Comment [DH1]: 99% good job!

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Jaleesa Clark

PATIENT ASSESSMENT TOOL .

1 PATIENT INFORMATION

Assignment Date: 4/2/14

Agency: BMC

Patient Initials: V.L.

Age: 48

Admission Date: 3/11/14

Gender: Female

Marital Status: Single

Primary Medical Diagnosis with ICD-10 code:

Nontraumatic intracerebral hemorrhage I61.9

Primary Language: English

Level of Education: Unobtainable

Other Medical Diagnoses: (new on this admission)

Neurogenic dysphagia R13.19

Occupation (if retired, what from?): Unobtainable

Number/ages children/siblings: Unobtainable

Served/Veteran: Unobtainable

Code Status: Full Code

Living Arrangements: Unobtainable

Advanced Directives: Unobtainable

If no, do they want to fill them out?
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: African American

Religion: Unobtainable

Type of Insurance: Unobtainable

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
Patient is a 48 year old African American woman who presented to the Emergency Department of Bayfront Medical
Center on 3/11/14 after a family member found her in her home nonverbal and unable to move the right side of her body.
After CT scan and MRI, she was found to have had a hemorrhagic stroke of large basal ganglia bleed and left
intraparenchymal hemorrhage and was admitted to the Neurointensive Care Unit. Patient had an abnormal
electroencephalogram (EEG) which showed evidence of a focus of left temporal paroxysmal activity and suggested that
the patient was at risk for seizures. Patient was diagnosed with right hemiplegia and neurogenic dysphagia. On 3/24/14 a
complete upper gastrointestinal endoscopy with placement of G-tube was performed because of the patients neurogenic
dysphagia. The patient is now on A2 and remains nonverbal and unable to move the right side of her body, however, she
is able to follow commands and move the left side of her body.

University of South Florida College of Nursing Revision August 2013

Comment [DH2]: Do you know her POC?

 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
A cerebrovascular accident (stroke) is the interruption of normal blood flow in one or more of the blood vessels that
supply the brain. The tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons.
In its mildest form, a cerebrovascular accident is so minimal that it is almost unnoticed. In its most severe state,
hemiplegia, coma, and death result. Cerebrovascular accidents are classified pathophysiologically as global hypoperfusion
(as in shock), ischemic (thrombotic, embolic), or hemorrhagic. Risk factors for stroke include arterial hypertension and
smoking. Diabetes, insulin resistance, polycythemia, thrombocythemia, atrial fibrillation, and the presence of lipoproteinA all increase the risk for ischemic stroke. Stroke is the third leading cause of death in the US and affects more than
600,00 Americans annually with 160,000 deaths per year. Strokes tend to run in families and are more common in men at
younger ages. The incidence is about 2 times greater in blacks than whites. Blacks between the ages of 55 and 64 who live
in Southern states are about 50% more likely to die of stroke than blacks of the same age who live in the North. People
with both hypertension and type 2 diabetes have a fourfold increase in stroke incidence and an eightfold increase in stroke
mortality. Hemorrhagic stroke (intracranial hemorrhage) is the third most common cause of cerobrovascular accident.
Hypertension, ruptured aneurysms or vascular malformation, bleeding into a tumor, or hemorrhage associated with
anticoagulants or clotting disorders, head trauma, or illicit drug use are common causes. A hypertensive hemorrhage is
associated with significantly increased systolic and diastolic blood pressure measurements over several years and usually
occurs in the brain tissue. A mass of blood is formed and grows, displacing and compressing adjacent brain tissue.
Rupture or seepage into the ventricular system occurs in many cases. Hemorrhages are described as massive (several
centimeters in diameter), small (1 to 2 cm in diameter), slit (lies in the subcortical area), or petichial (the size of a pinhead
bleed). The most common sites for hypertensive hemorrhages are in the putamen of the basal ganglia, the thalamus, the
cortex and subcortex, the pons, the caudate nucleus, and the cerebral hemispheres. Clinical manifestations vary,
depending on the location and size of the bleed. Individuals experiencing intracranial hemorrhage from a ruptured or
leaking aneurysm have one of three sets of symptoms: onset of an excruciating generalized headache with an almost
immediate lapse into an unresponsive state, headache but with consciousness maintained, or sudden lapse into
unconsciousness. If bleeding spreads into the brain tissue, hemiparesis/paralysis, dysphagia, or homonymous hemianopia
may be present. MRI and magnetic resonance angiography (MRA) are used to diagnose stroke. Treatment of an
intracranial bleed, regardless of cause, focuses on stopping or reducing the bleeding, controlling the increased intracranial
pressure, preventing a rebleed, and preventing vasospasm. Occasionally an attempt is made to evacuate or aspirate the
blood. Once a deep unresponsive state occurs, the person rarely survives. The immediate prognosis is grave. If the person
survives, recovery of function often is possible (Huether and McCance, 2012).

University of South Florida College of Nursing Revision August 2013

Comment [DH3]: You have a lot of information

what Id really like to see is the focus on the
hemorrhagic stroke and give patho on how DM &
HTN damage the vessels. +4.5

 5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and

Comment [DH4]: Overall very well done!

generic name.]
Name clindamycin

Concentration (mg/ml) 600mg/50mL

Route IVPB

Dosage Amount (mg) 600 mg

Frequency Q6H

Pharmaceutical class anti-infectives

Home

Hospital

or

Both

Indication Treatment of infections

Side effects- dizziness, headache, vertigo, arrhythmias, hypotension, diarrhea, nausea, vomiting, rash, phlebitis at IV site
Adverse effects- pseudomembranous colitis
Nursing considerations- assess for infection (vital signs, WBC, urine, stool) at beginning of and during therapy, obtain specimens for culture and sensitivity
prior to initiating therapy, monitor bowel elimination, assess patient for hypersensitivity,
Name Clonidine (Catapres)

Concentration

Dosage Amount 0.1 mg

Route G-tube

Frequency Q8H

Pharmaceutical class adrenergics

Home

Hospital

or

Both

Indication Mild to moderate hypertension

Side effects- drowsiness, dizziness, hallucinations, bradycardia, hypotension, palpitations, dry mouth, constipation, nausea, vomiting, rash, sodium retention,
weight gain, paresthesia
Nursing considerations- Monitor I&O ratios and daily weight, assess for edema daily, monitor BP and pulse before and during therapy
Name fluconazole (Diflucan)

Concentration 100mg/50mL

Route IVPB

Dosage Amount 100 mg

Comment [DH5]: Do you know the indication on

why this pt was on an anti-fungal?

Frequency

Pharmaceutical class antifungals

Home

Hospital

or

Both

Indication Fungal infections caused by susceptible organisms

Side effects- headache, dizziness, seizures, abdominal discomfort, diarrhea, nausea, vomiting, hypokalemia,
Adverse effects- hepatotoxicity, Stevens-Johnson Syndrome, allergic reactions including anaphylaxis
Nursing considerations- assess infected area and monitor CSF cultures before and periodically during therapy, assess patient for rash, monitor BUN and
Creatinine, monitor liver function tests (may cause increased AST, ALT, serum alkaline phosphate, and bilirubin concentrations)

Name levetiracetam (Keppra)

Concentration 1,000mg/100mL

Route IVPB

Dosage Amount 1,000 mg

Frequency BID

Pharmaceutical class pyrrolidines

Home

Hospital

or

Both

Indication Partial onset seizures

Side effects- aggression, agitation, anger, anxiety, depression, dizziness, personality disorder, weakness, drowsiness, dyskinesia, fatigue
Adverse effects- suicidal thoughts, Stevens-Johnson syndrome, toxic epidermal necrolysis
Nursing considerations- assess for CNS adverse effects throughout therapy, monitor mood changes, assess for suicidal tendencies, assess for rash periodically
Name lisinopril

Concentration

Dosage Amount 40 mg

Route G-tube

Frequency Daily

Pharmaceutical class ace inhibitors

Home

Hospital

or

Both

Indication Management of hypertension

Side effects- dizziness, fatigue, cough, impaired renal function, rash, Hyperkalemia, angioedema
Nursing considerations- monitor BP and pulse, monitor weight, assess for signs of fluid overload, monitor K+ levels, monitor renal function
Name metoprolol (Lopressor)

Concentration

Dosage Amount 50 mg

Route G-tube

Frequency BID

Pharmaceutical class beta blockers

Home

Hospital

or

Both

Indication Hypertension
Side effects-fatigue, dizziness, mental status changes, blurred vision, bronchospasm, wheezing, hypotension, constipation, nausea, hyperglycemia, hypoglycemia,
back pain, joint pain
Adverse effects- arrhythmias, bradycardia, HF, pulmonary edema, rashes
Nursing considerations- monitor BP and pulse before and during therapy, assess for hypotension, monitor I&O ratios and daily weight, assess for evidence of
fluid overload, assess for rash, instruct patient not to abruptly stop taking this medication because it can cause rebound tachycardia, life-threatening
arrhythmias or myocardial ischemia, take apical pulse before administering if <50 bpm, hold medication, administer with meals or directly after eating
Name polyethylene glycol 3350 (Miralax)

Concentration

Dosage Amount 17 GM

University of South Florida College of Nursing Revision August 2013

Route G-tube

Frequency Daily

Pharmaceutical class osmotic

Home

Hospital

or

Both

Indication Treatment of occasional constipation

Side effects- abdominal bloating, cramping, flatulence, nausea, urticaria
Nursing considerations- assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function; assess color, consistency, and amount of
stool produced

University of South Florida College of Nursing Revision August 2013

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Lab
WBC

Dates

8.7
8.3

(3/28/14)
(3/31/14)

Hgb
10.0 L
10.6 L

(3/28/14)
(3/31/14)

Hct
30.7 L
31.9 L

(3/28/14)
(3/31/14)

Platelet count
274
252

(3/28/14)
(3/31/14)

Trend
Upon admit, the patients
WBC were in the high
range indicating the
presence of an infection.
However, they have
dropped down into the
normal range after
receiving antibiotic
therapy.
Upon admit, patients
Hgb level was in the low
range, which was
expected due to her
condition. It is now
slowly trending up. This
value will be closely
monitored because a Hgb
level of less than 7 would
require a blood
transfusion and anemia
has been associated with
poorer outcomes
following hemorrhagic
strokes.
Upon admit, the patients
Hct level was in the low
range and has been
steadily increasing over
the course of treatment.

Upon admit, the patients

platelet count was in the
normal range and has
remained within normal
limits. The severity of
bleeding is related to
platelet count and platelet
function.

Comment [DH6]: Good job.

Analysis
Number of infection
fighting cells. High WBC
indicates the presence of
an infection or
inflammation.

Comment [DH7]: It could have been attributed to

the anti-inflammatory response too as you mentioned
on analysis.

Hemoglobin (Hgb) is the

main component of red
blood cells and indicates
the bloods oxygen
carrying capacity;
generally performed with
Hct as these levels
parallel each other and
are frequently used to
evaluate anemia.

Hematocrit (Hct) levels

indicate the percentage of
blood cells that are red
blood cells. Used to
monitor the effects of
stress on the patient, fluid
imbalances and low
levels could be seen after
significant recent blood
loss.
Platelet counts indicate
the number of platelets in
the blood and used to
evaluate preoperative and
postoperative coagulation
status. Decreased platelet
counts occur whenever
the bodys need for
platelets exceeds the rate
of platelet production.

University of South Florida College of Nursing Revision August 2013

*I forgot to change the search criteria to admission-present before printing the labs at the hospital, which
is why not all values are present above; however, I did review the trend of the all the lab values while at the
hospital and based the explanation in the trend section on this knowledge.
3/11/14- CT scan revealed intracerebral hemorrhage and hemorrhagic stroke of basal ganglia
3/13/14- Electroencephalogram results- Abnormal. The background is slowed and disorganized. There is
evidence of a focus of left temporal paroxysmal activity. Electroencephalogram suggests patient at risk for
seizure.
3/23/14- A swallow study confirmed the diagnosis of neurogenic dysphagia. A G-tube was inserted on
3/24/14.

University of South Florida College of Nursing Revision August 2013

 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Impaired swallowing r/t neuromuscular impairment aeb observed evidence of difficulty in swallowing.

Comment [DH8]: Very good you even have

them in ABCs.

2. Risk for aspiration r/t impaired swallowing.

3. Risk for ineffective cerebral tissue perfusion r/t hemorrhage from cerebral vessel.
4. Impaired physical mobility r/t loss of neurological control of involved extremities aeb inability to move right

side of body.
5. Unilateral neglect r/t effects of disturbed perceptual abilities aeb failure to move limbs on affected side.
6. Risk for impaired skin integrity r/t alteration in sensation and immobility.

University of South Florida College of Nursing Revision August 2013

 15 CARE PLAN
Nursing Diagnosis: Risk for aspiration r/t impaired swallowing.
Patient Goals/Outcomes Nursing Interventions to
Rationale for
Achieve Goal
Interventions
Provide References
Patient will maintain patent -Monitor respiratory rate, -Signs of aspiration
airway and clear lung
depth, and effort Q4
should be detected as
sounds during this shift.
hours and PRN with any
soon as possible to
changes. Note any signs
prevent further aspiration
Patient will remain free
of aspiration such as
and to initiate treatment
from aspiration for the
dyspnea, cough, cyanosis, that can be lifesaving
duration of this
wheezing, hoarsness, or
(Ackley and Ladwig,
hospitalization.
fever. If new onset of
2014).
symptoms, perform oral
suctioning and notify
provider immediately.

- Patients respiratory
rate, depth, and ease of
respiration were closely
monitored and remained
within normal limits. No
signs of aspiration noted.

-Auscultate lung sounds

at least Q4 hours and
PRN with any changes;
note any new onset of
crackles or wheezing.

-Auscultation of lung
sounds was shown to be
specific in identifying
clients at risk for
aspiration (Ackley and
Ladwig, 2014).

-Patients lung sounds

were auscultated Q4
hours and were clear. No
adventitious sounds
heard.

-Have suction machine

available. If aspiration
does occur, suction
immediately.

-A client with aspiration

needs immediate
suctioning and may need
further lifesaving
interventions such as
intubation (Ackley and
Ladwig, 2014).

-Suction was at the

bedside at all times. Oral
suctioning was
performed when
secretions were present.

-Keep the head of the bed

elevated at 30 to 45
degrees.

-Maintaining this
positioning can help
decrease aspiration
pneumonia (Ackley and
Ladwig, 2014).

-Head of the bed

remained elevated
between 30 and 45
degrees.

-If the client shows

symptoms of nausea and
vomiting, position on
side.

-The side lying position

can help the client expel
the vomitus and decrease
possible aspiration
(Ackley and Ladwig,
2014).

-Patient showed no
symptoms of nausea or
vomiting.

-Auscultate bowel sounds

Q4 hours, noting if they
are decreased, absent, or

-Decreased or absent
-Patients bowel sounds
bowel sounds can indicate were auscultated Q4
an ileus with possible
hours and noted and

Evaluation of Goal on
Day care is Provided

University of South Florida College of Nursing Revision August 2013

hyperactive.

vomiting and aspiration

(Ackley and Ladwig,
2014).

documented as
hypoactive.

- Note new onset of

abdominal dissention or
increased rigidity

-Abdominal distention o
rigidity can be associated
with paralytic or
mechanical obstruction
and an increased
likelihood of vomiting
and aspiration (Ackley
and Ladwig, 2014).

-Patients abdomen was

assessed Q4 hours and
no abdominal dissention
or rigidity was found.

-Provide meticulous oral

care at least two times per
day.

-Good oral care can

prevent bacterial or
fungal contamination of
the mouth, which can be
aspirated. Research has
shown that excellent oral
care can be effective in
preventing hospitalacquired pneumonia
(Ackley and Ladwig,
2014).

-Patient received oral

care including
chlorhexadine mouth
wash as ordered.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include
for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT
Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

University of South Florida College of Nursing Revision August 2013

References
Ackley, Betty J. and Ladwig, Gail B. (2014). Nursing diagnosis handbook. Maryland Heights, MO: Elsevier
Huether, Sue E. and McCance, Kathryn L. (2012). Understanding pathophysiology. St. Louis, MO: Elsevier.

University of South Florida College of Nursing Revision August 2013

10