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

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