Patient name: Mohammed Ahmed Omer .

File number : I3520

File date 10/8/2019
Admission date: 10/11/2020 .
Age: 62 years old.
Blood group: B+
Unit or floor: medicine word.
Medical diagnosis :Ischemic stroke.
Diet: low fat and salt diet .
Physical limitations :dysphasia and right side hemiplegia.
Allergic : not known.
Chif complains:
sever headache and drawsness for 2 days , dysphasia and Rt side hemiplegia for one
day.
History of present illness :-
The condition start one day prior admition with severe headache the pain was
strong ,constant and just relive by analgesia also he complain of drawsness. He didn't
seek any medical department .on 10 of November the condition become worth, pt
develop dysphasia and Rt side hemiplegia so he came to Ibrahim malk hospital in ER
department some investigation was done for him and he diagnosed as Ischemic stroke
now pt is a little bit stable
History of past illness :-
Pt had history of hypertension and diabetes, no similar condition and no history of
hospitalizations.
Diagnostic procedures :-
CT scan , MRI ,CBC (ptt raio).
Medical or surgical treatment :-
pt on oxygen ,anti hypertensive drugs ' anticoagulant
Current complain:-
confusion, hemiplegia, dysphasia .
Nursing dignosises :-
1- Ineffective cerebral tissue perfusion related to obstraction
2- impared physical mobility ralated to poor function.
3- impared verbal communication related to dysphasia .
Goals :-
1- keep cerebral perfusion within normal .
2-pt will maintain physical mobility and will be little bit independent.
Intervnations:-
1- provide adequate oxygenation , and ensure that the pt receive his medications.
2- discuss use of constraints therapy with physical and occupational therapists.
3- perform rang of motion.
4- implement measures to facilitated communication.