Assessment: Person Nursing (NS DX, Goal, Interven on (Wagner, 2022)

 Objec ve :63 yr. Caucasian female admi ed on 2/19/24 for Acute Ischemic  NS DX: Impaired verbal communica on related to cogni ve impairment
Stroke secondary to acute ischemic stroke, as evidenced by aphasia.
o A&0, unable to respond due to impaired speech. Full Code
 Goal: Pa ent will count from 1-20 by the end of the shi .
o HTT Assessment: WNL except facial asymmetry of Right sided facial
 Interven on
drop during smile and Right Hemiplegia, RUE & RLE weakness.
Unable to grip with right hand. Cannot move Right leg. Key 1. Provide clear, simple direc ons.
Priority a. Ra onale: The pa ent with dysphagia may require
o Diet: Dysphagia III
direc ons to be repeated frequently. Tasks need to be
 Subjec ve: Pt states uses “yeah” to answer mul ple ques ons. She has Ac ons explained in straigh orward steps at a me.
inappropriate words. 2. Allow adequate me for the pa ent’s response.
 PHM: HTN Explore emo onal
a. Ra onale: If the pa ent feels rushed, communica on
responses toward problems are worsened. The pa ent may need more me to
disordered thoughts. process informa on and formulate a verbal response
Health (Diagnosis, S/S, Patho, Labs, Meds cogni vely.
Involve the family. 3. Teach techniques to improve speech.
 S/S: extensive aphasia, inappropriate words, Right hemiplegia a. Ra onale:
Incorporate speech-  Ask to talk slowly and say each word clearly.
 Dx: Acute Ischemic Stroke
language therapy.  Encourage them to speak in short phrases.
 Pathophysiology: The brain depends on a constant supply of blood for the
 If verbal communica on is difficult, ask the pa ent to write a
oxygen and nutrients it needs to survive. Pipe-like vessels called arteries Pay a en on to message or draw a picture.
carry oxygenated blood from the heart and lungs to all parts of the brain. nonverbal cues and 4. Collaborate with a speech therapist.
Acute Ischemic stroke can occur when blood flow through one of these gestures. a. Ra onale: A comprehensive mul disciplinary plan of care
arteries is blocked. Stroke robs the brain of oxygen, causing brain cells to may be required to improve the pa ent’s communica on
become damaged or die. As a result, parts of the body controlled by those Use aids and devices. ability.
cells o en become disabled. (Acute Ischemic Stroke, n.d.)
 Diagnos c Tes ng: CT Brain: CT brain showed 15mm intracranial Con nue speaking to Evalua on: With mul ple trials of coun ng, Pa ent met goal with guidance. Pa ent
hemorrhage with vasogenic edema, possible ischemic stroke conversion the pa ent even if was able to repeat a er me 1-20. Pa ents seems to be very determined to improve. Is
versus hypertensive in origin. they can’t respond. working hard with speech therapist.
 Diagnos c Tes ng: MRI Brain: Le MCA ischemic infarct with addi onal
hemorrhage in basal ganglia, no midline shi . (Wagner, 2022)

Labs: Vitals: 0730 Vitals: 1130 Medica on:

See a ached page. Environment (SDOH)
Temp: 97.7 Temp:98.0 See a ached  Family: Divorced, and lives with 23 yr. old son.
HR:66 HR:74 page  Living Arrangement: Lives in one story home and has access to water and
RR:16 RR:18 food.
BP: 103/68 BP:110/70  Economic stability: Disability
Sp02: 98% RA Sp02: 99% RA  Educa on: College

Client Teaching & Evalua on of Goals/Interven ons (Wagner, 2022) References

 Pa ent will learn to u lize devices and equipment to replace verbal Acute Ischemic Stroke. (n.d.). Penumbra, Inc. Retrieved March 30, 2024, from
communica on. h ps://www.penumbrainc.com/therapies-condi ons/acute-ischemic-stroke/
 Pa ent teaching in ways to relieve frustra on during episodes of inability to
communicate. Wagner, M. (2022, January 17). Impaired verbal communica on nursing diagnosis & care plans. NurseTogether.
h ps://www.nursetogether.com/impaired-verbal-communica on-nursing-diagnosis-care-plan/