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Priority Nursing Problem: Susceptible to blood clots due to congenital…
Priority Nursing Problem: Susceptible to blood clots due to congenital conditions
Left cerebral ischemic stroke, numbness/tingling on right side of face, strength regained on right side, +5 grips bilaterally, +5 foot push/pulls bilaterally, absence of pronator drift, absent facial droop
Risk for another stroke
Patient will ambulate greater than 250 feet
Patient will continue to take medication to prevent clots
Risk for Deep Vein Thrombosis and Pulmonary Embolism
Patient will ambulate greater than 250 feet every day
Patient will wear SCDs or other compression devices
Short-term goal: Patient will not develop blood clots while in the hospital
Long-term goal: Patient will not develop blood clots after discharge and be re-hospitalized because the patient is high risk for readmission
Nurse will start patient on Eliquis for home medication
Nurse will monitor patient for signs of excessive bleeding
Nurse will monitor labs PTT and INR to determine if anticoagulants are therapeutic
Nurse will encourage and help the patient to ambulate greater than 250 feet each day
Nurse will assess lower extremities for DVT
Nurse will educate patient on the importance of medication adherence
Not responding to the patient experiencing excessive or unexpected bleeding
Not checking the patient for signs and symptoms and of blood clots
The plan after discharge is home; Stroke education is taught to patient and patient responds with verbal teach-back; Patient knows the signs and symptoms of stroke including facial droop, weak arms, speech difficulty, and then to call 911 immediately; Medication adherence to prevent blood clots and the adverse effects such as bleeding are taught to patient; Patient affirms adherence to medication and to report bleeding to provider; Nurse identifies support system
Giving the patient a razor
Assessment
Potential Complications
Actions to Prevent
Planning
What Should be Avoided?
Interventions
Discharge