P.J is a 73 year old male who was brought to the facility by a stretcher in the company of a paramedic and the son. The patient was admitted to the Emergency Department’s cardiac room and having been reported of experiencing a cerebrovascular accident. The son reported that the father had been found on the floor vomiting and could not even talk. The son admits that he l8ives with t5he father but sometimes he is out for long hours because he is a truck driver. He however has a social worker attached to him who regular pays visits when he notifies him that he will be away. On assessment, P.J’s vital signs included pulse 82, respiratory rate 25, blood pressure 222/121and temperature of 98.3 F. P.J has a positive family history for hypertension, diabetes, dementia and cerebrovascular accident (Elmhurst Hospital, 2007).
The patient is admitted for left-side cerebrovascular accident. The patient was also assessed for falls and placed on fall precaution. Further, the following measures and assessments were included in his care plan; pre-breakfast and post-lunch finger sticks and 4-hour interval neurovascular checks (Elmhurst Hospital, 2007). We also included the charting and assessment for P.J’s orientation (time, place, and person), level of consciousness as well as movement and reflexes of the extremities. For the period of his admission, the patient was placed on the following medication 4mg of Coumadin on a daily basis which is an anticoagulant, 75 mg of antidepressant Bupropion Hydrochloride, 100 mg of Metopelol (Lopressor) which is an antianginals and antihypertensives every 12 hours (Ciccone et al., 2014). On the second day, we included 20 mg of antiulcer to manage the digestive disorders as well as Nifedipine and Iron sulfate an antihypertensive and antianginal medication (Ciccone et al., 2014). We set to have the patient discharged in a minimum of 12 days with the following goals; remain away or prevent occurrences of falls, demonstrate optimal development of skills and techniques to help the memory loss, maintain electrolyte and fluid balance, achieve decreased glucose levels as well as develop other communication techniques as necessary (Jarvis, 2015).
References
Ciccone, A., Valvassori, L., Nichelatti, M., Sgoifo, A., Ponzio, M., Sterzi, R., & Boccardi, E. (2013). Endovascular treatment for acute ischemic stroke.New England Journal of Medicine, 368(10), 904-913.
Elmhurst Hospital (2007). “Client Record”. (June, 2, 2007). Retrieved July 5, 12 and 19, 2007, from the nursing station on the 4th floor
Jarvis, C. (2015). Physical Examination and Health Assessment–. Elsevier Health Sciences.
