Case Study – Ischemic, Thrombotic Stroke Mr. Gonzlez is a…
Case Study – Ischemic, Thrombotic Stroke Mr. Gonzlez is a… Case Study – Ischemic, Thrombotic Stroke Mr. González is a 70-year-old male who is a retired bus driver and was admitted after suffering from an ischemic, thrombotic stroke on November 26, 2020. He has been in the rehabilitation hospital for 6 weeks and now is now being prepared for discharge to his home with his wife. You are the discharge nurse completing the assessment. Mr. González is a DNR status and has no known allergies. He is a Catholic by religion. Mr. González, has a past medical history of type 2 diabetes. On admission he was also diagnosed with hypertension, hypercholesterolemia and constipation. He has no past surgical history. Mr. Gonzalez has started the following medications since admission: Metformin 500mg PO BID, Plavix 75mg, PO daily; Bisoprolol 5mg, PO daily, Atorvastatin 10mg, PO daily and Senokot 2 tabs, PO daily. His latest labs include a fasting BS of 8.4 taken this morning. His vital signs are as follows; T-36.8 degrees Celsius; Pulse (radial)-86 bpm; RR-17 breaths/min; BP is 148/96 mmHg; O2 sat-93% on room air; he denies any pain and reports no issues with sleeping. Mr. Gonzalez has mild dysphasia but is able to communicate well in English and Spanish, though takes a while to process words and respond appropriately. He has hemiparesis of his right side but can walk short distances with a walker, though is sometimes a little unsteady on his feet. His Hendrick II Fall Risk is currently 4. He requires some assistance to complete his ADLs such as bathing, dressing, toileting, and meal set up. Mr. González’ is continent of urine and feces. His appetite has decreased since his stroke, and he has lost 8 pounds in the past 6 weeks, now weighing 185 pounds. He is still only able to eat a minced diabetic diet with honey thickened fluids as otherwise he chokes. Mr. González’s abdomen is soft and slightly distended with hypoactive bowel sounds present in all four quadrants. He usually has a BM evert 2-3 days and it is hard and dry despite the laxative he is taking. Mr. and Mrs. González are both 70 years old and of Hispanic origin. They speak Spanish at home, though they are comfortable speaking English. On discharge, Mrs. González will be his primary caregiver and although they have no children they have a very involved extended family. Since he has new medications, he will need his blood pressure and blood glucose monitored frequently, requires assistance with his ADL’s, meal prep and set up, and has some safety concerns due to his hemiplegia. The nurse has been conducting a number of teaching sessions with Mr. González and his wife prior to discharge. These have also included fall prevention and stroke prevention. According to Mrs. González, the extended family believes in treating those who are “ill” with special foods and spices. The nurse conducts a more detailed assessment of home remedies with Mr. and Mrs. González and discusses the potential for harm from drug interactions. The nurse was informed that in the past week stressors have been interfering with the teaching sessions. Mr. González’s mood has become increasingly anxious, and he becomes easily frustrated. Mrs. González also seems anxious and concerned. She asks to speak to the nurse privately and confides that she “does not feel confident” about what she has learned and she is “worried” about being able to assist her husband with his care. She is also frightened that he might have another stroke. The nurse reassures her that a home care nurse will be visiting for the first few weeks to follow up on Mr. González’s care. She tells Mrs. González that she will call the home care nurse and provide an update of Mr. González’s status and inform the home care nurse of Mrs. González’s concerns. The work includes completion of: 1: One Nursing Diagnosis/Problem Select a priority problem from the problem area identified in part 1, and write one nursing diagnosis/problem statement. List the signs and symptoms that support your choice of priority problem. 2. One short term SMART Goal/expected Outcome Write one SMART nursing goal/expected outcome for the nursing problem. This is a measurable statement of accomplishment that may be related to physical health or areas that need improvement for your client. 3. Four Nursing Interventions with cited rationale Write a minimum of 4 appropriate interventions The interventions are nursing actions (treatments, behaviours, activities and therapies) that nurses perform independently on behalf of clients or in collaboration with other health care professionals. These are individual steps to help achieve the client outcome (goal). Provide ‘evidence based’ rationale to support and validate each intervention chosen. Use APA format for all evidence-based rationale supporting the chosen intervention. 4. Evaluation Reflect on the effectiveness of interventions and the client’s progress to achieve the outcome. Do you believe the interventions would be effective in achieving the client outcome? Because you cannot truly evaluate the outcome it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions? Assessment DataNursing Diagnosis/Problem StatementShort Term Goal/OutcomeNursing InterventionsRationaleEvaluation Health Science Science Nursing PNC 121
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