Dade Medical College School of Nursing Associate Degree Nursing Program Students Name: Clients Initials: D.O.

B: Allergies: Admitting Medical Diagnosis (es): Acute Cerebral Vascular Accidents ______________________ ______________________________ Surgical Procedure (s) (include date): N/A_________________________________________________________________________________ What brought you to the Institution (Hospital, Home?) Patient was found confused and soaked in urine___ History of present illness: Son found him lying on the floor confused, and soaked in urine ______________________ Clients Understanding of Illness: _Patient understand he has a trauma on his head __________________________________________ Past medical history: Depression Stroke ______________ ____ _________________________________________ What Medications are you currently taking, when/why? Medication 1 2 Amoxicillin 500mg
Guaifenesin

Luis Angel Zapata W.K. Sex: Age: 54

Date: 12/11/2011 M

Time: 14:03pm

Admission Date: 12/11/2011 Race: White

1957

__________________________

Time Every 8 Hr Every 8 hr

Why Broad Treatment of infection Symptomatic relief respiratory conditions

3 4

Paroxetine 12.5mg
Lorazepam 0.3 mg

Once a day Every 8 Hr

Relief of Depression Decreased anxiety.

Are your medications causing you any discomfort? _N/A__________________________________________________________________________________ ___________________________________________________________________________________

Medications: (Topical; PO; IM; SQ; IV) Name/Dose Route/Frequency

Amoxicillin 500mg PO Q8hr Func. Class Antiulcer, antiinfective Guaifenesin PO Q8hr Fun. Class expectorant Aspirin 325mg PO Daily Func. Class Nonopioid analgesic

Safe/ Range

Mechanism of Action
Interferes with cell wall replication (bacteria)

Indications

Side Effects
. Headache, Seizures, Confusion, dizziness, Anaphylaxis, respiratory distress. Drowsiness, headache, nausea and vomiting Drowsiness, headache, nausea and vomiting

Nursing Consideration
Assess patient for previous sensitivity reaction for penicillin.

PO CCr1030ml/min 250500 q12hr

Against infections

PO 200-400 mg Q4 hr max 2.4g/day.

Increased the volume and reduce the viscosity of secretions in the trachea Blocks Pain impulse in CNS, reduces inflammation by inhibition of prostaglandin synthesis

Decreased cough

Assess cough, type, frequency and character.

PO 3 g/ day divided doses q46hr

Decreased pain, inflammation, fever, absence of MI, transient ischemic attacks

Asses for pain, monitor liver, renal and blood functions.

Paroxetine 12.5mg PO max of 62 mg/ day PO Daily Func. Class Antidepressant,

Inhibits CNS neuron reuptake of serotonin but not of norepinephrine or Dopamine

Relief of depression

Seizures, vasodilatation, swelling, myasthenia, nasal congestion Drowsiness, headache, nausea and vomiting

Seizure history patients should be under costs benefits treatment ( notify MD) Monitor B/P, monitor hepatic function, Assess mental status and degree of anxiety.

Lorazepam 0.3 mg PO/ IV Q8hr Func. Class benzodiazepine

PO 2-6 mg/day in divided doses

Potentiates the action of GABA, an inhibitor transmitter, especially in the limbic system and reticular formation.

Decreased anxiety

LAB VALUES Chemistry Sodium Potassium Chloride C02 Calcium Phosphorus Cholesterol Albumin T-Protein Bun Creatinine Magnesium Uric Acid Biliburin Amylase Lipase LDH HDL LDL Urinalysis Color Turbidity SG PH Glucose Ketone Blood Protein Bilirubin
Urobilinogen

Normal Value 137-145 3.5 to 5.0 98-107 22-30 8.4-10.2

Clients Value 139 3.1 98 23 8.2

Date 12/11/2011 12/11/2011 12/11/2011 12/11/2011 12/11/2011

Hematology RBC HGB HTC MCV MCH MCHC WBC Neurophils Bands Segments Eosinophils Basophils
Lymphocytes

Normal Value 4 -5.50

Clients Value 5.4

Date 12/11/2011

3.8 to 10.8

24.2

12/11/2011

Monocytes Plat
Coagulation Normal studies Normal Value Clients Value

Date

Miscellaneous Test(Normal) <110 mg/dl 161 11/23/2002

Normal Value

Test
Clients Value

Date

Nitrate Leukocytes Cast RBC Crystals WBC

Epithelial Cells

TSH Bun/creat osmolality RDW MPV AIC-Hgb ALT(SGPT) AST(SGOT T.bilirubin

12/11/2011

O2 Sat
HDL LDL VLDL CHOL/HDL

95-100

95

11/23/2002

Relate the clinical significance of abnormal lab values above: WBC elevated due to an infection. High Glucose level due to high stress and anxiety. Low Potassium level due to urinary retention or dehydration

DIAGNOSTIC TESTS
X-RAYS/ CT SCAN/ US/MRI/EKG etc

RESULTS (Please include date of tests results) Normal 12/11/2011 Revealed evidence of old Strokes Bilateral acute infracts, atrophy and chronic ischemic change.12/11/2011

X-Ray CT SCAN MRI without contrast

Stage of Development
Describe the clients stage of development according to Piaget, Freud, or Eriksons theory. Compare the developmental stage to the client.

Theory

Generativity vs. Stagnation (Middle Adulthood, 40 to 65 years) Erikson

Psychosocial Crisis: Generativity vs. Stagnation Main Question: "Will I produce something of real value?" Virtue: Care Related Elements in Society: parenting, educating, or other productive social involvement

Client Patient is concerned about his family. He considers himself as the decision maker of the household. He beliefs his boss is needing him so much. Who is going to take care of the bills now?

Generativity is the concern of guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Pathophysiology of Medical Diagnosis: Acute Cerebral Vascular Accident
An abnormal condition f the brain characterized by occlusion by an embolus, thrombus, or cerebrovascular hemorrhage, resulting in ischemia of the brain tissues normally perfused by the damage vessel. Paralysis, weakness, sensory change, speech defect, aphasia death may occur. Diagnosis is usually based on symptoms and results of physical examination, imaging tests and blood tests (Merck Manuals, 2007). There is no blood test or electrocardiogram (ECG) specific for stroke, and CT scans may be entirely normal for up to six hours after acute onset of stroke. Thus the neurologist becomes an irreplaceable member of the team to acutely evaluate stroke patients (Llinas, 2006). A condition called "atherosclerosis" is commonly the cause of the blockage of the blood vessel, and atherosclerosis pertains to fatty deposits that accumulate on the walls of the vessels causing a disruption or total blockage to the much needed blood supply to the brain. These fatty deposits can cause two types of obstruction: Intra-cerebral Hemorrhage (ICH) Cerebral embolism

Dade Medical College School of Nursing Associate Degree Nursing Program Plan of Care

Medical Diagnosis: Supporting Data: Subjective: Objective :

Acute Cerebral Vascular Accident

Patient was found confused and soaked in urine CT and SCAN MRI without contrast shows previous and current stroke

Priority Nursing Diagnosis: Total urinary incontinence R/T flaccid bladder, confusion or difficulty in communicating AEB Foley catheter was in place Risk nursing Diagnosis: Risk for impaired skin integrity R/T decreased mobility AEB damage tissue on iliac, spinal cord and sacrum Expected Outcome for priority Dx: (Short Term Goal): Bring WBC down to normal values within 48 hrs. (Long Term Goal): Prevent malnourishment while patient is in the hospital as well as at home recovering from Stroke Nursing Interventions WBC value_________________________ Assess waist belt_____________________ Scientific Principle or Rationale Related to infection____________________ Patients comfort ______________________

Administer Meds as prescribed________ Labs_______________________________ Assess Foley catheter_________________ Assess skin__________________________

Avoid Complications___________________ Use it as a base line____________________ Prevent UTI__________________________ Prevent pressure ulcers_________________

Evaluation:

Modifications: