Professional Documents
Culture Documents
Patfall2015 Msii Anjouligerez
Patfall2015 Msii Anjouligerez
COLLEGE OF NURSING
Student: Anjouli Marie Gerez
Gender: Male
Served/Veteran: No
If yes: Ever deployed? Yes or No
Advanced Directives: No
If no, do they want to fill them out? Yes
Surgery Date: Not Applicable
Procedure: Not Applicable
1 CHIEF COMPLAINT:
I was feeling good in the morning and I took a nap. I woke up and my wife noticed that I was not talking clearly. I cannot
be understood clearly and she called 911 and the ambulance took me to the ER.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
This patient is a male who is 66 years of age. He was brought in by the ambulance to the Bayfront Medical Center (BMC)
emergency department on Monday, 10/12/2015. The patient mentioned that he attended to his morning routine of a full
breakfast and a morning walk on Monday, 10/12/2015. He decided to take a nap after lunch. The wife of the patient
noticed that he had a right facial droop, right sided weakness, and slurred speech after the patient woke up from his nap.
She also added that these symptoms started at around 1345 on Monday, 10/12/2015. Therefore, she called 911 and the
patient was taken to the emergency department in BMC. The patient also mentioned that he and his wife did not try any
treatment to treat for the facial droop, weakness, and slurred speech because his wife immediately called 911. A
Computerized Tomography (CT) scan of the brain was performed while he was in the emergency department and it
showed an acute parenchymal hemorrhage centered in the left basal ganglia. A chest x-ray was also performed in the
emergency department which showed a cardiomegaly. Lastly, a carotid ultrasound was also performed which showed no
significant common or internal carotid artery stenosis. The patient was seen by a neurologist at the emergency department
but he was initially admitted to the Neurology Intensive Care Unit (NICU) for further evaluation and management. While
in the NICU, neurologic assessments were done every two hours and nicardipine (Cardene) drip, a calcium channel
blocker, was administered to keep his systolic blood pressure below 150 mm Hg. The patient was transferred to the
neurology medical unit as his critical symptoms were managed and he is working with a physical therapist to regain his
strength back. The patient mentioned that he is hoping to continue physical therapy at a rehabilitation facility that he can
afford to pay with private pay.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
Operation or Illness
Father
85
Mother
92
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
Gout
(angina,
MI, DVT
etc.)
Heart
Trouble
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable)
Prostate
Cancer
Heart
Condition
Environmental
Allergies
2
FAMILY
MEDICAL
HISTORY
Alcoholism
Hypertension - lisinopril
2013
Brother
Sister
Comments:
Patient states, I have five sisters and four brothers. They are all in good health in the Caribbean."
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service (Not Applicable)
Adult Diphtheria
Adult Tetanus (1965; not given within ten years)
Influenza (flu)
Pneumococcal (pneumonia)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
NAME of
Causative Agent
None
YES
NO
None
Not Applicable
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)
Hemorrhagic stroke is the third most common cause of cerebrovascular accident and it accounts for approximately 15
percent of all strokes. It results from bleeding in the brain tissue itself or into the subarachnoid space (Lewis, Dirksen,
Heitkemper, Bucher, & Camera, 2011). The common causes of a hemorrhagic stroke are hypertension, ruptured aneurysm
or vascular malformation, bleeding into a tumor, medications such as anticoagulants, head trauma, and illicit drug use. In
addition, it is more common in older adults and younger age groups who are involved in motor vehicle crashes, assaults,
and falls (Osborn, Wraa, Watson, & Holleran, 2014). However, hypertension is the primary cause of a hemorrhagic
stroke. Hypertension involves primary smaller arteries and arterioles that results in the thickening of the vessel walls and
possible necrosis. The small aneurysms in these smaller vessels or arteriolar necrosis in the brain may precipitate the
bleeding. A mass of blood is formed into the brain tissue and the adjacent brain tissue may be deformed, compressed, and
displaced. Therefore, it produces ischemia, edema, and increased intracranial pressure (Huether & McCance, 2012). The
most common areas for a hemorrhagic stroke are the putamen and surrounding internal capsule. It may also occur in the
thalamus, cerebellum, brainstem, and the white matter of the frontal temporal, and parietal lobes (Osborn et al., 2014).
The most common clinical manifestations of a hemorrhagic stroke include severe headache, weakness or numbness on
either side of the body, difficulty with speech or understanding speech, visual disturbances, gait problems, and balance
problems (Osborn et al., 2014). Diagnostic studies are done to confirm that it is a hemorrhagic stroke and not a brain
lesion such as a subdural hematoma. The most important diagnostic tool is the non-contrast computed tomography (CT)
scan because it can help distinguish between an ischemic and hemorrhagic stroke. The CT scan will help determine the
size and location of the stroke. In addition, serial CT scans are used to assess whether the treatment is effective and to
evaluate recovery (Lewis et al., 2011). On the other hand, a CT angiography (CTA) provides visualization of the cerebral
blood vessels and it can be performed after or at the same time as the non-contrast CTA. The CTA will help estimate
cerebral perfusion and detect filling defects in the cerebral arteries. A Magnetic Resonance Imaging (MRI) is also used to
determine the stage of the brain injury and it can detect vascular lesions and blockages but a Magnetic Resonance
Angiography may be used to detect vascular lesions and damages similar with a CTA (Lewis et al., 2011).
The prognosis of a patient who has a hemorrhagic stroke is poor and the 30-day mortality rate is 40 percent to 80 percent.
Fifty percent of the deaths also occur within the first 48 hours (Lewis et al., 2011). However, treatment of a hemorrhagic
stroke depends on its location but it is focused on stopping or reducing the bleeding, controlling the increased intracranial
pressure, preventing another bleed, and preventing vasospasm (Huether & McCance, 2012). Anticoagulants and platelet
inhibitors are contraindicated with patients with hemorrhagic stroke. However, oral and intravenous (IV) agents like
calcium channel blockers and vasodilators may be used to maintain blood pressure within a normal to high-normal range
of possibly a systolic blood pressure less than 160 mm Hg (Lewis et al., 2011). In addition, medications and blood
products may be administered to correct abnormal clotting (Osborn et al., 2014). The patient was admitted with
symptoms of right-sided weakness, right facial droop, and slurred speech with a possible stroke due to the history of
hypertension. It was diagnosed through a collection of medical and family history as well as a CT scan, chest x-ray,
carotid ultrasound, and an MRI. The patient was treated with nicardipine (Cardene) drip, a calcium channel blocker, to
keep his systolic blood pressure below 150 mm Hg and neurological assessments were performed every two hours.
5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF), home (reconciliation), routine, and PRN
medication . Give trade and generic name.]
Name lisinopril (Prinvil)
Concentration
Dosage Amount 5 mg
Route Oral
Home
Hospital
or
Both
Concentration
Route Oral
Home
Hospital
or
Both
Concentration
Dosage Amount 10 mg
Route Oral
Home
Hospital
or
Both
Indication Management of moderate to severe hypertension and systemic blood pressure over 150 mm Hg
Side effects: Headache, anorexia, nausea, vomiting, diarrhea, muscle cramps, tachycardia
Adverse effects: Severe orthostatic hypotension, skin flushing, severe headache
Nursing considerations: Obtain blood pressure and pulse before each dose; Monitor blood pressure.
Patient Teaching: Rise slowly from lying to sitting position to minimize orthostatic hypotension; Assess feet and ankles for fluid retention.
Concentration
Route Oral
Dosage Amount 30 mL
Frequency One Time Daily, PRN (as needed)
Home
Hospital
or
Both
Concentration
Dosage Amount 4 mg
Frequency every 4 hour interval, PRN (as needed)
Home
Hospital
or
Both
Concentration
Dosage Amount 40 mg
Frequency Continuous
Home
Hospital
or
Both
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? Mechanical Soft Food
Analysis of home diet (Compare to My Plate and
Diet patient follows at home? Regular Diet
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast: One banana, One cup of rice porridge, One tuna
salad sandwich
Lunch: One cup of rice, Two pieces of small baked chicken
breast
Dinner: One piece of small baked chicken breast, One cup
of rice, one cup of raw spinach, one piece of baked potato
Snacks: One cup of papaya pieces, one cup of watermelon
pieces
Liquids (include alcohol): One cup hot chocolate, seven
glasses of water (approximately 56 oz. of water)
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
The wife of the patient helps him when he is ill.
How do you generally cope with stress? or What do you do when you are upset?
Patient states, I read religious books and most especially, the bible when I feel stressed.
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient denies feelings of depression, anxiety, and being overwhelmed with relationships, friends, or social life.
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage
for your patients age group:
Eriksons stage eight of psychosocial development is ego integrity versus despair which is applicable for individuals
over the age of 65 years old. This stage is about the acceptance of ones life, worth, and eventual death. Ego integrity
shows a satisfaction with life and an understanding of the place of a person in the life cycle. Meanwhile, despair is a
sense of discomfort with life and aging, loss, and fear of death (Treas & Wilkinson, 2014).
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
This patient is undergoing Eriksons psychosocial development of despair because the patient made a statement about
his illness and he stated that, It means a lot because I do not know if I will come back around and what will happen to
me. In addition, the patient had a flat affect and he was speaking at a slow rate while answering questions related to his
illness.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
The development of hemorrhagic stroke due to the history of hypertension led this patient to Eriksons stage eight of
psychosocial development of despair because the patient stated that, My health right now may be the cause of my death
and I do not know if I will make it to my next birthday.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Patient states, I have no idea and I do not know how it started. It is just all in my brain.
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?_Yes_____________________
Do you prefer women, men or both genders? _Women__________________________
Are you aware of ever having a sexually transmitted infection? __No_______________
Have you or a partner ever had an abnormal pap smear?__No________________
Have you or your partner received the Gardasil (HPV) vaccination? ___No________________
Are you currently sexually active? __Yes_________ If yes, are you in a monogamous relationship?_Yes__________
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? Patient states, I do not use anything because we are faithful with each other.
How long have you been with your current partner?_21 years______________
Have any medical or surgical conditions changed your ability to have sexual activity? __No___________
Do you have any concerns about sexual health or
how to prevent sexually transmitted disease or unintended pregnancy? No
Yes
No
For how many years? years
(age
thru
Pack Years:
Does anyone in the patients household smoke tobacco? If
so, what, and how much?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
What?
How much?
Volume:
Frequency:
If applicable, when did the patient quit?
Yes
No
For how many years?
(age
thru
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age
thru
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
Patient denies exposure to any occupational or environmental hazards or risks.
5. For Veterans: Have you had any kind of service related exposure?
Not applicable
10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: one to two times a day
Other: Patient denies use of sunscreen.
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
2x/day
Routine dentist visits
Vision screening
Gastrointestinal
Immunologic
Genitourinary
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known: B+
Other:
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 4-5x/day
Bladder or kidney infections
Hematologic/Oncologic
Metabolic/Endocrine
Diabetes
1x/year
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR? 10/12/2015
Other: Patient states, I feel like I want to
cough.
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Childhood Diseases
Measles
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?10/12/2015
Other:
Pain
Gout
Osteomyelitis
Arthritis
Other: Patient states, I have not had any
fractures but I was in a car accident
before.
Mumps
Polio
Scarlet Fever
Chicken Pox
Other: Patient states, I had measles as a
child in 1950.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
Patient denies seeking any medical attention with anyone.
Any other questions or comments that your patient would like you to know?
Patient does not have any questions or comment that he would like to know.
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 15 inches & left ear- 15 inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Cardiovascular:
No lifts, heaves, or thrills
Heart sounds: S1 S2 Regular
Irregular
No JVD
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)
The lead II on this ECG six second strip shows a normal sinus rhythm with depressed T wave. The depressed T wave may
be an indication of a cardiac ischemia due to his history of hypertension and recent cerebral hemorrhage.
GI/GU:
Bowel sounds hypoactive x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color: Yellow
Previous 24 hour output: 700 mLs
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 10 / 14 / 2015 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)
Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:
Biceps:
Brachioradial:
Patellar:
Achilles:
Comments: CN I (Olfactory), II (Optic), V (Trigeminal), VII (Facial), VIII (Vestibulocochlear), X (Vagus), XI (Accessory),
XII (Hypoglossal) are intact. CN III, IV, VI (Oculomotor) - Patient has an intact EOM without nystagmus towards his right
side. The patient was not able to follow proper commands in assessing the EOM towards his left side. CN IX
(Glossopharyngeal) Patient has difficulty sticking tongue out. Stereognosis, graphesthesia, and proprioception are not
intact on his right hand and intact on his left hand. Rombergs test and gait were not assessed because patient does not have
the strength to stand up and his RLE is weak. DTR and Babinski reflex were not assessed because a knee reflex hammer
was not available during the time of assessment.
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
White Blood Count (WBC)
Normal (4.5-11)
Dates
6.6
(10/13/2015)
7.7
(10/14/2015)
6.8
(10/16/2015)
(10/13/2015)
4.55 (L)
(10/14/2015)
4.33 (L)
(10/16/2015)
Hemoglobin
Normal (13.2-17.3 g/dL)
12.6 (L)
(10/13/2015)
13.2 (L)
(10/14/2015)
12.7 (L)
(10/16/2015)
Hematocrit
Normal (40.7-50.3%)
37.8 (L)
(10/13/2015)
39.9 (L)
(10/14/2015)
38.0 (L)
(10/16/2015)
Platelet
Normal (150,000 400,000
microL)
(10/13/2015)
187
(10/14/2015)
185
(10/16/2015)
177
Trend
On admission, the patient
has a WBC within the
normal range. The WBC
trend continues to be
within the normal range
that shows that the patient
is not fighting off any
infection or
inflammation.
Analysis
WBC evaluates viral and
bacterial infections. A
WBC within the normal
range shows that the
patient does not have any
infection or
inflammation.
Sodium
Normal (135-145mEq/L)
139
(10/13/2015)
138
(10/14/2015)
136
(10/16/2015)
Potassium
Normal (3.5-5.3mEq/L)
3.9
(10/13/2015)
4.2
(10/14/2015)
4.1
(10/16/2015)
Chloride
Normal (97-107 mEq/L)
107
(10/13/2015)
107
(10/14/2015)
106
(10/16/2015)
(10/13/2015)
11
(10/14/2015)
10
(10/16/2015)
Creatinine
Normal (0.61-1.21 mg/dL)
0.9
(10/13/2015)
0.7
(10/14/2015)
0.9
GFR non-African American
Normal (60 or more)
(10/16/2015)
>60
(10/13/2015)
>60
(10/14/2015)
>60
(10/16/2015)
(10/12/2015)
Troponin I
Normal (less than 4.8 ng/mL)
0.01
(10/12/2015)
(10/12/2015)
Chest X-ray
(10/12/2015)
(10/12/2015)
On admission, the CT of
the brain showed an acute
parenchymal hemorrhage
centered within the left
basal ganglia and it also
showed a chronic small
vessel ischemic disease
within the white matter.
This shows that the
patient has a cerebral
infarction and
hemorrhage.
cardiomegaly which
shows that he may have a
cardiovascular disorder
possibly due to his
history of hypertension.
A CT of the brain is used
to visualize and assess the
brain to help diagnose for
tumor, bleeding, infarct,
infection, edema, and any
structural changes. The
CT of the brain was
performed due to the
right-sided weakness,
possible stroke, and
history of hypertension.
The CT showed an acute
parenchymal hemorrhage
centered within the left
basal ganglia and a
chronic small vessel
ischemic disease within
the white matter. This
shows that the patient had
a possible infarction as
well as a hemorrhage that
needs immediate medical
attention.
A carotid ultrasound is
used to visualize and
assess blood flow through
the carotid arteries to help
in evaluating a risk for
stroke related to
atherosclerosis. The
carotid ultrasound was
performed due to the
right-sided weakness,
possible stroke, and
history of hypertension.
The carotid ultrasound
showed no evidence of a
significant common or
internal carotid artery
stenosis. This indicates
that the patient does not
have any blockage on his
carotid arteries that
contributed to his right-
(10/14/2015)
sided weakness.
The MRI of the brain was An MRI of the brain is
performed two days after used to assess and
admission and it showed
visualize intracranial
an acute or recent
abnormalities related to
infarction adjacent to the tumor, bleeding, lesion,
left lateral ventricle and
and infarct such as stroke.
intraventricular
The MRI of the brain was
hemorrhage. An extensive performed due to his
parenchymal hemorrhage right-sided weakness that
is situated slightly
may be related to a
inferior in the left
possible stroke. The MRI
lentiform nuclei and a
showed an acute or recent
mild extent of
infarction adjacent to the
presumptive small vessel left lateral ventricle and
ischemic changes. This
intraventricular
indicates that the patient
hemorrhage. An extensive
has some bleeding in his
parenchymal hemorrhage
brain and an infarct that
is situated slightly
may have caused the
inferior in the left
right-sided weakness
lentiform nuclei and a
leading to a possible
mild extent of
stroke.
presumptive small vessel
ischemic changes. This
indicates that the patient
has some bleeding in his
brain and an infarct that
may have caused the
right-sided weakness
leading to a possible
stroke. This also shows
that the patient may need
more medical attention
for the possibility of a
stroke.
addition, the home medication of the patient which was lisinopril (Prinivil) is continued during this
hospitalization to help control his blood pressure. An MRI of the brain was also done and the results showed an
acute or recent infarction as well as an intraventricular hemorrhage. As the symptoms of the patient became less
critical, he started working with a physical therapist to regain his strength in the neurology medical unit. The
patient was also ordered a mechanical soft diet to prevent aspiration due to his right facial droop and impaired
swallowing He may be discharged to a rehabilitation facility after a few more days of observation.
15 CARE PLAN
Nursing Diagnosis: Ineffective cerebral tissue perfusion related to interruption of blood flow by cerebral hemorrhage as evidenced by high blood
pressure as well as weakness on right upper and lower extremities (Doenges, Moorhouse, & Murr, 2010).
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions
Evaluation of Goal on Day Care
Achieve Goal
Provide References
is Provided
Patient will maintain appropriate
1. Assess verbal response every
1. It is important to assess verbal 1. The patient maintained proper
orientation to person, place, time,
four hours or per unit protocol.
response because it measures
verbal responses, alertness, and
and situation by the end of shift.
Note whether client is alert,
appropriateness of speech and
appropriate orientation to
oriented to person, place, and
content of consciousness. It
person, place, and time.
time.
may also tell the amount and
2. The patient maintained
2. Perform a neurological
location of damage in the
baseline neurological status
assessment every four hours or
brain. Damage to midbrain,
with no signs of irregular or
per unit protocol.
pons, and medulla is
change in neurological status.
3. Monitor for changes in mental
manifested by lack or
3. The patient did not show signs
status or behavior every four
appropriate responses to
or changes in mental status or
hours or per unit protocol.
stimuli.
behavior
Note if patient is confused or if 2. It is important to perform a
patient uses inappropriate
neurological assessment
words or phrases that make
because fluctuations in level of
little sense.
consciousness and aphasia are
symptoms of cerebral
vasospasm.
3. It is important to assess
changes in mental status or
behavior because these
changes may lead to decreased
cerebral perfusion (Ackley &
Ladwig, 2011).
Patient will maintain usual or
improve motor and sensory
function by the end of shift.
well as non-purposeful
movements such as posturing
on right and left side.
2. Note presence or absence of
reflexes blink, cough, gag,
and Babinski reflex every four
hours or per unit protocol.
2.
1.
2.
3.
Nursing Diagnosis: Risk for Aspiration as evidenced by impaired swallowing, depressed cough, and depressed gag reflex (Ackley & Ladwig, 2011).
Patient Goals/Outcomes
Nursing Interventions to
Achieve Goal
References
Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care.
St Louis, MO: Mosby Elsevier.
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing care plans: Guidelines for individualizing
client are across the life. Philadelphia, PA: F.A. Davis Company.
Huether, S., & McCance, K. (2012). Understanding Pathophysiology. St. Louis, MO: Mosby Elsevier.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing: Assessment
and management of clinical problems. St. Louis, MO: Mosby Elsevier.
Osborn, K. S., Wraa, C. E., Watson, A. B., & Holleran, R. (2014). Medical-surgical nursing: Preparation for
practice (2nd ed.). Upper Saddle River, NJ: Pearson Education Incorporated.
Treas, L.S., & Wilkinson, J.M. (2014). Basic Nursing: Concepts, skills, and reasoning. Philadelphia, PA: F.A.
Davis Company.
USDA (n.d.) Supertracker. Retrieved from http://supertracker.usda.gov