Good example of general plan of care: case study

Overview

Ischemic CVA, cerebrovascular accident, is the neurological disorder with compromised blood supply having risk factors that includes thrombus formation, emboli, history of hypertension and DM symptoms, hyperlipidemia, high BP, tachycardia, loss of consciousness, and paralysis. Ischemic strokes represent 87% of all strokes (Summers, Leonard, and Wentworth).
Male, 65, Latino, sedentary, Spanish, middle class, no existing disability, Christianity, current medication include Metformin 1000mg BID before meals, Glipizide 5 mg BID before meals, Lotrel 5/10 1 cap daily, Lipitor 40 mg daily, ASA 81 mg daily.
Current Medical History: Patient admitted to Emergency Department with the symptoms of CVA. MRI resulted in a left Ischemic CVA with the weakness on the right side of the body. The patient has been brought to the raised pulse rate, low respiratory rate, slurred speech, and with decreased peristaltic movement.
Past medical history: Patient has a medical history of Diabetic Mellitus, raised BP, and hyperlipidemia for which he is on several medications.
Vital signs: Blood Pressure (150/90), Respiratory Rate (16), Heart Rate (85), Temp (99. 0 F), Oxygen Saturation is 98% on 2 liter oxygen per nasal cannula.
Diagnostic study data including blood work: Patient’s basic line investigation is normal except random blood sugar is raised (205). High blood sugar, history of high blood pressure, weakness on one side of the body, and problems with swallowing signs towards the case of Ischemic stroke CVA.
Doctor’s orders: Patient is kept on NPO until the advice from the speech therapist. After that he will be transferred to the neurological intensive care and will be put on ST, OT, and PT.

Treatment of CVA will depend on the type of stroke confirmed by further tests.
Anticoagulant medicine: For the treatment ischemic stroke anticoagulant medicines that are also known as blood thinners are given to the patient. This medication keeps the clot formation in the blood at bay.

Antiplatelet aggregating medicine: These drugs interact with platelets (joins to form clots) for the prevention of blood clot formation.

Thrombolytic medicine: Used in a stroke that is caused due to clot formation in a blood vessel.
1. Ischemic Stroke CVA: It occurs when the supply of blood to the brain is blocked due to the blood clot in the blood vessel that handles the blood supply to the brain.
2. Stroke Symptoms:

• Weakness in the right side of the body.

• Trouble in speaking and also patient faced the dysphagia.
• Finding hard to walk due to the sudden numbness in the right side of the body.
3.

No drugs are given in the Emergency Department due to the swallowing problem of the patient.

4.

Nursing Measures:

For impaired physical mobility:
• Assess the magnitude of physical impairment regularly and rate it on 0-4 scale.
• Change physical positions after every two hour and more often if the patient is placed on the affected side.
• Use footboards during flaccid paralysis period maintain neutral head positions.
• Elevate the affected hand and arm and use trochanter roll for the neutral leg position.
• Assist in ROM exercises for both sides of the body whether affected or not (Vera)
For impaired speech:
• Assess the patient’s speech and differentiate between aphasia and dysarthria.
• Note the errors in speech for the feedback.
• Ask to follow easy to understand command like ‘ Raise your hand’. Do repeat.

• Alternative methods of communication should be provided.

• Refer or consult the speech therapist if needed (Vera).
6.
• Direct the family or caretaker to make sure that after discharge, the patient of CVA has a safe place to live.

• Arrange the health care provider who would monitor the medical and health needs of the patient.

• Choose a caregiver who would work with the patient as a partner and would provide daily assistance and care to the patient.
• Provide help to the patient in exploring employment opportunities or any other volunteer activity (US Agency for HealthCare Research and Quality).

Works Cited

Summers, Debbie, et al. ” Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient.” 28 5 2009. Stroke. Web. 8 7 2015 .
US Agency for HealthCare Research and Quality . ” Consumer Guide Number 16 .” Quality, US Agency for HealthCare Research and. Recovering After a Stroke:. Princeton: AHCPR Publication, 1995. 1-17. Print.
Vera, Matt. ” 8 Cerebrovascular Accident (Stroke) Nursing Care Plans.” 1 8 2013. nurseslabs. Web. 8 7 2015 .