nursing process Essay

Submitted By thrweatt
Words: 1014
Pages: 5


Client : D.M.
Date(s) of care: June 6 and 11, 2013
CRMC days of care: 14
6 East 6725
Age of client: 50
Occupation(s)/Significant Social History:
Divorced , 2 children
Occupation : Waitress/Hostess
Smoker, history of alcohol abuse
Allergies: Shellfish, Iodine

Weight: 134 lbs (60.7 kg)

Vital Signs
Day 1:

BP: 114/68
HR: 81 BPM
Respirations: 12
Temp 98.2 degrees F
O2 Sat 95%

Pain 9/10; in right shoulder, right hip

Intake & Output 24 hour recall
I= 2900 cc
O= 1200 cc

Intake & Output 0630-1430
I= 1080 cc
O= 500cc
Day 2

BP: 120/74
HR: 72 BPM
Respirations: 16
Temp 97.8 degrees F
O2 Sat 96%

Pain 4/10; in the right shoulder

Intake & Output I= 3200 O=1400 24 hour recall

Intake & Output

Primary (Admitting) Medical Diagnosis:
Cerabral Vascular Accident with right sided weakness and pain

Secondary Medical Diagnosis:
Chronic obstructive pulmonary disease
Diabetes Type 2
Narcotic Dependence
Chronic Pain
ETOH Abuse

Pathophysiology of Admitting Diagnosis:

A cerebrovascular accident also known as a CVA, is the interruption of the blood supply to the brain. A

CVA is caused by a lack of blood flow caused by thrombosis, arterial embolism or a hemorrhage. As a

result, the affected area of the brain function is disturbed, which can lead paralysis or severe weakness on

one side of the body, inability to understand or formulate speech, or an inability to see one side of the

visual field, inability to swallow or difficulty swallowing. The client may also experience incontinence of

bowel and bladder.A stroke is a medical emergency and can cause permanent neurological damage and


Assessment for Diagnosis:

A health history and physical assessment was performed of the client. The client reports that she did have

several spells of dizziness and blurred vision the week before her stroke and she experienced these

episodes for a few minutes at a time and she believed them to be due to “ her not getting enough sleep and

not keeping up with my sugar”. On the evening of admission, the client woke up from a nap and could not

move her right arm or leg nor was she able to speak clearly. The client’s daughter drove her to the ER.

Physical assessment findingsare as follows: The client is alert and responds to verbal stimuli. PERRLA

noted. Her speech is garbled at times and she has clear, low speech when she speaks slowly. Answers

questions and can perform tasks correctly. Client is lethargic , no apathy or combativeness noted. Normal symmetrical movement noted of the face. Client is receiving oxygen via nasal cannula at 2 liters per minute. There is no loss of gag reflex , bowel sounds present. There is urinary urgency and incontinence present , no complaints of pain with voiding. Minor paralysis is noted in her right arm and right leg, no response to stimuli noted in those extremities ; however she does experience severe pain at level 9 out of 10 in those areas noted. There is no extinction or inattention to the right side of the body. There is no complaints of blurred vision at this time, no decrease in visual acuity noted. A CT scan on admission reveals the medical diagnosis of a left-brain stroke due to a thrombus of the middle cerebral artery.
The client’s medical treatment includes heparin sodium 5000 units injection , with clotting studies to be performed QAM .

Nursing Diagnosis:
Impaired physical mobility related to neuromuscular impairment and decreased muscular strength and control as manifested by limited ability to perform gross and fine motor skills and limited ROM on the right side of the