USF College of Nursing Nursing Process Worksheet

Student: Stacy Dunham Date: 09/29/15

Instructor: Sandy Davis Team: SMH 5E w/ Robin

History of Present Illness (HPI):

97 y/o F brought to ED after her family noticed a decrease in her O - between bedtime & 4am
mentation. When her daughter went to wake her up in the a.m., the L - global deficits
patient was unable to get out of bed on her own, which she normally is D - unknown
able to. The daughter also reports the patients voice was also a whisper C - decreased mentation
and her gait was unsteady. A - none
R - none
T - unknown
S - patient had no complaints

Disease Specific Medications:

ASA: to prevent platelet aggregation not new
Coreg: antihypertensive not new
Both of these medications are necessary to decrease the patients chance of having a CVA or MI

Past Medical History (PMH):

HTN, CHF, NSTEMI, renal failure with cardio-renal syndrome, dementia, anemia, UTI

Subjective Findings:
The patient doesnt speak, unless she is spoken to. She doesnt always answer questions, and will sometimes
just stare at you. When asked if she had any pain, she said no, and she also said she was thirsty. Her daughter
reports she sleeps most of the time.
Objective Findings:
T: 98.9 HR: 76 BP: 174/59 RR: 16 O2: 96% via room air Glucose: 119

Assessment:
Neuro: Disoriented, A&O x 1 as she knows her name, also unaware what happened. Left-sided facial droop.
Generalized muscle weakness, unable to assess if deficits are more prevalent on one side than the other.
Cardiac: Hypertensive, pulse is equal and regular, normal sinus rhythm with occ PACs. Also has LVH.
Pulmonary: Equal chest rise and fall, RR 16, diminished lower lungs bilateral, clear upper bilateral
GI: WNL, soft, non-tender, NL bowel sounds GU: incontinent, wearing a diaper which is dry.
Skin: pink, warm, dry, no edema, fragile skin w/ Extremities: 1+ distal pulses, no edema, cap refill <3
ecchymosis seconds.
Lines/Devices: clean, dry, intact 20ga Left AC
Pain: none apparent
Other: Patient appears lethargic and sleeps a lot. She appears in no apparent distress.
Diagnostics/Procedures: Results/Findings/Interpretations: hemorrhagic CVA
CT Head w/o contrast: Acute Lt thalamic hematoma w/ intra-ventricular
extension
ECG: sinus rhythm w/ occ PACs and LVH
Chest X-ray: Rt basilar atelectasis, small focus of opacity Rt upper
lobe for small nodule, small focus of pneumonia Rt
upper lobe.

Common Lab Values: Disease Specific Lab Values:

Hemogram, platelet, differential WBC: 16.9 (infection), RBC 3.27 (anemia), HGB: 9.7
16.9 \ 9.7 / 297 (anemia), HCT: 31.1 (anemia/recent blood loss), BUN:
/ 31.1 \ 27 (renal/heart failure), Creat: 1.3, GFR: 40 (renal
Na: 137 } Cl-: 102 { BUN: 27 } Glu: 119 failure), U/A: 40-50 WBC per HPF (UTI), Leukocytes:
K+: 4.4 } Co2: 28 { Crea: 1.3 } small (UTI)
Todays Problem List:
Decreased mentation and generalized weakness with a decreased appetite. The patient is also unable to
communicate whether or not she has any needs on her own without any prompt.

Nursing Diagnoses:
Impaired verbal communication r/t hemorrhagic stroke resulting in decreased circulation to the brain
effecting the brains speech center, as evidenced by the patients inability to maintain her usual
communication.

Short Term Planning:

Assess for signs of pain, infection, and changes in neuro every 2 hours.
Turn the patient every 2 hours. Increase liquid intake to keep patient hydrated, and monitor I&O.

Short Term Interventions:

Assisting the patient to eat pureed food and Ensure. If signs of pain medicate per MAR, and reposition.
The family doesnt want anything else due to DNR and the patients current state.

Short Term Evaluation:

The patient shows tolerable levels or no pain at all, and is usually resting. She has increased the amount she
is eating and drinking. The patients output isnt where it should be, but the family wants comfort measures
Only and doesnt want fluids given via IV. The patient shows no signs of skin breakdown. The patients
neuro status has remained constant during the shift.

Long Term/Discharge Planning:

Going to hospice for end of life care.