Gastrointestinal
Abdomen soft, non-distended. Bowel sounds active in all 4 quadrants. No changes in appetite. Tolerates prescribed ADA diet well; no nausea, vomiting, diarrhea. Last BM 2/7. Regular, normal BM consistency; brown, soft, formed.

Genitourinary
Patient is continent of urine, no urinary catheterization. Urine is clear, yellow. Able to empty bladder without discomfort; no burning or pain with urination. Bladder is non-distended following void. No abnormal odor or discharge.

HEENT
Lips are smooth and pink. Facial structures are intact; no deformities. Mucous membranes are moist. No drainage or redness around ears, nostrils, or mouth.

Integumentary
No wounds or lesions present. Skin recoils immediately, no tenting. Nails are smooth, hard; no ridges or clubbing. IV is patent, no phlebitis or infiltration. Small incision on right thigh is clean, dry, and intact; well approximated, open to air. No tubes or drains.

Heart/Lungs
Skin is warm, dry, appropriate for ethnicity. Afebrile. No JVD or edema present. All peripheral pulses are present, equal to apical pulse. Regular HR. S1 and S2 present, no murmurs. CRT < 3 seconds. Respirations are even, unlabored. Breath sounds are clear, no adventitious sounds. RR within normal limits, 18 BPM. Room air only. No clubbing, no cyanosis.

Musculoskeletal
Full ROM upper and lower extremities, bilaterally. Generalized weakness; right-sided weakness > left-sided weakness. 5+ muscle strength in left upper and lower extremities; 3-4+ muscle strength in right upper and lower extremities. Ambulates with steady gate; stand by assist x 1.

Emotional
Appearance, behavior, speech, and affect are appropriate to situation. Pleasant mood, neutral affect. Patient is optimistic and ready to return to home.

Neurological
Patient is AO x 4; person, place time, and situation. Pupils equal, round, and reactive to light. Face is symmetrical, no facial droop or ptosis. Active ROM in upper and lower extremities, bilaterally. Right-sided weakness and decreased sensation. No difficulty swallowing. Speech slurred, but understandable.

General
Patient is a 46-year-old African American female who presented to the emergency department at South Austin Medical Center with complaints of right-sided weakness and slurred speech. The patient appears to be stable and does not appear to be experiencing any acute distress.

Nursing Interventions

• Assess patient’s motor skills, ease and capability of movement, posture, and gait
  • Assess degree of pain and client’s description about manner in which pain limits mobility
  • Determine degree of immobility, muscle strength and tone, joint mobility, cardiovascular status, balance, and endurance
  • Assess the safety of the environment and ensure that bed are rails up, bed in down position, important items close by
  • Execute passive or active assistive ROM exercises to all extremities
  • Provide periods of rest between activities
  • Provide for safety measures as indicated by individual situation, including environmental management and fall prevention

Diagnosis
Impaired physical mobility related to sedentary lifestyle, neuromuscular impairment, BMI above 75th age-appropriate percentile, decrease in muscle strength (4+), decrease in muscle control, and pain as evidenced by alteration in gait, decrease in active range of motion, decrease in fine and gross motor skills, and slowed movement.

Goal
Patient will verbalize understanding of situation and individual treatment regimen and safety measure by the end of hospital stay.

Goal
Patient will verbalize relief and/or control of pain or discomfort by end of shift.

Nursing Interventions

• Assess pain characteristics (quality, location, severity, onset, duration, precipitating factors, relieving factors) prior to, periodically throughout, and following intervention
  • Administer prescribed medications for pain relief as indicated
  • Evaluate response to prescribed medications
  • Teach patient about non-pharmacological pain management strategies
  • Implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions
  • Plan care activities around periods of greatest comfort whenever possible
  • Position patient for comfort
  

Diagnosis
Chronic pain related to female gender, emotional distress, alteration in sleep pattern, damage to the nervous system, and history of chronic migraines as evidenced by self-report of 6/10 pain on a numeric pain scale, alteration in sleep pattern fixed movement, and grimace.

Goal
Patient will verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider by the end of hospital stay.

Nursing Interventions

• Closely assess and monitor neurological status frequently and compare with baseline
  • Position with head slightly elevated and in neutral position
  • Cluster nursing interventions and provide periods of rest between care activities
  • Evaluate pupils noting size, shape, equality and light reactivity
  • Monitor blood pressure, heart rate and rhythm, and respirations
  • Administer anticoagulants and antihypertensive medications as indicated
  

Diagnosis
Risk for ineffective cerebral tissue perfusion related to recent cerebral vascular accident, hypertension, and hyperlipidemia.

Humalog (insulin lispro) Sliding Scale Subcut. ACHS

• Lower blood glucose

Apresoline (hydralazine) 25 mg PO TID

• Treat hypertension

Levemir (insulin detemir) 10 units Subcut. BID

• Lower blood glucose

Prinivil (lisinopril) 20 mg PO daily

• Treat hypertension

Lopressor (metoprolol) 50 mg PO BID

• Treat hypertension
• Lowered BP

Norco (hydrocodone/acetaminophen) 5/325 mg PO q4h PRN

• Treat moderate to severe pain
• Pain improved

Lovenox (enoxaparin sodium) 40 mg Subcut. daily

• Prevent blood clots and deep vein thrombosis
• No evidence of DVT or VTE
  

Lipitor (atorvastatin) 80 mg PO bedtime

• Decrease cholesterol and lipid levels
  -

Aventyl (nortriptyline) 10 mg PO bedtime

• Treat migraine headache
• Headache unrelieved