KEYS

-Female

-Male

-Died Female

-Female Patient

-Died Male

Family Age/Sex Relationship Health Status Remark

Members
Mrs.Vanajamm 54yrs Patient CVA Unhealthy
a (Lt)Hemiparesi
60yrs Husband s Healthy
Mr.Balraj 29yrs Son Nil Healthy
Mr.Rajesh 26yrs Daughter-in- Nil Healthy
Mrs .Anu law Nil
6yrs Granddaughte Healthy
Diya r Nil
 PHYSICAL EXAMINATION
HEAD TO TOE EXAMINATION
SKIN
Colour;brownish black
Moisture;dry skin
Temperature;normal
Texture;smooth
Turgor;good
Edema;absent
Lesions;absent
Pallor;absent
Cyanosis;absent
Jaundice;absent
Miscellaneous lesions;absent
GENERAL SURVEY
Body built;moderately built
Gait;unsteady
Posture;couldn’t maintain normal posture
MENTAL STAUS
Memory;normal
Consciousness;conscious
Orientation;oriented to time,place and person
Level of cooperation;obey verbal commands
ANTHROPOMETRIC MEASUREMENT
Height;1.5m
Weight;52kg
Body mass index=weight(kg)/height(cm2)
=52/(1.5)2
=22
Inference;patient had normal body weight
VITAL SIGNS
Vital signs Day 1 Day 2 Day 3 Day 4 Day 5
Temperatur 98.60f 980f 97.60f 970f 98.60f
e 74bts/mt 80bts/mt 76bts/mt 78bts/mt 82bts/mt
Pulse rate 18brths/ 20brths/mt 18brths/mt 20brths/mt 18brths/mt
Respiration mt 140/80mmh 150/70mmh 150/70mmh 140/80mmh
Blood 150/80 g g g g
pressure mmhg

NAILS
Colour;pink
Texture;smooth
Shape;convex
Clubbing of nails;absent
Capillary refill;normal,prompt retain within 1sec
HAIR AND SCALP
Distribution of hair;uniform distribution
Colour of hair;black in colour
Alopecia;absent
Dandruff;absent
Infections;absent
Lesions;absent
Skull;normocephalic
Redness;absent
Pallor;absent
Jaundice;absent
Pupillary reaction;PERRLA present
Myopia;absent
Presbyopia;absent
Visual field ;normal
Lumps or swelling;absent
Yellow sclera;absent
Red spots;absent
EARS
Infections;absent
Pain;absent
Discharges;absent
Lose of hearing;absent
Ringing in ears;absent
FACE
Puffiness of face;absent
Moon face;absent
Lesions;absent
Discolouration;absent
Infections;absent
EYES AND VISION
Visual acuity;able to see letters in snellens chart
Double vison;absent
Extra ocular movements;possible in all direction
Periorbital edema;absent
Infection;absent
Watering eyes;absent
Otitis media;absent
Nodular swellings;absent
Skin lesions;absent
Inflammation;absent
Hearing loss;absent
NOSE
Frequent colds;absent
Allergies;absent
Changes in sense of smell ;absent
DNS;absent
Bleeding;absent
Tenderness of nasal tip;absent
Polyps;absent
Local tenderness;absent
Rhinitis;absent
MOUTH AND THROAT
Dryness of mouth;present
Pallor;absent
Cynosis;absnent
Lesions on lips;absent
Bleeding gums;absent
Gingivitis; absent
Dentures;not present
Slurring of speech;present
Difficulty in swallowing;present
Mouth ulcer;absent
Stomatitis;absent
Sore gums;absent
Tonsillar node;absent
NECK
Range of motion;possible in all direction
Presence of pain;absent
Thyroid enlargement;absent
Lymphnodes;not palpable
Distention of neck veins;absent
Masses;absent
Benign or malignant nodules;absent
Enlargement of supraclavicular node;absent
Scars;absent
Lesions;absent
Swelling;absent
Axillary lymph nodes;not palpable
Lumps;absent
Infection;absent
Redness;absent
Unusual pigmentation;absent
THORAX AND LUNGS
Inspection
Chest shape;ecliptical in shape
Khyphosis;absent
Scoliosis;absent
Air entry;regular
Tactile fremitus;normal
Palpation
Pain;absent
Mass;absent
Tenderness;absent
Tactile fremitus;normal
Altered breath sounds;absent
Percussion
Resonance;heard on lung region
Dullness;heard over cardiac region
Hyperresonnce ;absent
Unilateral hyperresonanace;absent
Auscultation
Breath sounds;normal vesticular,bronchial and bronchiovesicalr sounds heard
Heart sounds;S1and S2 sounds heard
Wheezing;absent
Murmers;absent
Crackles;absent
Cough;present
ABDOMEN
Inspection
Skin colour;black
Prominent veins;absent
Incisional scars;absent
Distensions;absent
Ascities;absent
Lower abdominal mass;absent
Nasogastric tube feeding;present
Auscultation
Bowel sounds;heard in every second
Bruits;absent
Hyperperistalsis;absent
Abnormal bowel sounds;absent
Palpation
Pain;absent
Tenderness;absent
Masses;absent
Enlargement of organs;absent
Involuntary rigidity;absent
Percussion
Tympany;heard over abdomen
Dullness ;heard over liver and spleen
Rebound tenderness;absent
Pectoral inflammation;absent
BACK
Decubitus ulcer;absent
Kyphosis;absent
Scoliosis;absent
Abnormal spine symmetry;absent
Deviation of spine;absent
MALE GENITALIA
Redness;absent
Lesions;absent
Edema;absent
Discharge;absent
Pain;absent
Difficulty in voiding;absent
EXTREMITIES
Upper extremities
Range of motion;not possible in all irections due to left side weakness
IV cannula;presenton reight hand
Edema;absent
Swelling;absent
Lesions;absent
Tenderness;absent
Lower extremities
Range of motion;not possible in all direction due to left side weakness
Edema;absent
Swelling;absent
Lesions;absent
Tenderness ;absent
CENTRAL NERVOUS SYSTEM
Level of consciousness;conscious
Orientation;oriented to place, personand time
Speech ;slurred speech
Level of cooperation;relaxed
Weakness;present
Paralysis;present over left side
Memory;proper
Numbness;present on left side
GLASSGOWCOMA SCALE
Level of Day 1 Day 2 Day3 Day 4 Day 5
consciousness
Eye opening
Spontaneous-4 3 4 4 4 4
To verbal
command-3
To pain-2
No response-1
Motor response
To verbal 4 3 5 5 5
commands-6
To localised
pain-6
Flexes and
withdrawl-4
Reflexes
abnormalities-3
Extends
abnormalities-2
None-1
Verbal response 5 5 5 5 5
Oriented-5
Confused-4
Inappropriate
sound-3
Incomprehensive
sound-2
Lack of sound-1
Total score 12 14 14 14 14

CRANIAL NERVES
CRANIAL NERVES
1.OLFACTORY
Patient is able to identify odour of
Ask the client to close eyes and coffee powder.
identify different mild aromas such as
coffee powder
2.OPTIC NERVE
Ask client to read newspaper check Patient is able to read the newspaper.
visual field with confirmation.
3.OCCULOMOTOR NERVE
Assess the fine ocular movements Patient is able to move his eyes in all
and pupils reaction. directions.
4.TROCHLEAR
Assess six ocular movements. Patient is able to move his eyes on six
directions.
5.TRIGEMINAL NERVE
While client looks upward tightly The eye is blinking.
touch lateral sclera of eye with sterile
gloves.
6.ABDUCENT NERVE
Assess the eye movement in a Movement of eyeball is normal and
particular object. corneal reflex is good.
7.FACIAL NERVE
Ask the patient to smile, raise the Patient is able to smile puff out the
eyebrows, puff out the cheek and cheek and raise the eyebrows.
close eyes tightly
8.AUDITORY NERVE
Assess the patient ability to spoken Patient is not able to hear through
words and vibration of tuning fork. right ear.
9.GLOSSOPHARYNGEAL NERVE
Ask the patient to move tongue in Patient is able to move the tongue and
different direction and apply the taste taste sensation.
of salt and sugar.
10.VAGUS NERVE
Assess the patient speech for Patient have slurred speech.
hoarseness.
11.ACCESSORY NERVE
Ask the patient to shrink shoulder Not able to assess.
against resistance.

12.HYPOGLOSSAL NERVE
Ask the client to protrude tongue of Patient is able to move tongue side to
midline and then move side to side. side.

MOTOR FUNCTION
Strength Patient is not able to do.
Ask the patient to push and pull
against the resistance of your arm.
Tone
Ask the client to passively moving Patient can slightly move her limbs.
the limbs through there range of
motion.
 Cerebral function
 Romberg test Patient is not able to do.
Ask the patient to stand with feet
together and close his or her eyes.
 Finger nose test Patient is not able to do so.
Ask the patient alternately touch the
nose then touch examiners finger.
Sensory functions
 Touch
Gently stroke a cotton for each of Patient is able to detect.
four extremities and ask the patient to
indicate when the stimulus is felt.
 Pain
Touching skin with sharp end of pin Patient is able to identify the pain.
and also with dull end of pin.

LABORATORY FINDINGS
DAT SAMPLE PATIENT NORMAL VALUE REMARK
E VALUE
1/5/ Hb 13.5mg% 13.5 to 17.5 mg% Normal
2020 Total count 7800cells/cum 4500to11000cells/cum Leukocytosis
m m
Neutrophils 55% 54to62% Normal
Lymphocyte 37% 25 to 30% Lymphocytosi
s s
Esinophils 0.9% 0 to 9% Normal
ESR 22mm/hr 0 to 22mm/hr Normal
RBS 165mg/dl 79-160mg/dl Hyperglycemi
a
Sodium 141.3mg/dl 135-145 mg/dl Normal

4/5/ Hb 13.5 mg% 13.5 to 14.5 mg% Normal

2020 Total count 6800cells/cum 2500 to Leukocytosis
m 11000cells/cumm
ESR 20mm/hr 0-22mm/hr Normal
RBS 160mg/dl 79-160mg/dl Normal
Sodium 140mg/dl 135-145mg/dl Normal
 TREATMENT
Dose route Frequenc Action
Medication y
Trade name Pharmacological
name
T.ecospirin Aspirin 150m NG 0-1-0 Antiplatelet
g Tube
T.Atorva Atorvastatin NG HS Hypolipidemic
20mg Tube
T.Amlo Amlodipine NG BD Antihypertensive
5mg Tube
Inj.Pantop Pantoprazole IV BD Proton pump
40mg inhibitor
Inj.Taxim Cefexcim IV BD Broad spectrum
1g antibiotic
T.Clopilet Clopidogrel NG BD Antiplatelet drug
75mg Tube
Inj.Mannitol Mannitol IV IV Osmotic
100ml diuretics
Inj.Deriphyllin Theophylline IV IV Bronchodilator
Neb.Salbutamo Albuterol 100m INH Q8H Anti-
l g inflammatory
2.5ml steroids
Budesonide INH Q8H Anti
Neb.Budecort inflammatory
0.5mg corticosteroids
Losartan NG BD Angiotensin
T.Losartan Tube receptor
25mg blockers.
NURSING PROBLEMS
 Left side weakness
Patient verbalized left sided weakness
Left side paralysis present
 Impaired physical mobility
Inability to do daily activities
 Impaired verbal communication
Slurring of speech
 Impaired swallowing
Coughing while trying to swallow
Nasogastric tube present
 Loss of appetite
Decreased intake of food
 Fatigue
Patient looks so tired
 Risk for infection
 Risk for injury
 Anxiety
Patient asking too many questions
 Knowledge deficit
NURSING DIAGNOSIS
1. Ineffective cerebral tissue perfusion related to interruption of blood flow
as evidenced by weakness over the left side of body.
2. Impaired physical mobility related to decreased muscle strength as
evidenced by inability to do daily activities.
3. Impaired verbal communication related to impaired cerebral
circulation,neuromuculsr impairment as evidenced by slurred speech.
4. Impaired swallowing related to left side weakness as evidenced by
coughing while swallowing.
5. Imbalanced nutritional status less than body requirement related to
disease condition as evidenced by less intake of food.
6. Activity intolerance related to fatigue as evidenced by patient cannot
meet basic needs.
7. Risk for infection related to hospital stay and presence of nasogastric
tube.
8. Risk for injury related to neuromuscular impairment ,weakness of left
side of body.
9. Anxiety related to hospitalisation as evidenced by patient asking too
many questions.
10.Knowledge deficit related to treatment procedures as evidenced by
patient asking many questions.
HEALTH EDUCATION
Diet
 Advised the patient to take any digestible food.
 Encourage the bystanders to give small and frequent diet.
 Advised to include mix fruits and vegetables in the diet.
 Advised to restrict sodium diet.
Personal hygiene
 Encouraged the caregiver to give bath daily.
 Advised the care giver to clean the bed and bed side daily.
 Advised the patient to have hygienic practices.
Sleep and rest
 Advised to provide calm and quiet environment
 Advised the patient to take adequate rest and sleep.
 Advised the patient to avoid sleep at day time.
Medications
 Advised to give medications at prescribed time.
 Advised to complete the regimen of medication to get complete result.
ROM Exercise
 Educate the bystander regarding the importance of exercise.
 Advice the patient to avoid strenuous activities.
Follow up care.
 Advised not stop medication by self.
 Consult doctors as needed.
 Follow doctors order.
 Follow up after 2weeks as prescribed by doctor.
 PROGRESS NOTES
DAY 1

CONCLUSION
As a part of my 1st year MSc Nursing posting ,I was posted in Ward 4.I
took Mrs.Vanajamma 64 yrs old admitted with the complaints of slurred
speech,left sided weakness,breathing difficulty,cough.and later the doctor
diagnosed as Cerebrovascular accident(left) Hemiparesis.I provide complete
care for the patient for 5days .

BIBLIOGRAPHY
 Lewis,Text book of medical surgical nursing,Elsevier publication
 Ashalatha ,Anatomy and physiology .
 Mosby,Drug reference for Nurses,Elsevier publication.