Question

Mr. kaled, the 55-year-old man admitted with a stroke, has many abnormal findings.

He has a history of hypertension, smoking, and mild baseline dementia. He appears fearful and agitated, asking for cigarettes, oriented to name only. His speech is comprehensible but slurred.

Mr Ali is drowsy with periods of confusion. He has impaired short-term memory—remembers zero of three objects after 1 minute. He appears to have left visual field loss. He has right lower facial weakness left tongue deviation. His muscle bulk is symmetrical, tone slightly increased on left arm/leg. He has diminished attention to objects and people on the right side of bed.

A- What nursing assessment findings support the diagnosis of stroke?

B- What problems related to Mr Ali’s safety should the nurse consider?

C- What nursing care plan should the nurse formulate for the patient?

Answer 1

Nursing assessment findings to support stroke.  

Stroke is one of the major life threatening emergencies if given appropriate treatment at the right time can reduce mortality and morbidity. The symptoms listed above are classical symptoms of stroke.

Facial droop on one side.

Arm drift or weakness.

Slurring of speech.

Time of onset. This is the Fast assessment of stroke...

Left sided stroke.. Aphasia, left lateral gaze, right visual field deficit, right hemeparesis.

Right sided stroke. Flat effect, left visual field deficit.

Vertebro basilary stroke.. Diplopia, dysphagia, dysarthria, drop attack.

Temporal lobe CVA can cause seizures.

Safety issues a nurse should consider.

Physical safety. Ensuring that side rails are put.

Encourage the presence of relatives.

Use physical restraints if the client is restless.

Orient the client to the environment.

Put in an Naso gastric tube to prevent aspiration of food.

Monitor for seizures.

Nursing diagnosis...

Ineffective cerebral tissue perfusion.

Impaired physical mobility.

Impaired verbal communication.

Disturbed sensory perception.

Ineffective coping.

Self care deficit.

Activity intolerance.

Deficient knowledge.

Risk for injury.