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

Let the Experts Do Your Homework Now



Do you have a similar question? Our professional writers have done a similar paper in past.
Give Us your instructions and wait for a professional assignment!

Get a plagiarism-free order today

we guarantee confidentiality and a professional paper and we will meet the deadline.

How it works

  • Paste your instructions in the instructions box. You can also attach an instructions file
  • Select the writer category, deadline, and education level and review the instructions
  • Make a payment for the order to be assigned to a writer
  • Download the paper after the writer uploads it

  • Will the writer plagiarize my essay?
    You will get a plagiarism-free paper and you can get an originality report upon request.

    Is this service safe?
    All personal information is confidential and we have 100% safe payment methods. We also guarantee good grades