Case study

Nursing C
Nursing Diagnosis

Impaired physical mobilityare.1

related to hemiparesis, loss of balance and coordination,  

.spasticity, and brain injury

Impaired verbal communication related to brain .2

.damage

Risk for impaired skin integrity related to.3

.hemiparesis or hemiplegia and decreased mobility

Significant diagnostic evaluation

Test Normal values Patient result rational

WBC /3*10 4.0-10.9 ml/3*10 12.9 ,High
ML
RBC /6*10 3.76-5.70 ml/6*10 2.56 Low, B/f anemia
CBC ML
HGB G/dl 12-17.5 g/dl 7.7 Low, B/f low of
RBC
HCT %.33.5-51 % 22.6 Low,B/f low of
RBC
PT sec 11-15 sec 14.5 With normal
rang
INR - 1.23 High, B/f
ischemic stroke
PTT 25-35 sec 35 Within normal
sec rang
ESR m (0-15 mm 65 High
mm)
glucose )74-109( 189 High, patient
 mg/dl diabetic
+Na 135-145 133 Within normal
Bio meq/l rang
+K meq/l 2.5-3.5 4.5 High , renal
disease
creatinin 0.7-1.2 11.51 High, renal
disease

PATHOPHYSIOLOGY
Pathophysiology Ischemic Occlusion of a blood vessel from
thrombus, embolism, or conditions that produce low systemic
perfusion pressure Cerebral thrombosis is a formation or
developing clot within the cerebral arteries or their branches.
Thrombi can lead to ischemia or occlusion of an artery which
could result in a cerebral infarctions or tissue death
(atherothrombotic brain infarction [ABI]) subtypes include large
artery, atherosclerosis, cardiogenic embolism, small vessel
.occlusive disease

Risk Factors Major risk factors heart disease hypertension

diabetes Risk factors such as diabetes mellitus, hyperlipidemia,
cigarette smoking, and hypertension fail to distinguish between
.ischemic and hemorrhagic types of stroke

Confirmed diagnosis : ischemic stroke

Age: 68 year
Gender: female
Assessment
:reason for hospitalization 1

Left side weakness, Dizziness, fatigue, loss of

consciousness

history 2
Signs and symptoms: weakness, fatigue, slurred speech,
severe headache from increased intracranial
 pressure

Risk factor: Diabetes

HTN, DM, Age
Past medical history: Diabetic since 2005, Hypertension
since 2008
Past surgical history: Free surgical history

Druds
Trade Generic name dos indication classification
name e
Acetylsalicyli 100 Aspirin blocks the Platelet inhibitor
Aspiri c acid mg effects of
n *1 cyclooxygenase-1
(COX-1) and COX-
2 enzymes which
prevents the
synthesis of
.prostaglandins
lolip Atrovastatin 40 Inhibitor of 3- antihypercholesterolemia
mg hydroxy-3-
 *1 methylglutaryl
coenzyme A
(HMG-CoA)
reductase, the
rate-limiting
enzyme in
cholesterol
synthesis
Randine ranitidine  50 Competitive
mg inhibition of
*3 histamine at H2- antiacid
receptors of the
gastric parietal
cells, which
inhibits gastric
acid secretion,
gastric volume,
and hydrogen ion
concentration are
.reduced
plavix clopidogrel 75 Inhibit platelet Platelet inhibitor
mg aggregation by
*1 blocking APP
receptor on platelet
,preventing
clomping of platelet

Nursing Intervention
 Positioning. Position to prevent contractures, relieve pressure, attain
good body alignment, and prevent compressive neuropathies.
 Prevent flexion. Apply splint at night to prevent flexion of the affected
extremity.
 Prevent adduction. Prevent adduction of the affected shoulder with a
pillow placed in the axilla.
 Prevent edema. Elevate affected arm to prevent edema and fibrosis.
 Full range of motion. Provide full range of motion four or five times a
day to maintain joint mobility.
 Prevent venous stasis. Exercise is helpful in preventing venous
stasis, which may predispose the patient to thrombosis and pulmonary
embolus.
 Personal hygiene. Encourage personal hygiene activities as soon as
the patient can sit up.
 Manage sensory difficulties. Approach patient with a decreased field
of vision on the side where visual perception is intact.
 Visit a speech therapist. Consult with a speech therapist to evaluate
gag reflexes and assist in teaching alternate swallowing techniques.
 Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on
patient’s voiding schedule.
 Assess skin. Frequently assess skin for signs of breakdown, with
emphasis on bony areas and dependent body parts.