Answered step-by-stepCLINICAL SCENARIO: September 23, 2021 a
Answered step-by-stepCLINICAL SCENARIO: September 23, 2021 at 5 am Mr. Fernandez a 43…CLINICAL SCENARIO: September 23, 2021 at 5 am Mr. Fernandez a 43 year old lived in Bulacan, City, Filipino, Roman Catholic, a jeepney driver his birth day is on March 13, 1978, was been confined again in the hospital of FUMC under the service of Dr. Jose with initial admitting diagnosis of CVA probable infarct vs. Hemorrhage, with chief complain of impaired verbal communication and he spent more than 7 days in the hospital. Mr. Fernandez wife said that while Mr. Fernandez is talking with is friend and drinking alcohol he experienced severe headache, sudden dizziness, paralysis in the right part of his body, numbness, blurred vision and loss of consciousness. And made his family to bring him into the hospital. Mr. Fernandez wife verbalized that Mr. Fernandez was already been confined on the hospital before due to mild stroke last year December 2020, while he is in their house he experience sudden headache, dizziness, numbness, blurred vision and that made his wife to bring him into the hospital. Mr. Fernandez was confined for 4 days and after a week he was able to work again as jeepney driver though the doctor said he need to take rest from work, avoid stress, smoking, alcohol intake, and high fat/ salt food to avoid the stroke. The patient’s family history has hypertension in her mother side, diabetes mellitus And his father and grandfather die because of stroke but there are no other medical illnesses indicated. No known allergies. Mr. Fernandez wife said that his husband was a smoker, he consumed more than 30-40 pieces a day (1 1/2 pack) since 20 years old and he also drink 1 bottle of alcohol since 23 years old. Mrs. K said that her husband likes to eat pork after a long day of handling his jeep. COURSE IN THE WARDThe patient lying on bed, unconscious with an IVF of PNSS 1 L regulated at KVO level infusing well at left hand using gauge 20. With Nasogastric Tube inserted. Start OF 1, 600 kcal/day divide into 6 equal feeding, plus 60 cc of water after each feeding With Foley Catheter inserted with 2000 ml. urine bag with in your shift “The patient is having a hard time speaking and sometimes she is mumbling.” as verbalized by Mr. Fernandez’s wife.”(+) difficulty in speaking, (+) weakness, (+) dizziness, (+) blurred vision (+) paralysis on right part of the body.Citicoline 1 gram TIV every 12 hours (9am-9pm) Aspirin 8o mg 1 tab OD at 1 pm Metropolol (Neobloc) 100 mg tab 1 tab. OD (9am)Hydralazine (Apresoline) 25 mg 1 tab every 6 hours ( 12 mn, 6 am, 12 noon , 6 pm) Mannitol 100 mg thru soluset IV every 6 hours (12 mn, 6 am, 12 noon, 6 pm) Lab. Request for CBC with platelet count, HDL, Crea, ECG, CT scan of the Brain Stat, Urinalysis GENERAL SURVEY September 23, 2021 at 6:00 am VITAL SIGNS FINDINGSTemperature 37.3Pulse Rate 77 bpm Oxygen Saturation 94%Respiratory Rate 21 cpm Blood Pressure 200/110 mmHgMAP:Weight : 60 kg Height : 5′ 6 PHYSICAL ASSESSMENT: AREA ASSESSED ACTUAL FINDINGS SKIN Color Pale Texture Smooth, soft Turgor Skin snaps back immediately When pinched Hair Distribution Evenly distributed Temperature Warm to touch Moisture Dry, skin folds are normally moist NAILS Color of Nail bed Pink and clear Texture Smooth Shape Convex curvature Nail base Firm Capillary refill time 4 second HAIRColor Black (varies) Distribution Evenly distributed Moisture Neitherexcessively dry nor oily Texture Silky, resilient HEAD Scalp symmetry SymmetricalSkull size NormocephalicShape Round Nodules/masses Absence of nodules and masses FACESymmetry Symmetrical Facial Movement Symmetrical Skin color Pale EYESEyebrows Symmetrically aligned, equal movement Eyelashes Slightly curved upwardEyelids Smooth, tan, do not cover pupil as sclera, close symmetrically Ability to blink Blinks involuntarily Frequency of blinking To speech Ocular movement Lack of eye movement Position Drawn from lateral angel Size Medium Texture Mobile, firm and non-tender CONJUCTIVA Color Transparent with light color Texture Shiny and Smooth Presence of lesions No lesions APPARATUS CorneaColor Black Texture Shiny and smooth PUPILS Color Black Reaction to light Pupils Equally Round and React to LightAccommodation (PERRLA)Size Equal Shape Round and constrict briskly Symmetry Equal in size Visual Acuity Cannot able to real news print Visual Fields With blurred vision and cannot classify objects inperipheryOcular Eyes move freely NOSESymmetry, shape, size and color Symmetrical, smooth and tan Mucosa color Reddish to pinkish NASAL SEPTUM Nares Oval, symmetrical Nasal discharge No discharge Sinuses Not tenderMOUTH Secretion Without mucus production LIPSColor Dark and brown and crackling lips Symmetry SymmetricalTexture Crack, roughsMoisture DryGUMSColor PaleMoisture MoistBUCCALMUCOSAColor Slightly paleTexture SoftMoisture MoistTOUNGEColor Slightly pinkishSize MediumSymmetry SymmetricalMobility Moves freely UVULALocation At the midlineSymmetry SymmetricalTONSILSColor PinkishDischarges No dischargesTEETHColor YellowishNumber of teeth 28NECKPosition Head-centeredMovement Moves freelyRange of motion No ROMConsistency No enlargementHEARTHeart rate 77 bpmHeart sounds ClearLung field ResonantTHORAX & LUNGS POSTERIOR THORAXSymmetry SymmetricalRespiratory rate 21 cpmSpinal Alignment Spine vertically alignSkin integrity Skin intactANTERIORTHORAXBreathing patter Breathing is automatic and effortless, regular and even and produces no noiseLung/ breathsounds Bronchia-vesicularABDOMENContour FlatTexture SmoothFrequency and character Audible; soft gurgling sound occur irregularly and rages from 5-30 minsUPPER/ LOWEREXTREMITY (+)Paralysis on right part of the bodyNEUROLOGICALLevel of consciousness UnconsciousBehavioral and appearance Does not make eye contact with the examiner.Mood Expresses feelings which corresponds to the examinerMANNERISMS & ACTIONSLANGUAGESlightly curved upward AphasiaTone AphasiaManner and speech Cannot give answer or talk.MENTAL STATUSOrientation Disoriented with timeTIMERecall recent and remote memory Cannot recall events readily, immediate recall of remote informationJudgments and thoughts Cannot make logical Neurological Assessment (September 23, 2021)Gloscow Coma Scale Result TotalEyes To speech- 3 Total GCS=Verbal None- 1 Motor Flexion pain- 4 Cranial Nerve Actual ResultOlfactory Nerve Cannot able to extinguish smellOptic Nerve Without 20/20 vision.Occulomotor Nerve PERRLAAbducens Nerve Cannot move eyes in lateral direction.Trochlear Nerve Pt. cannot move eyes up and down.Trigeminal Nerve Pt. cannot localize sensation.Facial Nerve Cannot follow specific command.Acoustic Nerve Cannot follow specific command.Glossopharengeal Inability to swallow due to presence of NGT.Vagus Nerve With NGT inserted.Accessory Nerve With no muscle strengthHypoglossal Nerve Cannot localize taste.5. Laboratory ProceduresLaboratory Precedure Sept. 23, 2021 Result InterpretationCreatine 63.6 HDL 1.30 Hematocrit Hgb 0.44 g/l10.2 g/l Leucocytes 12.4 x 10 g/l Platelets 648 x 10/l Laboratory Procedure Result InterpretationURINALYSIS Yellow Turbid Ph 6.0 Specific gravity 1.030 Pus Negative Diagnostic ProcedureDiagnostic Procedure ResultElectrocardiogramReport Rhythm:Sinus AL: 120/m PR:0.20 sec. QRS:0.40 sec. QT:0.32 sec. Axis:+250CT Scan result: Axial unenhanced CT images 2 hours after stroke show a hyperdense left MCA (thick arrow) and loss of the insular ribbon *thin arrow). Patient received intravenous thrombolysis after the CT. Axial unenhanced CT images show petechial hemorrhages in the striatocapsular area and a hematoma within the left lentiform nucleus, consistency with hemorrhagic transformation after thrombolysis. Stage HI CT perfusion image shows a large area of delayed mean transit time on the left. CT angiogram shows truncation of mid M1 segment of the left middle cerebral artery (arrow). .1. Do the nurse’s notes (FDAR) Health ScienceScienceNursingNCM 123Share
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