Question

To start, thank you to whoever can help me clear this up a little better! I have a simulation to prepare for in Nursing in which I care for this hypothetical patient and I wanted to make sure I have all my priorities straight. I was given a hypothetical patient with the below characteristics, and my question is what are my priorities with this patient as a senior nursing student and challenges might I expect to be thrown at me during my simulation?

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CLINICAL CASE INFORMATION:

M.J. is a 77 year old man who presented to the emergency department after a 48 hour history of right facial droop, difficulty swallowing, slurred speech, and marked weakness of his right arm and leg. He additionally admitted to a headache and “heart skipping” for about a week prior. Initial vital signs were T- 36.8, BP- 240/100, P- 136, RR-22, SpO2- 90% room air, Weight- 82kg. CT imaging 2 confirmed a left sided thromboembolic CVA and EKG revealed a new diagnosis of atrial fibrillation. Routine lab work was significant for a serum blood glucose of 422. Oxygen at 2L NC was applied. An IV site was established in his left hand and left forearm with a Heparin drip of 25.000 units/ 250 cc NS to run at 1,000 units an hour. He was additionally treated with IV Cardizem that has been bridged to an oral dose. His blood glucose was treated with Novolog insulin per sliding scale and a 16F NGT was placed to his left nare at a marking of 64 cm. Placement was confirmed via xray (KUB) and pH aspirate.

Medical History: HTN, Hyperlipidemia, Diabetes Mellitus Type II

Surgical History: Inguinal hernia repair 2002

Social History: : Non-smoker. Social drinker 1-2 drinks/week. Married to wife Betty, they live in a one story ranch home with 5 steps to enter home. Five children with one deceased. Youngest child and family are 20 minutes away and visit weekly.

Allergies: NKDA

Home Medications: Metoprolol, Hydrochlorothiazide, Aspirin, Potassium, Simvistatin, Glipizide, and a Multivitamin

Current Medications: Above listed plus- Heparin drip per protocol, Oxygen with titrate, Cardizem, Coumadin, Labetalol, Novolog sliding scale

REPORT FROM OUTGOING NURSE:

M.J. is alert and oriented. He has slurring of his speech and a right facial droop. Speech evaluation has not been completed yet. Pupils are equal and reactive, gag reflex is diminished, 5/5 strength on left side and 3/5 strength right arm and leg. Positive sensation in all extremities. Denies headache presently. S1, S2 are present and irregular. +1 edema of right ankle and foot, generalized edema of right arm. +2 bilateral radial and pedal pulses. Lung expansion is equal with good effort and diminished bases bilaterally, posteriorly. 2L NC is intact. Neutrin is infusing at 40 cc/ hour through NGT to left nare. Bowel sounds are present. Voiding clear yellow urine in urinal without sediment or odor. IV to left hand intact with Heparin infusing. Lab work for this morning has been drawn and results are pending.

EXPECTED OUTCOMES

1. Nurse understands proper patient positioning and ramifications in regard to NG tubes and feedings.

2. Nurse understands relationship between abnormal vital signs to disease state and treatments.

3. Nurse understands relationships between predisposing factors to past and current disease states.

4. Nurse critically thinks through scenario and takes action based on findings.

5. Nurse determines educational needs and provides appropriate education to patient and family.

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Answer 1

Below are broadly discussed the nursing diagnosis based on priority along with the interventions that needs to be taken for each problems-

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

• Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.
• Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.
• Monitor vital signs
• Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
• Assess higher functions, including speech, if patient is alert.
• Position with head slightly elevated and in neutral position.

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

• Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.
• Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.
• Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.
• Place pillow under axilla to abduct arm
• Discontinue use of footboard, when appropriate.
• Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.
• Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet.
• Encourage patient to assist with movement and exercises using unaffected extremity to support and move weaker side.

Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.

• Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated.
• Always check the position of the client. Make sure that the position of the client with a tube feeding remain with the head of bed elevated at least 30 to 40 degrees. Never feed the client with supine position. Semi-Fowler’s or full-Fowler’s position prevents aspiration pneumonia and possible death due to pulmonary complications.
• Clamp the feeding setup and suspend on pole. Add feeding solution to the bag. Open the clamp and prime the tubing. Formula clears air from the tubing and prevents it from entering the stomach.
• Stop the feeding every 4 to 8 hours and assess the residual. Flush the tube every 6 to 8 hours.
• Stop feeding when completed. Instill prescribed amount of water. Keep the client’s head elevated for 20 to 30 minutes.

Impaired Verbal Communication: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

• Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making self understood. Differentiate aphasia from dysarthria.
• Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences;
• Point to objects and ask patient to name them.
• Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid pressing for a response
• Consult and refer patient to speech therapist.

Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

• Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination.
• Eliminate extraneous noise and stimuli as necessary.
• Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.
• Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.
• Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching walls boundaries.

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

• Identify meaning of the dysfunction and change to patient. Note ability to understand events, provide realistic appraisal of the situation.
• Determine outside stressors: family, work, future healthcare needs.
• Encourage patient to express feelings, including hostility or anger, denial, depression, sense of disconnectedness.
• Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Use words (weak, affected, right-left) that incorporate that side as part of the whole body.
• Emphasize small gains either in recovery of function or independence.
• Support behaviors and efforts such as increased interest/participation in rehabilitation activities.
• Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, withdrawal.

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

• Assess type and degree of sensory perceptual involvement.
• Discuss specific pathology and individual potentials.
• Identify signs and symptoms requiring further follow-up: changes or decline in visual, motor, sensory functions; alteration in mentation or behavioral responses; severe headache.
• Reinforce current therapeutic regimen, including use of medications to control hypertension, hypercholesterolemia, diabetes, as indicated; aspirin or similar-acting drugs, for example, ticlopidine (Ticlid), warfarin sodium (Coumadin). Identify ways of continuing program after discharge.
• Provide written instructions and schedules for activity, medication, important facts.
• Encourage patient to refer to written communications or notes instead of depending on memory.
• Discuss plans for meeting self-care needs.