PHYSICAL ASSESSMENT 1

  • Category:
    Nursing
  • Document type:
    Article
  • Level:
    Undergraduate
  • Page:
    3
  • Words:
    1825

Physical Assessment

Physical Assessment

Name: Alice Palmer

Age: 54 years

Sex: female

Chief complaint

Hemiparesis

Poor memory of recent occurrence

Bilateral visual fields deficit

Hypertension

History of presenting illness

She reports to being hypertensive for years with poor compliance to antihypertensive drugs. Mrs. Palmer presents with weakness of the entire left side of the body, bilateral visual fields deficit and difficulty in recalling recent data. On Glasgow coma scale evaluation, she scores 15.

Past medical/surgical history

Mrs. Palmer is a known patient with hypertension.

Physical examination

Head — She has normal hair distribution with no scars.

Eyes — Mrs. Palmer has bilateral visual fields deficit.

Ears — There is no discharge or pain, and her sense of hearing is normal.

Nose — There is no swellings, polyps, discharge or any deformities on examination

Mouth — She is unable to move the tongue with ease and slurred speech due to entire left side weakness.

Neck — There is lymphadenopathy.

Chest — On inspection, the chest sounds are normal. On breast examination, there is no discharge or palpable masses. The respiration rate is 20 breaths per minute. On auscultation, the heart rate is 89 beats per minute.

Arms — There is a weakness of the left arm. The arms appear equal. The blood pressure is 155/90mmhg.

Abdomen — On inspection abdomen is of average size and shape without any scars. On auscultation, bowel sounds are present. On palpation, there is no hepatosplenomegaly, hernias, masses or tenderness.

Genitalia — There is no discharge or odor.

Lower limbs — The left lower limb presents with weakness, the limbs appear equal with no other abnormalities detected.

Back — The spinal curve is normal with no growths or tenderness (Forbes & Watt, 2012).

Vital signs

Bp — 155/90 millimetres of mercury

Heart rate — 89 beats per minute.

c (Lakatos & Somogyi, 2013).oAssessment of stroke follows 4steps FAST that includes facial weakness, arm weakness, speech problems and time to call for emergency help. Following the presented information, history of the actual period is that she has been hypertensive. The other consideration is the treatment she is supposed to be taking, the duration she took and missed treatments. A history of other symptoms she may be experiencing, duration and precipitating factors like aphasia, diplopia, vertigo or facial droop. The practitioner needs to know if the patient is getting numbness, uncontrolled reflexes or incontinence. Reports of any speech difficulty are necessary. It is crucial to enquire of the history of coronary artery disease that is a predisposing factor for ischemic stroke. Enquire of the history of facial weakness through assessing if she can smile or having mouth and or eye drooping. Assessment of limbs for edema is crucial too. It is important to ask for the presence of dizziness or loss of balance that occurs with an inner ear injury. Also, enquire for the history of seizures that indicates subarachnoid hemorrhage. Measuring her oxygen saturation levels is important to predict the need for oxygen compensation. Also, maintain a strict input-output monitor to assess fluid balance. The process might need catheterization or supplement fluids. Temperature monitor is crucial and use of antipyretics for temperatures greater than 37.5

Mrs. Palmer is experiencing bilateral visual fields deficit depending on the affected part of the brain. She is reporting hemiparalysis that calls for some consideration. Other considerations include swallowing problems that may cause foods or drinks going through the windpipe rather. A swallowing test is hence important and a feeding tube for affected patients. Mrs. Palmer’s poor hypertension management, follow-up issues, and elderly age play a crucial role to the current ischemic stroke. Mostly, ischemic stroke is due to poor hypertension management. The high blood pressure weakens the blood vessels predisposing them to easy blocking (Jensen, 2014). According to research, old age is a contributing factor to ischemic stroke following collapsed blood vessels raising the incidence of blocking. She is 54 years old and therefore is at a risk of stroke. Mrs. Palmer is presenting with remembering recent information that is due to difficulty in mental processes. The Glasgow coma scale is 15 indicative of mild brain interference and predicts good prognosis with first and correct management (Dains, Bauman, & Scheibel, 2015).

Blood pressure monitoring using a blood pressure machine since persistent blood pressure might complicate to a hemorrhagic stroke. An MRI, cerebral angiography, and CT-scan of the head that helps determine the affected part of the brain, stenosis of a large vessel and occlusion. The tests also play a role in differentiating between an ischemic and a hemorrhagic stroke helping make an actual diagnosis precluding thrombolysis utilization. The MRI is also important in excluding possible infarcts. Relatively, an echocardiogram of the heart or ultrasound of the carotid artery helps determine the position of the blocking clot (Greer, 2007). Blood glucose level is an important test to ruling out hypoglycemia or hyperglycemia as the compounding factor to the stroke assessment of Mrs. Palmer in accordance with the National Institute of Health Stroke Scale (NIHSS). The scale rates under the level of consciousness, visual function, motor function, language, cerebral function, sensation and neglect. It is a 42 points scale with <5 points indicating a minor stroke or greater than ten signaling vessels occlusion. Hand in hand, a carotid doppler is an essential test that allows visualizing the carotid artery to assess arteriosclerosis. A Magnetic Resonance Angiogram can contribute in the examination of the blood vessels in the brain (Alfaro-LeFevre, 2013). It is significant to take note of the cholesterol levels since it is a contributing factor. High cholesterol levels cause the blood vessels to shrinking allowing them to block easily. A chest x-ray can assist in determining the involvement of the heart like in arterial fibrillation. Conduct blood tests to eliminate systemic conditions that may mimic an ischemic stroke. Among the tests include platelet count, prothrombin time, activated partial thromboplastin time, renal and hepatic function tests (Lewis & Foley, 2011)

According to Bendok (2012), ischemic stroke is stroke due to the loss of blood supply to part of the brain caused by a clot blockage. The blood pressure is 155/90 hence the systolic is higher than the normal range of 100-140. The elevation is due to the body’s compensation technique in an attempt to pump enough for the body requirements. Her compliance to antihypertensive drugs is poorly contributing to the high reading. Mrs. Palmer is unable to remember recent information due to the blockage causing oxygen supply cut out to the brain. She is experiencing entire left body side weakness due to hemiparalysis (González, 2005).

The goal of therapy is to prevent infarction by returning blood flow to the affected part. Hand in hand, it is critical to managing her per ABC that is ensuring airway is patent, breathing is present, and the circulation is adequate. Management of ischemic stroke is aimed to cure, prevent complications and recurrence. The management may be via drugs, surgically or rehabilitative. According to Becker and Spencer (2010), drug management includes anticoagulants like heparin, anti-platelet like aspirin, antihypertensive like labetolol, anti-diabetics for blood glucose and thrombolytic therapy like rtPA intravenous thrombolysis (0.9 mg per kg). The thrombolytic therapy enables dissolve the clot (Gordon, 2016). The anti-coagulants help in dissolving the blood clot causing a blockage. Platelets are blood components that allow blood clotting hence anti-platelets reduce the clotting factor of blood. Mrs. Palmer is hypertensive hence it is crucial to managing her hypertension but following close monitoring (González, 2005)

Research has shown that high or low blood sugars are related to ischemic stroke occurrences and even act as a differential diagnosis. In the acute ischemic stroke stage, anti-hypertensives are withheld unless blood pressure >220/120 millimeters of mercury. It is then treated with 10-20 mg of labetolol intravenously for 1-2 minutes. For arterial fibrillation, an anticoagulant like warfarin is prescribed. Among surgery management includes surgery to the carotid artery to open and clear the artery and revascularization that involves artery endarterectomy (Von, Back, & Ay, 2006). The procedure is successful via placing a stent that increases blood flow. Rehabilitative care is to retrieve fluent speech and cognitive communication. Physiotherapy enables motion and prevents occurrence of deep venous thrombosis. A comprehensive assessment of Mrs. Palmer is crucial to identify warning signs early. Among the assessments include respiration system to note the case of hypoxemia and appropriately manage like with ventilation. In cases of increased intracranial pressure, mannitol is the drug of choice (Stein, 2009)

In conclusion, the predisposing factors for ischemic stroke include high cholesterol levels, hypertension, smoking, alcohol, geriatrics, and genetics. The preventive measures are classified into primary and secondary. The primary preventive measures are for patients with no history of stroke and incorporate avoiding predisposing factors, early diagnosis, and management. The secondary is for post-stroke patients and include antihypertensives, statins, platelet antiaggregant plus the primary prevention (Levett-Jones, 2013). Dipyridamole is a drug used with post-stroke patients to prevent recurrence. Asprin use is indicated for patients with risk or history of cardiovascular disease. Patients with seizures can use anti-epileptics like barbiturates. Patients with deteriorating neurologic status require a reassessment of the ABCs and reimaging. The outcome is dependent on the extent of brain damage. The possible complications are heart failure, heart attack, pneumonia, deep venous thrombosis, bedsores and urinary tract infection among others. However, the healthcare team has an obligation to prepare the patient and the family in readiness for all possible outcomes. The preparation promotes coping (Kasner & Gorelick, 2004)

Reference

Alfaro-LeFevre, R. (2013). Applying nursing process: The foundation for clinical reasoning. (8th ed.).Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Dains, J., Baumann, L., & Scheibel, P. (2015). Advanced health assessment and clinical diagnosis in primary care. (5th ed.). St Louis: Mosby.

Becker, R. C., & Spencer, F. A. (2010). Antithrombotic therapy in the prevention of ischemic stroke.

Bendok, B. R. (2012). Hemorrhagic and ischemic stroke: Medical, imaging, surgical and interventional approaches. New York: Thieme.

Forbes, H., & Watt, E. (2012). Jarvis’s Physical examination and health assessment. (Australian and New Zealand 2nd ed.). Chatswood, NSW: Saunders/Elsevier.

González, R. G. (2005). Acute ischemic stroke: Imaging and intervention. Berlin: Springer.

Gordon, M. (2016). Manual of nursing diagnosis. (13th ed.). Burlington, Ma: Jones & Bartlett.

Greer, D. M. (2007). Acute ischemic stroke: An evidence-based approach. Hoboken, N.J: Wiley-Liss.

Jensen, S. (2014). Nursing health assessment: A best practice approach Kluwer Health /Lippincott Williams & Wilkins.
. Philadelphia: Wolters

Kasner, S. E., & Gorelick, P. B. (2004). Prevention and treatment of ischemic stroke. Philadelphia: Butterworth-Heinemann.

Lakatos, V., & Somogyi, B. (2013). Ischemic stroke: Symptoms, prevention & recovery. Hauppauge, N.Y: Nova Science.

Levett-Jones, T. (2013). Clinical Reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson Australia.

Stein, J. (2009). Stroke recovery and rehabilitation. New York: Demos Medical.

Lewis, P. & Foley, D. (Eds.). (2011). Weber & Kelley’s health assessment in nursing. (Australian NewZealand ed.). North Ryde, NSW: Lippincott Williams & Wilkins.

Von, K. R., Back, T., & Ay, H. (2006). Magnetic resonance imaging in ischemic stroke

. Berlin: Springer.