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					                     CHARITY SCHOOL OF NURSING
                    DELGADO COMMUNITY COLLEGE

                    NURSING OF THE ADULT CLIENT I

             CARE MAP CLINICAL PREPARATION SHEET

GENERAL INFORMATION

Client’s Initials: E.D.                              Student’s Name: Dawn Fabre
Date of Admission: 3/13/2008                         Date of care: 3/18/2008
                                                     Hospital unit/Bed: T658A
Medical Diagnosis: Acute CVA, HTN                     Safety Precautions: both bedrails up,
                                                     bed in low position, call bell in reach
Surgery: PEG tube

Age: 77 Sex: F Race/Culture: African American Learning Needs: Educate on low
Religion: Christian                            sodium diet to lower blood pressure
Occupation: Homemaker                          and on smoking cessation .
Height: 4’11”       Weight: 96
Allergies: NKDA

Developmental stage with rationale: Integrity vs. Despair— patient identifies with
Integrity, she has fully accepted her accomplishments in life and is trying to come to terms
with death.

Current V/S: T 98.5 P 84 R 19 BP 185/117
Admit V/S: T 98.3 P 68 R 20 BP 192/76
Pain Scale rating (0-10): 0

BIOPSYCHOSOCIAL HISTORY:
Past medical history includes hypertension and bilateral cataracts. There is hypertension
in her family history. Client smokes cigars 3-4 a day for the past 3 years. Client does not
use recreational drugs and does not drink alcohol. Client is not married and has 1 child
that lives in another state. She lives alone, but has a sister and a niece that help to take
care of her. The client is on Medicaid.

COURSE OF HOSPITALIZATION:
The client was at home drinking water and had problems swallowing and started choking.
She and was found on the floor a couple of hours later by a relative. Afterwards, she was
having difficulty with speech. She was brought to the ER by her relative where they
admitted her. There were several tests done including a CT scan and a Transesophageal
Echocardiogram. The patient had a PEG tube inserted. However, the PEG tube was
removed because of an occlusion and the patient did not want the PEG tube re-inserted.
CURRENT ASSESSMENT DATA:
T 99.3 P 91 R 20 BP 133/49
Pain scale rating (0-10): 3
AAOx2 to name and place but not time. Client’s speech is slurred and slow. Client is
lethargic. Client’s color is brown, no reddened areas, no tears or pressure ulcers. The
skin is warm, supple and dry. The left side of her face was drooping. Her left pupil was
approximately 4 mm and her left was slightly smaller 2mm. Both were reactive to light.
Lungs sounds clear to auscultation in all posterior and anterior lobes. Respirations
unlabored. Client has a productive cough with clear sputum. She states that she has a
sore throat. Apical pulse 5ICSLMCL, rate 85, rhythm 2+. All peripheral pulses 2+.
Abdomen flat, soft and non-tender. Bowel sounds hyperactive in all 4 quadrants. Last
BM on 3/16/2008. Negative Homan’s Sign bilaterally. Patient had weakness to her left
extremities. Right extremities showed no weakness. Sensation intact. Capillary refill less
than 3 seconds. Grip strength on right side was strong. Grip on left side was weak.
Client has a Heplock IV site on RUE. IV site is free from redness and swelling.


BRIEF DESCRIPTION OF PATHOPHYSIOLOGY
(CLIENT’S PRIMARY MEDICAL/SURGICAL DIAGNOSIS):
CVA (Cerebrovascular accident) AKA Stroke – Occurs when there is ischemia to a part of
the brain or hemorrhage into the brain that results in brain cell death. Functions such as
movement, sensation or emotions that were controlled by the affected brain area are lost
of impaired. The severity of the loss of function varies according to the location and
extent of the brain involved. The patient suddenly experienced problems with swallowing
and her speech was slurred. Her relatives state that she did not have problems with speech
or swallowing prior to admission.


REFERENCE:
Dirksen, O’Brien, Lewis, Heitkemper, Bucher. (2007). Clinical companion to medical-
       surgical nursing. St. Louis, Missouri: Mosby Elsevier.


DISCHARGE CRITERIA:
BP 154/103 P 69 R 21 T 98.5
Client’s blood pressure will be within normal limits within 2 days before discharge. Her
nutritional status will also improve within 3-4 days before discharge. Client will show no
further signs of a possible CVA.


DISCHARGE PLAN:
Client will go home with her niece. She will assist her with ADL’s. Client may need
some equipment upon discharge such as walker/wheelchair and a bedside toilet. Client
will follow-up with doctor after discharge to discuss any new medications.
Impaired Swallowing R/T neuromuscular impairment 2 CVA

      D/C
             Evidence of aspiration of mucous
             Patient states difficulty in swallowing
             Choking and coughing

      Expected Outcomes:
            Patient shows no evidence of aspiration pneumonia
            Patient will achieve adequate nutritional intake
            Patient will maintain weight
            Patient and family members will demonstrate correct feeding techniques
            Patient and family members will list strategies to prevent aspiration
            Patient will maintain oral hygiene

      History:
             She is unable to swallow due to the effects of a CVA. The client had a
             PEG tube, The tube had an occlusion. The patient stated she did not want
             the PEG tube anymore. The PEG tube was removed. The doctor is
             meeting with the family to discuss it the importance of the PEG tube since
             the patient is unable to swallow.

      Treatments/Medications:
            The patient’s medications are currently on hold due to inability to
             swallow and no PEG tube
            Suction apparatus at the bedside

      Interventions:
             Assess patient for signs of aspiration such as choking and coughing
             Elevate the head of the bed to decrease the risk for aspiration
             Suction mouth as needed
             Keep suction machine at the bedside to decrease the risk of aspiration
             Provide mouth care three times a day to promote comfort
             Lubricate the patient’s lips to prevent cracking and blisters

      Evaluation:
            Patient shows no evidence of aspiration pneumonia, breath sounds
              remain bilaterally clear
            Patient and family demonstrates proper feeding techniques to minimize
              risk of complications
            Patient and family lists strategies to prevent aspiration
Imbalanced Nutrition: Less then body requirements R/T inability to ingest foods

      D/C
             Weight loss of 12lbs since admitted
             Body weight is under ideal weight
             Hyperactive bowel sounds
             Inadequate food intake
             Inability to ingest foods

      Expected Outcomes:
            Client will have no further weight loss
            Client and family members will demonstrate correct tube feeding
            procedures
            The patient will have proper nutrition through the PEG tube
            Patient will avoid skin breakdown and infection around the tube site

      History:
             She is unable to swallow due to the effects of a CVA. The client had a
             PEG tube, The tube had an occlusion. The patient stated she did not want
             the PEG tube anymore. The PEG tube was removed. The doctor is
             meeting with the family to discuss it the importance of the PEG tube since
             the patient is unable to swallow.

      Treatments/Medications:
            The patient’s medications are currently on hold due to inability to
             swallow and no PEG tube
            Suction apparatus at the bedside, mouth suctioning as needed

      Interventions:
             Assess the patient’s daily weight at the same time every day to obtain
              accurate readings
             Monitor fluid intake and output because body weight may increase as
              a result of fluid retention
             Assess bowel sounds once per shift to monitor for increase or decrease
             Auscultate breath sounds every 4 hours to monitor for aspiration
             Instruct patient and family members in tube feeding procedures. Allow
              them to demonstrate the procedures. This encourages the patient and
              family to participate

      Evaluation:
            Weight shows no further weight loss
            Patient consumes specified amount of calories daily
            Patient and family communicate understanding of special dietary
              needs and plan appropriate diet
            Patient and family demonstrate correct tube-feeding procedures
Risk for Aspiration R/T impaired swallowing

      D/C
             There are no defining characteristics as this is a Risk diagnosis

      Expected Outcomes:
            Maintain patent airway
            Auscultation will reveal clear breath sounds
            Auscultation will reveal presence of bowel sounds
            Patient will breathe easily, cough effectively and show no signs of
             respiratory distress or infection
            Family members will demonstrate ways to prevent aspiration

      History:
             She is unable to swallow due to the effects of a CVA. The client had a
             PEG tube, The tube had an occlusion. The patient stated she did not want
             the PEG tube anymore. The PEG tube was removed. The doctor is
             meeting with the family to discuss it the importance of the PEG tube since
             the patient is unable to swallow.

      Treatments/Medications:
            The patient’s medications are currently on hold due to inability to
             swallow and no PEG tube
            Suction apparatus at the bedside

      Interventions:
             Assess patient for swallowing reflexes, impaired reflexes may cause
              aspiration
             Assess respiratory status every 4 hours to detect signs of aspiration
             Suction mucous as needed to prevent aspiration, suction mouth as needed
             Auscultate bowel sounds every 4 hours because delayed gastric
              emptying may cause regurgitation of stomach contents
             Elevate the head of the bed to aid breathing
             Help patient turn, cough and deep breathe every 2 hours to promote
              drainage of secretions and full expansion of the lungs

      Evaluation:
            Maintains patent airway
            Clear breath sounds
            Presence of bowel sounds
            Breathes easily, coughs effectively and shows no signs of respiratory
              distress or infection
            Patient and family members demonstrate measures to prevent aspiration

				
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