Question

Situation: Mr Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a CT and received thrombolytic therapy in the ED. He is not by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today.

Background: Mr. Russel has a history of hypertension, coronary disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise.Assessment: We have already checked his glucose level this morning. His vital signs have been stable and he slept well last night. he was able to get up to go to the bathroom with the use of a walker. His neurological checks are stable and continue to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. Swallow reflex is intact, He is oriented x 3. I have done a Morse Fall Risk assessment with a total high-risk score of 60.

WHAT IS THE PRIORITY NURSING DIAGNOSIS FOR THIS PATIENT?

WHAT ARE THE GOALS AND EXPECTED OUTCOMES?

WHAT ARE THE NURSING INTERVENTIONS?

Answer 1

PRIORITY NURSING DIAGNOSIS FOR Mr. RUSSELL

1. Ineffective tissue perfusion related to interruption of blood flow
2. Risk for injury related to changed sensory perception
3. Risk for decreased cardiac output related to inadequate blood pump to heart to meet the metabolic requirements (Hypertension)
4. Risk for unstable blood glucose related to insulin resistance (diabetes mellitus type 2)
5. impaired physical mobility related to the weakness of muscles
6. Knowledge deficit related to lack of exposure to any previous education program elated to disease condition.

SL. NO	NURSING DIAGNOSIS	GOALS & EXPECTED OUTCOMES	NURSING INTERVENTIONS
1.	Ineffective tissue perfusion related to interruption of blood flow	Help the patient to maintain normal level of consciousness.	assess the general condition of the patient. check the vital signs of the patient closely monitor the neurological status of the patient. (use glascow coma scale) position the head slightly elevated and neutral (This will help in improve the cerebral perfusion). administer oxygen (It helps to reduce hypoxemia). administer medication if indicated.
2.	risk for injury related to changed sensory perception due to interruption of cerebral blood flow	help the patient to reduce the risk of injury by giving extra manual support, raise the side rails etc..	assess the general condition of the patient. encourage the patient to use the nondominant hemisphere. assist the patient in all his daily living activities. provide physical and psychological support to the patient. encourage the patient to consciously scan the environment before moving. remove all the unnecessary articles away from the patient's room. provide adequate lighting in the room.
3.	risk for decreased cardiac output related to inadequate blood pump to heart to meet the metabolic requirements (Hypertension)	help the patient to maintain stable cardiac rate and rhythm	assess the general condition of the patient check the laboratory testings of the patient like blood cell count, electrolytes etc. monitor the blood pressure of the patient (Including both arms and thighs). monitor the heart sounds. monitor the breathing sounds of the patient. check the patients skin color. provide sodium restricted diet to the patient. administer the medication as per doctors order.
4.	risk for unstable blood glucose related to insulin resistance (diabetes mellitus type 2)	help patient to maintain the normal blood glucose level	assess the general condition of the patient. check the level of glucose before and after the meal. assess the patient level of physical activity. monitor the signs of glucose resistance. advise the patient to the importance of prevention of injury administer medication as per doctors order.
5.	impaired physical mobility related to the weakness of muscles	improve the physical mobility and strengthen the muscles	assess the extent of impairment of physical mobility. observe th affected side properly and regularly. check the skin regularly and apply emollients to the affected side to prevent bed sore. advise the patents to change the position of the patient every 2 hourly. advise the patient to do some light exercise regularly in the bed.
6.	knowledge deficit related to lack of exposure to any previous education program elated to disease condition.	improve the knowledge level of the patient.	assess the knowledge level of the patient and family members. clarify the simple doubts what the patient ask to the nurse. encourage the family and the patents to ask the questions. explain the condition to the patient and care members in their local language. include the family and the patient in the discussion related to the care.