Question

Mr. Ali, the 56-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

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

Following Neuro assessment reveals that Mr  ALI is suffering from stroke.

Disoriented to place and time,confusion,slurred speech,right lower facial weakness with left tongue deviation,hemianopsia(left visual field loss,diminished attention to the objects and people on right side and Muscle tone asymmetry.

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

• Risk of Fall is a major safety concern as the patient is disoriented ,confusion and vision problems.Therefore adequate fall prevention measures should be initiated.
• Risk of Aspiration also is a concern as the patient is drowsy,confused with facial weakness.therefore proper swallowing assessment and feeding technique needed.
• Risk for pressure injury .

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

Nursing diagnosis:

1.Ineffective tissue perfusion related to decreased blood flow to brain.

Evidenced by confusion,memory loss ,hemianopsia and facial weakness.

Nursing care plan	Rationale
Close monitoring of vital signs.	To evaluate the patient deterioration and to prevent further complications.
Asses factors related to impaired cerebral perfusion and increased intracranial pressure(ICP)	It will help to identify and reduce ICP provoking factors and complications associated with stroke.
Assess pupils for PERLA.Note the hemianopsia	visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.
perform neuro assessment .	Neuro assessment helps to find out the neuro deformities and able to identify the area of brain involved and also help in implementing the safety concerns for the patient .
Administer antihypertensive medications as per the order	Controlling blood pressure is a key point in stroke to prevent the further stroke and complications and also to keep the Cerebral perfusion pressure(CPP).
prepare the patient for thrombolytic therapy or surgical intervention as per doctors order.	Early administering TPA or doing surgical intervention show great recovery in regaining the cerebral perfusion.

2.Impaired verbal communication related to the facial weakness.

Evidenced by slurred speech and facial weakness

Nursing care plan	Rationale
Asses the speech pattern of the patient	It helps to find out aphasia and its types and helps in advising the speech modalities.
Provide alternative methods of communication like writing or pictures.	It helps to communicate for there needs.
Talk directly to patient, speaking slowly and distinctly. Phrase yes or no questions for the patients	Talking slowly to patient will give time for the patient to listen and respond.Also yes or no question will reduce the speech strain of patient.
Encourage family and visitors to communicate with the patient	It will stimulate the patient to speak.
Refer to speech therapist consultation.	Speech therapist assessment and interventions help to gain techniques of speech.