Question: Care Plan Case Study CVA N.T., A 79-year-old Woman, Arrives At The Emergency Room With Expressive Aphasia, Left Facial Droop, Left-sided Hemiparesis, And Mild Dysphagia, Her Husband States That When She Awoke That Morning At 0600, She Stayed In Bed, Complaining Of A Mild Headache Over The Right Temple And Feeling Slightly Weak. He Went And Got Coffee, …

Care plan case study CVA N.T., a 79-year-old woman, arrives at the emergency room with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia, Her husband states that when she awoke that morning at 0600, she stayed in bed, complaining of a mild headache over the right temple and feeling slightly weak. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure (BP) has been well controlled. N.T. is currently taking Amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). An acute cerebrovascular accident (CVA) was confirmed on CT. PMH includes A-fib, hyperlipidemia, HTN Surgical history: D+C years ago, colon resection Lives with husband in ranch house and has 2 children that live close Family history of asthma, CAD, DM, CVA Allergies: Dilaudid BMI 34 Assessment includes: Pt alert and oriented x2. Unsure where she is. N.T. states” wish I knew more about strokes and how to prevent them”. Temp 99, HR 96, RR 20 and BP 160/96, sat 96% on RA. Pt states she has no pain. HR irregular and capillary refill 2 seconds on all extremities. Lungs CTA. Respiratory rate 20 and unlabored. Abdomen soft and nondistended. Bowel sounds normoactive in all quadrants. Last bowel movement was yesterday according to patient’s husband. Incontinent of urine. Some bruising noted on patient’s right hip from recent fall. Weakness in left upper and lower extremities. Continues with some difficulty saying words. Unable to stand alone and needs assistance of 2 to ambulate. Needs assistance with ADLs. When administering Amlodipine, patient states “what is that pill for?” CT head shows acute infarcts involving the right frontal lobe EKG shows AFIB Chest xray shows clear lung fields Lab results include: BMP: Fasting glucose 184mg/dL, sodium 140, Chloride 101, potassium 3.8, CO2 19, BUN 19, Creat 0.8 CBC: Hgb 13, Het 40, WBC 16, RBC 4.56, Platelets 300 Lipid Profile: Total cholesterol 296mg/dL, Triglycerides 246mg/dL, Low-density lipoprotein (LDL)155mg/dL, High-density lipoprotein (HDL)22mg/dL Assessment Data Relevant objective and stive finding that wantite Noi Diagnosis Nursing Diagnosis #4 (from ESU Nursing Database) Nursing Diagnosis Expected Outcomes Nursing Interventions Rationale with Sources Restament dels Overall me and als Identies whewhat, where States and intervention includes related precipitating Short Term Owl, I Long Tuss foton, pred by wher, and ww, Independent can be expected to accomplish Goalppropriate to diagnosis, uning actions or olaborative objective widoce med M’s bechy patient centrele, practice, includes medi, labs, de example book, ing article einstimeframine (NOT limited to: DIAGNOSIS STG with time frame 1 1 Evaluation This derived from comes Ineledes mig value mesures clientes, follow-up find cement of outcome meditation STG SUBJECTIVE: RELATED TO OBJECTIVE LTG with time frame LTG 3 AS EVIDENCED BY: Note: Risk Dx do not have AEB data 9/2015 acs; reviewed 8/2016 acs