T.C. is a 65-year-old African American truck driver who woke up
with weakness of the left side of his body, loss of vision in one
eye, and an inability to speak this morning. He sat on the edge of
the bed, and the symptoms resolved in about 20 minutes. His wife
insisted that she bring him to the emergency department, where he
insists that he is fine, doesn’t need to see a doctor, and that he
has never been sick a day in his life. Despite his protests, you
take his vital signs while performing a brief health history and
physical assessment. Assessment findings include the following
vital signs: BP 194/108 mm Hg, heart rate (HR) 84 beats/minute,
respiratory rate (RR) 22 breaths/minute, temperature 97.8° F (36.6°
C). He moves all of his extremities well, he has equal grip
strength in his hands, and his pupils react equally and briskly to
light. His last visit to a health care provider was 7 years ago
when he finally had a repair of an inguinal hernia that he had had
for more than 20 years. He tells you that he doesn’t smoke or drink
alcohol, but he has been a “steak and potato” man all of his
life. T.C. stayed in the hospital for completion of the carotid scan
and CT angiography. The angiogram revealed a large right internal
carotid artery stenosis with stagnant flow and a 50% obstruction of
the right middle cerebral artery. The health care provider refers
T.C. to a neurosurgeon who recommends he undergo an endarterectomy
of the right internal carotid artery as soon as possible. 9. Even though the embolus was removed from T.C.’s middle
cerebral artery, he still displays clinical manifestations related
to a stroke. You note that he has a left hemiparesis that is more
pronounced in his upper extremity, drooping of the left side of his
face, drooling, left homonymous hemianopsia, neglect syndrome, and
dysarthria. Twice he has impulsively tried to get out of bed
without calling you for . He is voiding with assistance
(placement of urinal) and has not had a bowel movement for 2 days.
Select the nursing diagnoses that are appropriate for T.C. based on
the assessment data. There are 7 correct answers. Impaired Memory Impaired physical mobility Impaired skin integrity Impaired verbal communication Ineffective breathing pattern Risk of constipation Risk for aspiration Risk for injury Disturbed sensory perception Unilateral neglect 10. T.C.’s wife is concerned about his mood and states that
he “doesn’t seem like himself.” She tells you that she thought he
would be very angry for not having the carotid endarterectomy when
he initially had his TIA. However, he seems not to care, and often
he ignores her when she sits at his bedside.
Your response to her is that A) he probably is very angry but just can’t express himself
because of language problems, so he ignores her as a means of
communication. b) his indifference to his situation is a common effect of some
strokes, and he doesn’t see her if she sits on his left side. c) he is most likely in denial about his situation and is
blocking out his whole environment, including her. d) he has suffered so much brain damage that he is not aware of
his situation and cannot respond to her. 11. You identify that T.C. has a completed stroke and develop a
plan of care for him based on the identified problems. List 10
appropriate nursing interventions you would implement with T.C. and
his wife.
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