Mr. Y is a 59-year-old Head of the Accounting Department in a certain Information and Technology Company. While having his breakfast at home, Mr. Y suddenly experienced slurring of speech, facial droop on the left side with weakness in left side of upper and lower limbs. His wife noted these sudden onset of symptoms and immediately called for help. Past health history revealed asthma which started at age 8. He was on prediabetes state 5 years ago and was diagnosed with Hypertension Stage 1 three years ago. He used to work for 50-60 hours per week as compared to his working hours during the pandemic which is recently reduced to 30 hours per week. Minimal change in lifestyle was done after he was diagnosed with hypertension, but remains a smoker for approximately 39 pack years. A social beer drinker about 10 standard drinks per week at 3-4 sessions. Outside work, he enjoys playing online games. Upon assessment patient was confused, with mild left sided neglect and altered sensation. Blood Pressure of 190/110 mm Hg Pulse of 90 beats/minute Blood Glucose = 155 mg/dl Assessment Using the BEFAST scale: With loss of balance Problem with vision on Left Eye Left Facial Droop Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5 Slurred Speech CT Scan Result: Hyperdensity of the right Middle Cerebral Artery with provisional diagnosis of Acute Ischemic Stroke Cerebral Angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery origin through the Right Middle Cerebral Artery Trunk. Medical Management were done such as Thrombolysis in less than 2 hours after the onset of symptoms, Recanalization was attempted at 5 hours after the onset of symptoms Mr. Y was admitted to Acute Stroke Unit for 24 hour monitoring NIH Stroke Scale were: 19 - on admission 15 - 12 hours post tPA 9 – 24 hours post tPA What are the assessment findings, a corresponding medical management (medications) and nursing diagnosis with list of interventions of it?
CASE SCENARIO
Mr. Y is a 59-year-old Head of the Accounting Department in a certain Information and Technology Company. While having his breakfast at home, Mr. Y suddenly experienced slurring of speech, facial droop on the left side with weakness in left side of upper and lower limbs. His wife noted these sudden onset of symptoms and immediately called for help.
Past health history revealed asthma which started at age 8. He was on prediabetes state 5 years ago and was diagnosed with Hypertension Stage 1 three years ago.
He used to work for 50-60 hours per week as compared to his working hours during the pandemic which is recently reduced to 30 hours per week. Minimal change in lifestyle was done after he was diagnosed with hypertension, but remains a smoker for approximately 39 pack years. A social beer drinker about 10 standard drinks per week at 3-4 sessions. Outside work, he enjoys playing online games.
Upon assessment patient was confused, with mild left sided neglect and altered sensation.
Blood Pressure of 190/110 mm Hg
Pulse of 90 beats/minute
Blood Glucose = 155 mg/dl
Assessment Using the BEFAST scale:
With loss of balance
Problem with vision on Left Eye
Left Facial Droop
Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5
Slurred Speech
CT Scan Result: Hyperdensity of the right Middle Cerebral Artery with provisional diagnosis of Acute Ischemic Stroke
Cerebral Angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery origin through the Right Middle Cerebral Artery Trunk.
Medical Management were done such as Thrombolysis in less than 2 hours after the onset of symptoms, Recanalization was attempted at 5 hours after the onset of symptoms
Mr. Y was admitted to Acute Stroke Unit for 24 hour monitoring
NIH Stroke Scale were:
19 - on admission
15 - 12 hours post tPA
9 – 24 hours post tPA
What are the assessment findings, a corresponding medical management (medications) and nursing diagnosis with list of interventions of it?
Trending now
This is a popular solution!
Step by step
Solved in 3 steps
