Developing Critical Thinking Through

Understanding Pathophysiology
Primary problem (medical diagnosis) of patient: Embolic Stroke

1. Define and describe in your OWN WORDS, the pathophysiology of the primary problem of your patient:

An embolic stroke is a type of ischemic stroke. A thrombus that had formed somewhere in the body loosened and
traveled through the blood vessels to the brain. Once in the brain the thrombus became lodged in a blood vessel. It
blocked the flow of blood to the tissues in the brain. This results in ischemic areas in the brain which results in a decrease
in brain function and permanent damage.

2. How would you explain and teach your patient about the pathophysiology of this medical problem using non-
medical terminology?

You have suffered from a stroke. There was a blood clot that formed in your body, and it became lodged in a blood vessel
in your brain. The brain needs blood to function properly, and the clot was blocking that blood flow. This has caused your
brain to become damaged.

3. What body system(s) are directly impacted by this disease and how are those systems affected?
BODY SYSTEM(S): HOW BODY SYSTEM IS AFFECTED(S):
Neuro Loss of motor functions affecting the left side of the body; hemiplegia of the left side.
Respiratory Loss of movement lead to atelectasis and pneumonia.
Digestive Dysphagia; unable to swallow foods; PEG tube placement.
Skin Loss of movement lead to impaired skin integrity; pressure injury on coccyx.
Circulatory Risk for developing blood clots

4. PRIORITY nursing assessments with this disease? (refer to body system that is most affected). What assessment
findings may be abnormal as a result of this illness?
PRIORITY ASSESSMENTS: EXPECTED ABNORMAL ASSESSMENTS:
Assess respiratory function, Adventitious breath sounds, shortness of breath, low O2 saturation, dyspnea, fever,
neurological function, level of elevated pulse, tachypnea, tachycardia, fatigue, altered nerve sensation, sluggish pupil
consciousness, nutritional status, response, reduced ROM, reduced muscle strength, altered mental status, altered LOC,
hydration status, skin integrity, dysphagia, dysphasia, inadequate nutrition intake, poor skin turgor, reddened areas of
circulatory function, and skin, areas of skin that are warm to touch, pressure injuries, non-blanching skin,
psychological assessment. abnormal electrolyte levels, weight loss, slow capillary refill, edema, chest pain,
hypotension, pain in extremities, behavior and mood changes

5. What lab tests are altered by this problem? How are those lab tests affected? Does the altered lab test affect any
physical assessment findings?
ABNL. LAB TESTS: HOW LAB TESTS AFFECTED: DOES IT IMPACT ASSESSMENTS?
WBC Increased WBC count may indicate an infection. Assess and monitor S/S of infection.
Platelets Increased platelets may indicate inflammation and Monitor for anemia & blood clots.
H&H anemia. Assess and monitor nutritional status.
Decrease in hemoglobin & hematocrit may indicate Assess and monitor for overt & occult
anemia, bleeding, malnutrition. bleeding.
6. What medications are most commonly used to manage this problem?
MEDICATIONS:
Heparin
Percocet
Gabapentin
Zosyn
Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
Problem # 1 Impaired physical mobility
Assessment
Abnormal Findings
Formulate Diagnosis
Nursing Diagnosis formed
from NANDA category R/T
S/O data
Plan
Goal from patient’s
viewpoint.
Indicate measurable
outcomes and include time
frame.
Interventions (6)
Important: Begin with action
verb; indicate type,
frequency, amount where
appropriate;
State scientific rationale/
psychological principle for
each intervention.
MECHANISM OF ACTION (OWN WORDS):
Anticoagulant to help prevent further blood clots from forming.
Opioid to control pain
To control nerve pain
Antibiotics to help combat bacterial infection that has caused pneumonia.
Subjective Data: RN states “Our patient has suffered a stroke and is currently unable to
move his left side.”
Objective Data: pt unable to move left side of body; can sense feeling and pain on left side of
body; unable to sit up in bed; unable to perform ADLs
Nursing Diagnosis (actual or risk for)
Impaired physical mobility R/T inability to move upper and lower extremities on the left
side.
Goal: The pt. will improve in physical mobility by 9/12/23
Outcomes: As evidenced by patient’s ability to participate in ADLs as independently as
possible; sit at the end of the bed with assistance
Interventions: Rationale:
1. Assess patient’s physical deficiencies and 1. Establishes a baseline to
abilities at the beginning of treatment compare progress to.
and on the regular basis. 2. Exercise program needs to be
individualized to meet each
2. Consult with PT and OT to make an patient’s needs.
effective plan of action. 3. Helps to prevent contractures,
decreases atrophy of the
3. Teach and encourage ROM exercises muscles, and increases
starting with passive and move into circulation.
active as tolerated by the patient. Active 4. Helps to prevent foot drop and
ROM should be completed by the patient contractures.
on the unaffected (right) side. 5. When the patient is involved in
the care plan they are more
 4. Keep extremities that are immobile in likely to follow through and this
their functional position. gives them a sense of
independence.
5. Include the patient in their exercise 6. Enhances neurological
planning and goal setting. pathways, motor response, and
proprioception.
6. Assist the patient in developing their
balance for sitting up by raising the HOB
a little more each day to better prepare
them gradually until they are ready to sit
up at the edge of the bed.

Evaluation Goal has been: partially met

Have the goals/outcomes

been met? Provide evidence: PT is actively working with
patient to sit at the edge of the bed but is only
Provide evidence. able to do so for a few seconds at a time. Patient
can brush their own teeth with a little assistance.

Problem # 2 Impaired verbal communication

Assessment Subjective Data: RN states “Our patient has a trach so he will be unable to speak.”

Abnormal Findings
Objective Data: Tracheostomy is impeding the patient from communicating verbally; Patient
can understand what is being said to them; responds to questions with hand gestures and
head movements.

Formulate Nursing Diagnosis (actual or risk for)

Diagnosis
Impaired verbal communication R/T tracheostomy
Nursing Diagnosis
formed from
NANDA category
R/T S/O data

Plan Goal: The pt. will establish an effective way to communicate their needs by 9/6/23

Goal from patient’s

viewpoint. Outcomes: As evidenced by the patient’s ability to communicate their needs through an
Indicate measurable alternative means of communication.
outcomes and
include time frame.

Interventions: Rationale:
Interventions (6)
1. Post signage to indicate that the 1. This makes medical staff aware of
Important: Begin patient is non-verbal. the patient’s situation.
with action verb; 2. Gives a form of communication so
indicate type, 2. Provide the patient with an alternate that the patients needs can be
frequency, amount way of communication such as a expressed and met.
where appropriate; picture board or a list of needs so that 3. A speech therapist may be better
State scientific he can point to indicate his current able to assess the pateient and
rationale/ needs. come up with various ways to aid
psychological the patient in regaining means of
principle for each 3. Consult with speech therapist. communication.
intervention. 4. Avoids additional confusion and
4. Speak to the patient in a clear and anxiety when the patient is already
concise manner. having a difficult time
communicating.
5. Provide hourly checks on the patient. 5. Since the patient is non-verbal
regularly checking in on them can
6. Keep the call bell within reach of the help prevent frustrations of unmet
patient and answer the call quickly. needs.
6. The patient needs to be able to call
for help or assistance and since the
patient is non-verbal this is one of
the only ways that can be
accomplished. Answering he call
promply can alleviate the patient’s
anxiety and feelings of
helplessness.

Evaluation Goal has been: partially met 9/6/23

Have the
goals/outcomes Provide evidence: Patient is able to point to
been met? thing he needs; answers yes or no questions
with a thumbs up or down.
Provide evidence.
Problem # 3 __Risk for infection_

Assessment Subjective Data:

Abnormal Findings
Objective Data: Patient has a tracheostomy that bypasses the nose and mouth which are
major components of the innate immune system

Formulate Nursing Diagnosis (actual or risk for)

Diagnosis
At risk for infection R/T tracheostomy
Nursing Diagnosis
formed from
NANDA category
R/T S/O data

Plan Goal: The patient’s stoma site will remain free from infection during this hospital stay.

Goal from patient’s

viewpoint. Outcomes: As evidenced by the patient’s stoma will remain free of erythema, inflammation,
Indicate measurable exudate, and lesions.
outcomes and
include time frame.

Interventions: Rationale:
Interventions (6)
1. Assess the skin’s integrity underneath 1. Infection and skin breakdown
Important: Begin the faceplate and ties of the happen here often so it is
with action verb; tracheostomy. imperative that the area is
indicate type, monitored for S/S of infection.
frequency, amount 2. Perform hand hygiene properly before 2. Proper hand hygiene is the best
where appropriate; and after giving any care to the stoma way to prevent hospital aquired
State scientific area. illness.
rationale/ 3. Secretions can build up and pool
psychological 3. Keep the area around the stoma and around the stoma and the back of
principle for each around the neck ties clean and dry the neck creating a breeding
intervention. utilizing aseptic technique. ground for bacteria, skin irritation,
and breakdown.
4. Wear the proper PPE when providing 4. Helps to reduce the transmission of
stoma care. infection.
5. The inner cannula should be
5. Provide stoma care utilizing clean and cleaned or replaced regularly to
aseptic techniques. prevent secretions from building
up. These secretions could occlude
6. Observe and monitor the stoma for the airway and harbor infectious
S/S of infection such as redness, microorganisms.
exudates, and lesions. 6. At the first S/S of infection the
provider should be contacted so
that a culture and sensitivity test
can be performed. That way
treatment for any infection can be
treated before it spreads.
 Evaluation Goal has been: met as of 9/6/23

Have the
goals/outcomes Provide evidence: The patient’s stoma has
been met? been free of S/S of infection since 8/5/23 when
the tracheostomy was performed.
Provide evidence.

Patient Medication Profile

Patient # ____S____________ Age ___52________ Admitting Diagnosis _Embolic Stroke________

Comorbidities _Pneumonia, sepsis, HTN,

Diabetes_______________________________________________________________

History _DVT, Diabetes, Hypothyroidism,

Cancer____________________________________________________________________

Medication:
Reason Required
Dosage Drug Category Side Effects
Prescribed Assessments
Frequency
Chlorhexidine Antimicrobial To prevent Be sure the Staining of the teeth,
gluconate 0.12% nosocomial patient is not increase in plaque buildup
oral rinse respiratory allergic to (calculus), and altered
BID infection chlorhexidine. taste perceptions, irritation
Patients should in the mouth, and
 not swallow hypersensitive reactions
the rinse.
Folic acid Antianemic To help correct Assess Rash, irritability, difficulty
1 mg tablet Vitamin anemia patient’s sleeping, malaise,
crushed & supplement hemoglobin confusion, fever
administer via and hematocrit
PEG for
Once a day effectiveness
Gabapentin Analgesic Postherpetic Assess pain ataxia, confusion,
250 mg/5mL neuralgia, level, monitor depression, dizziness,
Oral solution neuropathic for changes in drowsiness,
administer via pain, & behavior, Rhabdomyolysis, Stevens-
PEG migraine monitor Johnson Syndrome,
BID prevention respirations Suicidal thoughts
when
administered
with an opioid
analgesic
Guaifenesin Expectorant Aids in Assess lung dizziness, headache, rash,
200mg/10mL expectorating sounds, cough, urticaria, nausea, diarrhea,
Oral solution excess mucous and bronchial stomach pain, vomiting
administer via from upper secretions.
PEG respiratory Maintain
Q 8hrs infection by adequate fluid
thinning lung intake to help
secretions reduce
viscosity of
lung
secretions.
Heparin Anticoagulant Prophylaxis for Assess for S/S Increased risk for
5,000 U thromboembolic of bleeding, Bleeding, Heparin induced
Subq Antithrombotic disorders (decrease in thrombocytopenia (HIT),
Q 8hrs hematocrit, rash, urticaria,
decrease in BP, hyperkalemia, increased
guaiac, other liver enzymes, anemia,
occult pain at injection site, fever
bleeding),
monitor CBC
and platelet
count (HIT)
Hydralazine Antihypertensive HTN treatment Monitor BP & Hypotension, orthostatic
50 mg tab to reduce BP pulse. Some hypotension, tachycardia,
crushed & Vasodilator populations angina, arrhythmias,
administer via may be slow edema, dizziness,
PEG acetylators and drowsiness, headache,
Q 8hrs at risk for diarrhea, nausea,
toxicity. Some vomiting, rash, arthralgias
populations (joint stiffness), arthritis,
may be rapid peripheral neuropathy,
acetylators and drug-induced lupus
at risk for syndrome
 failed
treatment.
Insulin glargine Antidiabetic Long-acting Assess for S/S Hypoglycemia,
100 U/ml insulin used to of hypokalemia, cutaneous
Once daily reduce blood hypoglycemia amyloidosis,
Sub q glucose and lipodystrophy, pruritus,
hyperglycemia. erythema, swelling
Monitor
changes in
weight (might
need to adjust
dose)
Insulin regular Antidiabetic Dose coverage Assess for S/S Hypoglycemia,
100 U/3mL protocol for of hypokalemia, cutaneous
Sub q hyperglycemia hypoglycemia amyloidosis,
Q 6hrs and lipodystrophy, pruritus,
hyperglycemia. erythema, swelling
Monitor
changes in
weight (might
need to adjust
dose)

Medication:
Reason Required
Dosage Drug Category Side Effects
Prescribed Assessments
Frequency
Lansoprazole Proton pump Prophylactic toMonitor for S/S of Hypocalcemia,
30 mg solutab inhibitor prevent gastricoccult bleeding. hypokalemia,
dissolved & Antiulcer ulcerations Monitor stools for hypomagnesemia,
administer via signs of CDAD. diarrhea, B12 deficiency,
PEG Monitor for severe nausea, dizziness,
skin reactions (i.e., headache, CDAD
DRESS, SJS,
TEN)
Levothyroxine Thyroid hypothyroidism Assess apical pulse Hyperthyroidism, angina,
175 mcg tabs hormone & BP before arrhythmias, tachycardia,
crushed & replacement administering and sweating, heat intolerance,
administer via periodically during abdominal cramps,
PEG treatment. Monitor diarrhea, vomiting, weight
Q AM for loss, headache, insomnia,
tachyarrhythmias irritability
and chest pain
Losartan Angiotensin II Reduces BP & Assess BP and Hypotension, dizziness,
50 mg tab receptor blocker reduces risk of pulse. Assess for fatigue, headache,
crushed & (ARB) stroke face swelling & insomnia, weakness, chest
administer via Antihypertensive dyspnea (S/S of pain, edema, nasal
PEG angioedema) congestion, hypoglycemia,
Once daily weight gain, diarrhea,
abdominal pain,
dyspepsia, nausea,
impaired renal function,
 hyperkalemia, myalgia,
angioedema, fever
Melatonin Sedative Helps to Assess sleep Hypotension, drowsiness,
3 mg tab crushed hypnotic maintain patterns for headache, dizziness,
& administer via regular sleep effectiveness and nausea, vomiting,
PEG patterns improvement. abdominal cramps
Before bedtime Monitor for
bleeding when
taken with
anticoagulants.
Monitor blood
glucose levels as
drug can reduce
effectiveness of
hypoglycemic
meds.
Nystatin Antifungal Treatment for Assess oral cavity diarrhea, nausea, stomach
100,000 U/ 5mL candidiasis of & mucous pain, vomiting, contact
oral suspension the mouth membranes before, dermatitis, Stevens-
QID (thrush) during, & after Johnson syndrome
treatment & for an
increase in
irritation.
Polyethylene Osmotic laxative Treatment for Assess bowel Abdominal bloating,
glycol occasional movement cramping, flatulence,
17G constipation frequency, amount, nausea, urticaria
Administer via color, consistency.
PEG Assess bowel
Once daily sounds, abdominal
distension.
Potassium & Mineral & For inadequate Monitor calcium, hypocalcemia,
sodium electrolyte phosphorus phosphate, hyperkalemia,
phosphate supplement intake from potassium, & hypernatremia,
TID NPO diet sodium levels. hyperphosphatemia
Assess for S/S of arrhythmias, cardiac
hypokalemia arrest, bradycardia, EKG
hypophosphatemia. changes, diarrhea,
Monitor I&O for abdominal pain, nausea,
significant vomiting
changes.
Quetiapine Antipsychotic For decreasing Monitor for weight gain,
150 mg tabs Mood stabilizer episodes of changes in mental hyperglycemia,
crushed & depression & status, suicidal constipation, dizziness,
administer via psychosis tendencies, weight. sweating, dry mouth,
PEG Monitor for sedation, DRESS, SJS, GI
At bedtime extrapyramidal obstruction, Pancreatitis,
side effects and Seizures, Agranulocytosis,
tardive dyskinesia neuroleptic malignant
syndrome, extrapyramidal
symptoms
 Medication:
Reason Required
Dosage Drug Category Side Effects
Prescribed Assessments
Frequency
Senna/docusate Stool softener Preventative Assess bowel Electrolyte imbalances,
sodium Stimulant for opioid movement dehydration, abdominal
8.8 mg/5mL laxative induced frequency, cramps, nausea, vomiting,
solution constipation amount, color, diarrhea, rashes, urine
Administered via consistency. discoloration (reddish)
PEG Assess bowel
Once daily sounds,
abdominal
distension.
Thiamine Vitamin B1 dietary Assess Side effects are rare and
100mg tab supplement supplement nutritional generally only occur with
crushed & status. Monitor large doses or IV
administer via for thiamine administration
PEG deficiency
Once daily
piperacillin / Antibiotic Combat Ask patient of pain, phlebitis at the IV
tazobactam Extended pneumonia & known site, nausea, vomiting,
3.375G IVPB spectrum sepsis allergies to constipation, diarrhea,
run over 4hrs penicillin penicillin & superinfection, CDAD,
Q 8hrs cephalosporins DRESS, SJS, TEN,
. Assess confusion, dizziness, rash,
infection urticaria, seizures in high
before & doses, interstitial nephritis,
during renal failure, bleeding,
treatment. leukopenia, neutropenia,
Monitor for thrombocytopenia
anaphylaxis &
skin reactions.
Monitor bowel
movements for
CDAD.
Monitor for
DRESS &
eosinophilia
Acetaminophen Antipyretic Fever Monitor for Rash, SJS, TEN, urticaria.
650 mg Non opioid reduction hepatotoxicity hepatotoxicity, increased
suppository PRN analgesic with regular liver enzymes,
for fever use and ETOH renal failure, neutropenia,
Q 4hrs abuse. Assess pancytopenia
pain & fever
level. Monitor
for rash & SJS.
Percocet 5/325 opioid/nonopioid Control Assess Respiratory depression,
1 tab PRN for analgesic moderate pain respiration, orthostatic hypotension,
pain rated 4-7 combination BP, & pulse flushing, sweating, blurred
verbal or 3-6 on before & after vision, diplopia, miosis,
NVPS administering. adrenal insufficiency,
Q 4hrs via PEG Monitor for constipation, dry mouth,
respiratory choking, GI obstruction,
depression. nausea, vomiting, urinary
Assess pain retention, confusion,
level before & sedation, dizziness,
1 hour after dysphoria, euphoria,
administering. floating feeling,
Assess bowel hallucinations, headache,
function. unusual dreams, physical
Assess risk for & or psychological
opioid dependence, tolerance
addiction,
abuse, or
misuse before
administering.
Percocet 5/325 opioid/nonopioid Control severe Same as above Same as above
2 tabs PRN for analgesic pain
pain rated 8-10 combination
verbal or 7-10 on
NVPS
Q 4hrs via PEG