History of Present Illness
Chief Complaint: left side weakness, slurred speech, headache and blurred vision.
Admission Diagnosis: Stroke
History: patient started feeling left sided weakness about two days ago. She then developed some mild pain in her limbs, and her speech became slurred. Also, she was started experiencing headaches, and her vision became blurred. She did not take any medication or do any other thing to relieve the symptoms before reporting to the hospital.
Signs and Symptoms: the patient is confused and has slurred speech and poor understanding. She has left sided weakness and feels mild pain on the limbs on that side. She is experiencing headaches, and her vision is tainted. If not managed, the patient would likely develop numbness of the face and the limbs on the left side and may lack co-ordination of movement. The long-term effects of stroke lead to paralysis of the weak side, bladder, and bowel problems, severe pain and emotional problems.
Physical examination: the patient is presenting with one-sided weakness, headaches, slurred speech and blurred vision that are indicative of a stroke.
Blood count: this test is done to show whether the patient has anemia or an infection. The patient results were as follows. WBC 6.6 (4.0-11.0 x109/L), RBC 5.18 (3.8-5.8 x1012/L), Hemoglobin 14.3 (115-160g/L), Hematocrit 42.8 (38-46%) and Platelet 220 (150-400 x109/L). From the results, the patient is not exhibiting any signs of infection. However, her hemoglobin levels are very low, and she could be possibly having anemia.
MRI: a magnetic resonance imaging of her brain was done. It showed a small chronic appearing lacunar infarct in the right lentiform nucleus. The images showed no hemorrhage but ischemic changes in the brain were seen.
Past Medical and Surgical History
Tonsillectomy. The patient has a history of chronic tonsillitis that led to the surgical procedure. Tonsillitis is a bacterial and viral infection commonly caused by Streptococcus. It results in inflammation of the tonsils that in severe cases may block the airways. The patient feels pain and tenderness in the throat, loss of appetite, difficulty in swallowing and breathing through the mouth, fever, chills and halitosis. On physical examination, the tonsils have a white or yellow coating on them and appear red. The patient had been on antibiotics for a long time until they became resistant, necessitating a tonsillectomy.
Mastectomy. The patient underwent a mastectomy on the right breast three years ago following a carcinoma. Cancer of the breasts tends to start in the inner lining of the milk ducts. Cancer can remain within the breast or spread to the rest of the body parts. The risk factors for breast cancer include advanced age, exposure to radiation, genetic predisposition, exposure to estrogen, and obesity. The common signs and symptoms of breast cancer is a lump in the breast, pain in the armpits, reddening around the breast, rash around the nipples and bleeding from the nipples. Mastectomy is done after chemotherapy and radiation therapy have failed.
Fibroidectomy. Fibroidectomy is the surgical removal of fibroid which are uterine leiomyomas that cause pelvic pain, uterine bleeding, and infertility. Also, they cause menstrual irregularities and low back pain. Surgery to remove the fibroid is indicated when they cause excess bleeding, chronic pelvic discomfort and when they are palpable in the abdomen. In extreme, cases the patient undergoes hysterectomy which involves the removal of the entire uterus.
Erickson Developmental Stages
Eric Erickson developed eight stages of psychosocial development from childhood to adulthood. Each stage entails a crisis that which develop the personality positively or negatively depending on the reaction to it. These stages are trust vs. mistrust, autonomy vs. shame, initiative vs. guilt, industry vs. Inferiority, ego identity vs. role confusion, intimacy vs. isolation, generativity vs. stagnation and finally, ego integrity vs. despair. The patient is 46years old and is in the seventh stage, generativity vs. stagnation. By the time individuals get to this stage, they have established their careers and families. They raise their children while giving back to the society. If the individual has not achieved any of this, they tend to feel stagnant and unproductive.
Interprofessional consults and discharge referral
On discharge, the patient will need a lot of rehabilitative services to ensure proper recovery. It can only be achieved through the collaboration of different healthcare personnel working together for the wellbeing of the patient. The team should comprise radiologists, neurologist, physiotherapists and occupational therapist. The neurologist must review the patients neurological status two weeks following the discharge. Imaging of the brain, done by the radiologist are essential to show the progress of the ischemia. Physical and occupational therapy are important to help the patient regain their physical strength and function as stroke leads to weakness and sometimes paralysis.
Potential health deviations
Stroke impairs movement and balance, speech, vision, and cognition. Although patients can progress to full recovery and return of function, they may develop certain complications following the illness. First, reduced movement and physical activity will result in certain limitations. They may develop pressure ulcers and deep venous thrombosis. Nurses, must therefore ensure that the patient is turned to bed periodically and that easy physical movements are introduced. The second complication is malnutrition. Some patients will experience difficulty in swallowing, and oral feeding can be contraindicated. Feeding must be supervised by a specialist and in the case of tube feeding, the nurse and nutritionist must ensure food is balanced.
Third, stroke patients are prone to infections particularly in the chest and the urinary tract. Chest infections are because of aspiration of material into the lungs. The urinary tract infections are because of urine retention. Finally, stroke impacts the patients social life as well as that of their family. It comes with cost and time constraints for the family members who have to take care of the patient. The nurse must counsel the patient and their family on how to cope with the illness.
Priority nursing diagnosis
- Ineffective cerebral tissue perfusion related to ischemia as evidenced by slurredspeech and poor vision.
- Activity intolerance related to left-sided weakness as evidenced by patient verbalizing weakness and fatigue.
- Impaired verbal communication related to compromised cerebral circulation as evidenced by slurred speech.
Planning goals and evaluation
The goals of nursing care are as follows:
- To improve and maintain the patients level of consciousness, cognition and physical coordination
- To assess the communication problem and establish the best method for the patient to use for effective communication.
- To engage the patient in activities so as to improve their tolerance to physical and mental activities.
Implementation and rationale
- The nurse administered the prescribed medication, which were, antihypertensive, antiplatelet and fibrinolytic agents. These medication will lower the blood pressure, break the clots causing the infarct and prevent further formation of clot. Once the blockage is resolved, blood flow is restored to the brain improving function.
- The level of the patients communication was established. The patient could read and write. However, verbal communication was slowed. The rationale for this was to design the best appropriate to communicate with the patient. Speech and writing would be used to pass and receive information from the patient.
- The care of the patient should involve mild physical activities with periods of rest. However, this is done with caution while assessing the cardiopulmonary response of the patient. The activities are increased gradually as the patients condition improves.
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- Antihypertensive. The patient was given metoprolol. It is a beta blocker administered to the patient to help lower the blood pressure. Its side effects are shortness of breath, confusion, dizziness, diarrhea, mild itching and rashes. The nurse must monitor the mental status of the patient as well as the level of consciousness while she is on this therapy.
- Antiplatelet. Aspirin was given. It helps to prevent the formation of clots and therefore limits the recurrence of the stroke. The side effects are stomach upset and heartburns. It is contraindicated in patient with gastric ulcers. The nurse must monitor the patient for side effects.
- Fibrinolytic agents. Alteplase was used. It is given to help in the breakdown of blood clots thus promoting perfusion of the brain cells. The drug does not have common side effects. However, in severe cases, the patient may experience allergic reactions, color changes of toes and fingers, speech problems, stomach pains and kidney problems. The nurse must carefully watch the patient for any symptoms or reactions which determine the termination of the dose.