Introduction Stroke can cause severe disability and death. Timely diagnosis and appropriate treatment can significantly reduce the risks of impairment and mortality (Kimera et al. 2010).
Mr David King, a 71 year gentlemen was admitted to emergency at 8.45am with unconfirmed diagnosis of a Cerebral Vascular Accident (CVA). At 7.30am this morning, he was found in the shower by his wife Mary. She reported the right side of his body was flaccid, his face and mouth had drooped, he had difficulty communicating with slurred speech, couldn’t raise his arms and was incontinent of urine. This report describes the assessment processes, priority health problems, short term goals, outcomes, interventions, and discharge planning for Mr King.
Mr King requires a full neurological assessment which will include the monitoring of ABC, vital signs, oxygen saturation, and blood pressure. The monitoring of ABC will ensure the immediate safety of Mr King, as any deteriorations may indicate an underlying condition (Summers et al. 2009). Vital signs assessment will give baseline measurements to monitor his continuing stability.
Mr King requires a clinical health assessment. It is important to determine time of symptom onset and prior medical history including a history of diabetes, seizures, hypertension, atrial fibrillation, heart disease, past transient ischemic attack (TIA) or CVA, and any trauma related to Mr King’s current event. It will also determine Mr King’s current medication regime including anti-coagulant medication which may influence future treatment (Summers et al. 2009, table 8).
Health Problems (in order of priority)
1. Ineffective cerebral perfusion caused by unconfirmed CVA, evidenced by symptoms of right sided hemiparesis, motor deficit, language deficit and incontinence.
A CVA reduces blood flow to the brain causing ineffective cerebral perfusion which may result in severe disability or death. Timely diagnosis and treatment of ischemic CVA with thrombolytic therapy can reduce the risks of severe impairment and death (Summers et al. 2009, p. 5). Time of symptom onset to therapy commencement should be no more than 4.5 hours for therapeutic results (The ATLANTIS, ECASS & NINDS rt-PA Study Group Investigators, 2004, p. 772). Mr King requires immediate confirmation of CVA to receive maximum benefit from intravenous anteplase medication should he be eligible for treatment.
2. Impaired mobility indicated by symptoms of right sided hemiparesis, drooped face and mouth and inability to raise arms.
Severe hemiparesis can reduce airway patency, and increase the risks of aspiration and atelectasis (Summers et al. 2009, p.7). Early mobilisation and good positioning can help patients regain function and reduce complications of pressure damage, deep vein thrombosis, decreased range of movements, joint contractures, muscle atrophy and oedema according to Keating et al. (2012 p. 16). Correct bed positioning and assistance to sit up when...