College of Southern Nevada – Nursing 211 Clinical
Professor Judith Alewel, MSN, RN
October 15, 2012
AV is a 57 year old male whom presented to the Emergency Department of Valley Hospital Medical Center in Las Vegas, NV on September 7, 2012 with the classic signs and symptoms of a left-sided middle cerebral artery (MCA) infarct and was admitted to the medical intensive care unit (MICU). These signs included left sided facial drooping, non-reactive left pupil, right sided weakness in the upper and lower extremities, and the inability to speak. Along with the signs and symptoms of the stroke, a 12-lead EKG revealed that he also has atrial ...view middle of the document...
His presenting vital signs were as follows: Blood pressure 145/95, heart rate 106 beats per minute, respiration rate 20 breaths per minute, oral temperature 36.8⁰ Celsius, oxygen saturation 97% on two liters of oxygen via nasal cannula. His left pupil was 2mm larger than his right, and did not react to light. His right pupil was 4mm, and did react to light. Neither of his two eyes accommodated when tested, and there was left-sided hemiparesis in his face. His gag reflex was absent when tested as well. Right-sided hemiparesis in his upper extremity was present, but his lower right extremity was just weakened as he was able to move his leg. He was able to dorsiflex and plantar flex both of his feet with grades of +1 on the right and +3 on the left. The left side of his upper body had good strength of +3, and right grip strength of 0. His heart sounds were abnormal, as an S3 sound and murmur were auscultated, but there were no carotid bruits heard. The cause of this was later found to be severe mitral and moderate tricuspid valve regurgitation. His lung sounds were clear in all fields bilaterally. His bowel sounds were present and normoactive and he didn’t report any pain or tenderness when palpated. The rest of his skin was clean, dry, intact, and no lesions or bruising was noted.
Systems Review – Assessment
When I entered the patient’s room, I introduced myself and asked the patient if I could do a physical assessment on him, and he shook his head yes. I asked if he could speak English, and he again shook his head yes. While speaking Spanish, I asked if he could speak Spanish, and he again shook his head yes. I then asked if he would mind if I turned the light on, and he shook his head no. I took his vital signs, which were as follows: Blood pressure 120/81, heart rate 92 beats per minute, respiration rate 18 breaths per minute, oral temperature 36.5⁰ Celsius, oxygen saturation 98% on two liters of oxygen via nasal cannula.
AV appears his documented age and is alert. When I asked him if he knows where he is, he mumbled something, but it wasn’t very clear or rational, so expressive aphasia is noted and assessing orientation cannot be done at this time. He doesn’t appear to be in distress, his body parts appear equal and proportionate bilaterally, and he appears to be lying in bed comfortably with the head of his bed elevated approximately 50 degrees. AV’s mood is pleasant, and appears clean but not groomed. When asked about pain, he shakes his head no. I asked him to use his hands to rate his pain on a zero-to-ten scale, and explained the scale to him. He held up a zero. I asked him if that means everywhere, and he shook his head yes. I pointed to the window, the television, and the curtain and asked him to remember these items. Three minutes later I asked him to point to the items from earlier, and he pointed out all three in the same order I did.
His skin is warm, dry, intact, and the color is appropriate for his race and nationality. He...