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Physical Chief Complaint: slurred speech

Age/Sex:78, Male Admit date:11/8/2

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Student Name: Ruth Omwenga

interactive Patho for main Medical Diagnosis: What am I? is a sudden focal neurological deficit.

Date of care:11/8/20 Allergies/BMI:

NKA

Neuro:A+0X3, denies headache,

What causes me? Blocked artery or bursting of a blood vessel.

dizziness, vertigo, falls ,vision ,hearing,

Labs/Diagnostics:

Medical/Surgical history:

CT scan -11/8/20 reveals thrombus in a branch of the left internal carotid artery with 50%occlusion, there is a rea of infarction in the left anterior hemisphere.

Right sided Bell’s palsy

What are the S&S of me? Paralysis /numbness of the face, leg or arm, trouble speaking, blurred vision, headache

Herpes zoster

RBC 5.01 within normal range Hb 15.4 within normal range

depression

taste, difficult swallowing.

Hyperlipidemia Carpal tunnel syndrome Right hip &knee arthroplasty

WBC 6.5 within normal range

Assessment: well

Possible complications of me? Blood clots, aphasia, chronic headache, involuntary muscle tightening.

Respiratory

: RR.22, No

Hct 45.2 within normal range M.C.V 90.2 within normal range

SOB

M.C.H31within normal range MCHC 34 within normal range Platelets 209 within normal range

Home Meds (brand & generic):

Hospital meds (brand & generic):

Ciprofloxacin 500mg qd x 7 days

Aspirin 325 mg qd IV rt-PA 0.9mg/kg

Nortriptyline 100mg daily Ibuprofen 600mg 6 hrs. prn

Diagnosis NURSINGPrimary INTERVENTIONS

Cardiac:tac

STROKE

What priority interventions will you implement today for this patient?: manage stroke with thrombolytic therapy ie IV rt-PA and antiplatelets ie. Aspirin. Maintain patent airway and administer oxygen. Use adaptive equipment for effective communication. Education/Teaching needed: Teach patient on importance of treatment/medication compliance.

hycardic p.

129, regular Top 2 Priorities for this patient: Adequate cerebral tissue perfusion rhythm communication Adequate

GU: 20 RNSG-1461-Spring

GI:BS normactive, no masses, or hepat0splenomegally abd soft...