Você está na página 1de 2

Substance Use/Abuse The effect of alcohol on No significant PMH noted.

History of Smoking
stroke risk appears to anxiety, depression, headache. No surgical
depend on the amount history known besides the intracranial
surgery she just had on 11/8/16. Gravida 2,
consumed. Women who
para 1, miscarriage 1. Smokes 1 PPD.
drink more than one Alcohol & Cocaine use.
Smoking is a modifiable risk factor of strokes.
Priority Nursing Diagnosis:
Impaired verbal communication related to
alcoholic drink per day are Smoking nearly doubles the risk of stroke. The risk
cerebral vascular accident with right MCA at higher risk for HTN associated with smoking decreases substantially over
as evidenced by ventilation and sedation, (even though my patient
lethargy, no verbal communication, and did not have a history of time after the smoker quits. After 5-10 years of no
unknowing of complete neuro status due it), which increases their tobacco use, former smokes have the same risk of
to intubation . chance of stroke. Illicit stroke as nonsmokers (Lewis, p. 1390)
Measurable Outcome with Timeframe: drug use, especially
By 1400, the patient will be more cocaine use, has been
responsive and alert to commands from 1. Levetiracetem 1,000mg in 0.9% sodium chloride IVPB 40ml/hr every 12 hours
doctors, nurses and other interdisciplinary
associated with stroke risk anticonvulsants inhibiting simultaneous neuronal firing that leads to seizure activity.
team members. (Lewis, p. 1390) L.S. 37 yo. 2. Nicardipine 25mg in 0.9% sodium chloride 0-15mg/hr 0-150ml/hr IV titrate CCB inhibits
Nursing Interventions you need with calcium ion influx across cardiac and smooth muscle cells more selective to vascular smooth
Caucasian muscle than cardiac muscle. Dilates coronary arteries and arterioles.
Rationales:
1.Provide clear, simple directions and Female 3. Phenylephrine 30,000mcg in 0.9% sodium chloride 250ml infusion 10-100mg/min 5-50ml/hr
IV titrate vasoconstrictors causes local vasoconstriction of dilated arterioles, reducing
repeat them frequently. Tasks need to be blood flow.
explained in very simple steps and 4. Propofol infusion 5-50mcg/kg/minX69.5kg 0.3475-3.475mg/min IV titrate hypnotics
presented one at a time. CVA R. MCA rapid acting IV sedative hypnotic
2.Allow adequate time for the patients
response. The patient needs more time to Safety: cardiac monitoring, Psychosocial: Great family support
cognitively process information and
formulate a response.
pressure ulcer risk, seizure system. Education & inclusion of family
3.Encourgae the family to communicate precautions, restraints, heel Pathophysiology: Occurs when there is ischemia members in patients care. Sedated and
with the patient. Consistency in the suspension boots, fall risk level (inadequate blood flow) to a part of the brain or ventilated so will need education and
approach by professional caregivers and hemorrhage into the brain that results in death of brain
family members promotes more effective
3, bed in lowest position, arm explanation of what is going on and what
cells. Affects movement, sensation and emotions that were
communication for the patient. Family rails x 3, HOB elevated, bed controlled by that area of the brain. It is the leading cause
happened once her mental status is
members may need reminders to let the alarm on, Prevention of germs of serious, long-term disability. When ischemia occurs, assessed and she is able to understand.
patient respond rather than talking for the (infection control), fall cerebral autoregulation may be impaired and it is often Plans for rehab after discharge and plan
patient. dependent on changes in BP. If blood flow to the brain is
Evaluation: risk/safety measures, skin of care goals discussed with family.
totally interrupted, neurologic metabolism is altered in 30
Goal partially met as evidenced by patient safety/breakdown, Continued seconds, metabolism stops in 3 minutes, and cellular death
Coping mechanisms.
responding to verbal commands SCD use discharge occurs in 5 minutes. (Lewis, p. 1388-1389)
throughout the day in regards to holding
up two fingers, her thumb in a thumbs up, planning/teaching (going to Diagnostics:
squeezing hand and wiggling her toes on rehab facility). -CT Abd/Pelvis w/o contrast 11/8/16 subcutaneous fat
the right side. There was unilateral neglect stranding lateral to the left hip most likely representing
as she could not do these movements on ecchymosis. Hepatic cysts, dependent atelectasis at the
her left side and was still not opening lung bases. No evidence of retroperitoneal or pelvic
Pertinent Physical Exam Findings: A/OX0, PERRLA, grips and dorsi/plantar flexion unequal LLE/LUE weakness, diminished lower lung
either eyes. sounds bilaterally and clear upper, unlabored, regular respirations, ventilator and sedated with small amount of clear to white secretions, hematoma.
(Gulankick & Myers, p. 570-571). stimulus to pain, no eye opening, regular HR S1/S2, HOB elevated, brisk capillary refill, strong, palpable pulses, bowel sounds hypoactive, -CT head 11/8/16 extensive edema involving the r.
abdomen soft and non-tender. Foley patent and draining yellow/straw color urine 380ml during shift, Braden 11, Schmidt 4, SCDs
bilaterally, Left side limited movement/weakness, right side weakness, follows commands occasionally, Right heel and sacrum stage 1
frontal lobe and anterior r. temporal lobe with significant
pressure ulcer open to air. NPO. Pupils brisk and round 2 equally. NSR. Symmetrical chest expansion, + Babinski, deceberate posturing, mass effect. No associated enhancing interval carinectomy
GCS 7, drowsy, RASS = -1. . mass is seen. No evidence of intracranial hemorrhage.
-CT head w/o contrast 11/8/16 large R. MCA infarct
with mass effect and high density hemorrhage in the r.
Labs: CK 3,870 (increased) CK-MB 12.4 (increased) = rhabdomyolysis/muscle breakdown WBC 13.8 (increased) RBC 2.70 (decreased) HGB 8.3 (decreased)
HCT 25.2 (decreased) Neutrophils 76 (increased) ABS. Neutrophils 10.4 (increased) ABS. Monocytes 1.1 (increased) PTT 11.2 (increased) middle cerebral artery
Sodium 155 (increased) Potassium 3.4 (decreased) Chloride 121 (increased) Creatinine 0.53 (decreased) Calcium 7.2 (decreased) -X-ray chest portable 11/9/16 minimal atelectasis
Total protein 50 (decreased) AST 59 (increased) ALK Phosphate 36 (decreased) Albumin 2.7 (decreased) Phosphorus 1.4 (decreased) -X-ray abdomen (KUB) 11/8/16 no acute process NGT
Hyponatremia, High anion gap, ketonuria, leukocytosis Blood Gasses pCO2 30.5 (decreased); pO2 120 (increased); HCO3 20.4 (decreased); SO2 99 (increased) Albumin is off because
of stroke and nutritional needs. Electrolyte imbalances could be due to all of the medications and fluids she is on as well as everything she has going on in her body as well as not eating. Blood gasses are
tip projects over the fundus, normal bowel gas pattern
associated with the extent of motor impairment. Other labs are off because of inflammation and possibility of an infection due to the abnormal body functioning and processes.
Guide for Reflection
Guide for Reflection Using Tanners (2006) Clinical Judgment Model

Program Thread: Safe, Quality, Evidence-Based Practice

This week I really enjoyed my overall experience in the ICU at St. Marys. I was able to learn a lot emotionally, skillfully, personally, and
educationally. I am very thankful that we have these experiences and wish we would have more time there as well! It was very tough to have such an
intensive patient who had so much going on and was going through a critical phase in her life at such a young age. I was so glad to see she had a very
supportive family who was eager to know everything and be involved in her care. I think that is important for her recovery. The nurses on the floor were so
welcoming, friendly and knowledgeable and I think this really helped to make me feel more comfortable in this setting.
My nurse Sara was amazing from the very beginning of our shift. She showed me everything on my patient and helped to explain to me what was
going on with each of the machines the patient was hooked too which I really appreciated. This made me feel a lot better about how the day was going to
go. We then proceeded to complete our assessment together since somethings you do in the ICU are so different from the floor. I really enjoyed working
with her and for her going out of her way to include me in her two patients care and skill completions. I can tell the difference in the nursing care that
patients receive on this unit versus some of the other general floors. By only having two patients, even though they are very critical, need a lot and keep
you equally as busy, I feel like care is more specialized and individualized to what the patient and family needs which allows me to feel like I can provide
the care to my patients that I should be able too. I liked to see that two times, we printed and reviewed policies before carrying out tasks that we may not do
very often to make sure we are doing evidence-based practice. Overall this was a great day where I was able to learn and see a lot and become comfortable
in the higher settings of care. I am excited for another week next week!

List two goals for the next practicum experience:

1. Be able to focus more on charting throughout the day since I am now more accustomed to the process in the ICU now.
2. Continue to get to do new things and tasks that I have never done before.

References:

Gulanick & Myers (2014) Nursing Care Plans: Diagnoses, Interventions, and Outcomes (8th ed.). Philadelphia, PA: Elsevier Mosby

Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. (2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed.). St. Louis, MO: Elsevier, Mosby.