development of skin
breakdown.
4. An albumin level less than 2.5 g/dl is a grave sign,

4. Assess patient’s nutritional status, including weight, indicating severe protein depletion. Research has shown
weight loss, and serum albumin levels. that patients whose serum albumin is less than 2.5 g/dl
are at high risk for skin breakdown, all other factors
being equal.
5. Encourage patient and/or caregiver to maintain 5. Limit chair sitting to 2 hours at any one time.
functional body alignment. Pressure over sacrum may exceed 100 mm Hg
pressure during sitting. The pressure necessary to
close skin capillaries is around 32 mm Hg; any
pressure greater than 32 mm Hg results in skin
ischemia. * Encourage ambulation if patient is able.*
Increase tissue perfusion by massaging around
affected area. Massaging reddened area may damage
skin further.
6. Encourage adequate nutrition and hydration: 2000 to 6..Hydrated skin is less prone to breakdown. Patients
3000 kcal/day (more if increased metabolic with limited cardiovascular reserve may not be able to
demands). Fluid intake of 2000 ml/day unless tolerate this much fluid.
medically restricted.
7.The urea in urine turns into ammonia within minutes
and is caustic to the skin. Stool may contain enzymes that
7. Assess for fecal and/or urinary incontinence. cause skin breakdown. Use of diapers and incontinence
pads with plastic liners traps moisture and hastens
breakdown.
..
1. Evaluate responses on diagnostic examinations (e.g., Test ability to receive and send effective communications.
memory impairments, reality orientation, attention span, Ability and/or willingness to respond to verbal direction
calculations). and/or limits may vary with degree of reality orientation.
2. Provide calm environment, eliminate extraneous

2. Minimize sights and sounds that have a high potential for
noise/stimuli.
misinterpretation such as buzzers, alarms, and overhead
paging systems. Sensory overload can result in agitated
3. Talk with significant other(s) regarding baseline behaviors,
length of time since onset/progression of problem, their behavior in a client with dementia. Misinterpretation of the
perception of prognosis, and other pertinent information and environment can also contribute to agitation.
concerns for the patient.
3. Assessment can identify areas of physical care in which the

patient needs assistance. These areas include nutrition,
elimination, sleep, rest, exercise, bathing, grooming, and
4. Encourage participation in resocialization groups. dressing. It is important to distinguish ability and motivation
in the initiation, performance, and maintenance of self-care
activities. Patients may either have the ability and minimal
motivation, or motivation and minimal ability.
4. Avoidance of social situations denies the social phobic

opportunities to disprove catastrophic fears. The anxiety
relief that temporarily occurs when a situation is avoided
reinforces further avoidance. When feared social situations
are confronted, in contrast, catastrophe rarely materializes.
This confrontation affords an opportunity to correct mistaken
beliefs and makes future exposure less anxiety provoking.
5. Prevent further deterioration/maximize level of function. Dopaminergic, serotonergic, and noradrenergic systems have
been suggested to play a role in the neurobiology of social
phobia. Dopamine is thought to mediate the motivational and
rewarding mechanisms of the central nervous system;
heightened social interest, gregariousness, and confidence
may reflect that influence.
5. Patients with preexisting dementia can deteriorate into

delirium with seemingly minor stressors such as urinary tract
infections, traumatic injuries, or even environmental
change. Focal CNS disorders in strategic locations can
also cause delirium. Strokes are frequent causes of delirium.
Hippocampal lesions, such as acute posterior cerebral artery
territory strokes or herpes simplex encephalitis.In addition,
Wernicke aphasia and mirror-image lesions of the area
analogous to the Wernicke area in the right temporal lobe can
also present with acute confusion or agitation, as can some
thalamic les ions causing aphasia. Strokes are more likely to
be associated with delirium when they occur in elderly
patients with preexisting cerebral atrophy, and also when
they are accompanied by seizures. Multifocal strokes in
embolic conditions, vasculitis, or hypoxic-ischemic
encephalopathy are also frequent causes of delirium.
• Encourage the patient to keep a pain diary to help in identifying aggravating and relieving
• factors of chronic pain.
Knowledge about factors that influence the pain experience can guide the patient in
making decisions about lifestyle modifications that promote more effective pain
management.
• Acknowledge and convey acceptance of the patient’s pain experience. The patient may have
had negative experiences in the past with attitudes of health care providers toward the
patient’s pain experience. Conveying acceptance of the patient’s pain promotes a more
cooperative nurse-patient relationship.
• Provide the patient and family with information about chronic pain and options available for
pain management. Lack of knowledge about the characteristics of chronic pain and pain
management strategies can add to the burden of pain in the patient’s life.
• Assist the patient in making decisions about selecting a particular pain management strategy.
Guidance and support from the nurse can increase the patient’s willingness to choose
new interventions to promote pain relief. The patient may begin to feel confident about
the effectiveness of these interventions.
• Refer the patient to a physical therapist for evaluation. The physical therapist can help the
patient with exercises to promote muscle strength and joint mobility, and therapies to
promote relaxation of tense muscles. These interventions can contribute to effective pain
management
• Describe all prescribed medications and IV solutions, including those with additives.
Drug, Dose, Usual and Drug Nursing Why is this client

Route, and maximum dose. Classification and Implications receiving this
Frequency Include 24 hr Action (What must you drug?
range, if check or do prior
available. to administering
this medication?)
and
Major Side Effects

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Name:

MOTT COMMUNITY COLLEGE

Client InitialsNURSING HOME Age 73 Gender FEMALE Room # 55B

Admitting Diagnosis (es): Cardiovascular Accident (CVA), Alzheimer Disease, Multiple

1. Define the client’s current medical diagnosis (es) and/or surgical

Alzheimer’s Disease: is a progressive neurodegenerative

Cerebrovascular Accident: Alzheimer’s Disease

Reference (s) of the above:

Intervention Rationale (Scientific Explanation)

2. Perform passive or active assistive ROM exercises to

3. Use prophylactic antipressure devices as appropriate.

4. An albumin level less than 2.5 g/dl is a grave sign,

2. Provide calm environment, eliminate extraneous

3. Assessment can identify areas of physical care in which the

4. Avoidance of social situations denies the social phobic

5. Patients with preexisting dementia can deteriorate into

Drug, Dose, Usual and Drug Nursing Why is this client

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