Question

Mr. Ali, the 56-year-old man admitted with a stroke, has many abnormal findings.
He has a history of hypertension, smoking, and mild baseline dementia. He appears fearful and agitated, asking for cigarettes, oriented to name only. His speech is comprehensible but slurred.
Mr Ali is drowsy with periods of confusion. He has impaired short-term memory—remembers zero of three objects after 1 minute. He appears to have left visual field loss. He has right lower facial weakness left tongue deviation. His muscle bulk is symmetrical, tone slightly increased on left arm/leg. He has diminished attention to objects and people on the right side of bed.



A- What nursing assessment findings support the diagnosis of stroke?


B- What problems related to Mr Ali’s safety should the nurse consider?

C- What nursing care plan should the nurse formulate for the patient?  
    

Answer 1

A. History of hypertension, mild baseline dementia, GCS score and vision field loss, memory impairment, lower facial weakness left tongue deviation and increase muscular tone on left leg.

B. Dementia, orientation, left visual field loss and increase muscular tone on left leg/ arms and right lower facial weakness, these all are problems need safety precautions to Mr Ali 's safety.

C. Nursing diagnosis for this patient.

1 . Hypertension related to disease conditions

2 Risk for injury related to all risk factors of disease conditions

3. Impaired communication related to confusion and memory impairment

4 . Anxiety related to health status.

5. Deficient knowledge related to disease progression.