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) Asessment of a stroke patient involves stabilising the Airway,Breathing and Circulation,followed by a rapid concise,history and examintion.

• speech is comprehensible but slurred
• left visual field loss.
• Right lower facial weakness
• left tongue deviation.
• 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.

All this assesment findings supports the diagnosis of stroke

B) Fall prevention should be considered as most priority

C) Nursing Care Plans:

• Ineffective Cerebral Tissue Perfusion
• Impaired physical mobility
• Impaired verbal communication
• Disturbed sensory perception
• Risk for injury