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Concept Map 1

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by

Meghan Dusha

on 26 March 2014

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Transcript of Concept Map 1

Signs and Symptoms 5/23 G.D.'s wife heard him making "grunting" noises, he complained of right sided weakness. EMS brought him to Glens Falls Hospital where they gave him a CT scan. They determined it was an ischemic stroke, they administered TPA and he had a hemorrhagic conversion. He was transferred to AMC Neuro ICU for a higher level of care on 5/24. He was transferred to D5E on 5/26. Pathophysiology Hemorrhagic strokes account for approximately 15% of all strokes and result from bleeding into the brain tissue itself ( intracerebral hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage).
Intracerebal hemorrhage is bleeding within the brain caused by a rupture of a vessel and accounts for about 10% of all strokes. Hypertension is the most important cause of intracerebral hemorrhage. Hemorrhagic strokes have a poor prognosis, and patients are at a high risk for a coma. Patient: G.D. 63 Year Old Caucasion Male Diagnostic tests Socioeconomic/
Cultural Factors Lives at home with his wife
Middle-class
Retired
Practicing Catholic
Wife reported his alcohol intake around 4-5 drinks per day Nursing Diagnoses 1. Impaired swallowing related to weakness or paralysis of affected muscles as evidenced by drooling, difficulty swallowing, and choking.

2. Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control evidenced by limited ability to perform gross and fine motor skills, limited range of motion, and difficulty turning.

3. Impaired verbal communication related to residual aphasia as evidenced by inability to speak, and difficulty expressing and receiving verbal communication. Shy'na Foster & Meghan Dusha Concept Map Dx: Hemorrhagic Stroke Hx: Crohn's, essential tremor, ETOH, rosacea, Afib Past surgical Hx: bowel resection x2 Medications Assessment Goals Interventions 5/23 CT Angiography, Head & neck Cranial- acute nonhemmorrhagic infarction in left MCA
Neck- negative 5/24 MRI Brain & MR Angio Brain and Neck Large acute left MCA infarction, complete occlusion of the left middle cerebral artery 5/23 Cranial CTA Occlusion of the left MID segment 5/24 CT Head Large area of abnormal hypodensity occupying much of left MCA territory including basal ganglia 5/29 TEE Results not yet available Aspirin- reduces blood clots
Famotidine (Pepcid)- prevents stress ulcers
Ferrous Sulfate Solution- prevents anemia
Folic Acid- lowers homocysteine levels (high levels linked to stroke)
Heparin- reduces blood clots
Multivitamin- prevents vitamin deficiency
Nystatin Suspension- prevents growth of fungus
Propranolol- controls blood pressure
Vitamin B12- treats anemia
Vitamin D3- prevents vitamin D deficiency (related to ETOH)
Acetaminophen- controls pain
Adalimumab (Humira)- manages Crohn's disease Lab Values Risk Factors Atrial Fibrillation
Alcohol Abuse
Age > 55 years old
His original ischemic stroke (prior to his hemorrhagic conversion) is more common in men than women Right facial droop
Aphasia- expressive & receptive
Ptosis on right side
Glasgow coma scale- 12
Left & right pupil size 4 mm, brisk reaction
RUE flaccid, RLE flicker. LUE normal, LLE normal. WBC 5.6
RBC 4.31 (Low)
Hemoglobin 13.2 (Low)
Hematrocrit 39.5 (Low)
Platelet Count 142
Mean Platelet Volume 12.3 (High)
*Low Hct and Hgb could be from the hemorrhagic conversion* Glucose 96
BUN 28 (High)
Creatinine 1.2
*He is on aspirin and propranolol which can lead to increased BUN* Numbness/ Weakness on right side of body (due to left side damage) Slurred words Loss of balance Neuro: GU: GI: Skin: Respiratory: Hyperactive bowel sounds, liquid stool (related to Crohn's) Hesitancy, incontinence Rosacea, excoriation to scrotum (due to incontinence) Upper lung sounds clear
Lowe lung sounds- diminished Treatments Q2h neuro checks
Q4h vitals
Dobhoff tube
NPO except meds (for TEE)
Swallowing eval by speech therapy
PT/OT referral
Barrier cream for excoriation
Discharge planning -> REHAB & Treatments & Lab Values Hematology Chemistry APTT 60 sec
INR 2.0
*greater than normal because he is on heparin* HOB 30' Alcohol withdrawal protocol A stroke is a characterized as sudden lost of blood flow to an particular part of the brain. Goal for nursing diagnoses 1;
1. patient will demonstrate effective swallowing without choking, coughing or aspiration.

Goals for nursing diagnoses 2;
1. Patient will demonstrate increased muscle strength and ability to move
2. Patient will use adaptive equipment to increase mobility Interventions for diagnoses 1;
collaborate with other members of the health team to provide continuity in patient's rehabilitative plan.
assist patient to sit in an erect position for feeding/exercise to provide optimal position for chewing and swallowing without aspirating.
assist patient to position head in forward flexion in preparation for swallowing (chin tucking)
assist patient to maintain sitting position for 30 min after completing meal to prevent the patient from throwing up.
Interventions for diagnoses 2;
Collaborate with physical, occupational, and recreational therapists in developing and performing a exercise program
determine patients readiness to engage in physical activity
encourage to practice exercise to improve range of motion
provide rest in between activity
apply splints to achieve stability of proximal joints involved with fine motor skills to prevent contractures.
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