D.O., a 76-year-old retired farmer, was admitted to the emergency department with left-sided…

D.O., a 76-year-old retired farmer, was admitted to the
emergency department with left-sided hemiplegia, difficulty swallowing, and
inability to speak. He was awake and watching the staff upon admission. He
moved his right arm to indicate that M.O. was his wife but was unable to speak
or form sounds. M.O. stated that her husband was working in the garden, picking
tomatoes and cucumbers, when he fell to the ground 30 minutes before admission.
The department room nurse administered oxygen through nasal cannula at 2 liters
per minute and obtained vital signs. His blood pressure was 182/110 mm
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D.O., a 76-year-old retired farmer, was admitted to the
emergency department with left-sided hemiplegia, difficulty swallowing, and
inability to speak. He was awake and watching the staff upon admission. He
moved his right arm to indicate that M.O. was his wife but was unable to speak
or form sounds. M.O. stated that her husband was working in the garden, picking
tomatoes and cucumbers, when he fell to the ground 30 minutes before admission.
The department room nurse administered oxygen through nasal cannula at 2 liters
per minute and obtained vital signs. His blood pressure was 182/110 mm Hg,
pulse was 88 beats per minute, respirations were 20 breaths per minute, and
temperature was 100.5°F. The emergency department physician ordered an MRI scan
of the head, a complete blood count, and prothrombin time (PT). The MRI
indicated that D.O. experienced a CVA caused by bleeding into the brain.

The following questions will guide your development of a
nursing care plan for the case study.

1. List clinical manifestations other than the symptoms D.O.
experienced that can occur with a CVA.

2. List subjective and objective data that a nurse would
obtain.

3. Identify three individualized nursing diagnoses and goals
for D.O.

4. D.O. is transferred to a general medical unit for 3 days,
and then is transferred to a rehabilitation center for intensive therapy. What
pertinent nursing actions should a nurse perform in caring for D.O. in the
acute setting and the rehabilitation setting related to:

Mobility

Safety

Elimination

Skin integrity

Comfort and rest

5. What teaching will D.O. need before discharge from the
rehabilitation facility?

6. List at least three client outcomes for D.O.

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