Nursing Care Plan - Musculoskeletal System - Cardiovascular System - Nursing Assignment Help

Assignment Task:

Biographic Data: 

• DOB: September 24th, 1936

• Race: Italian

• Marital Status:  Widow

• Occupation: Not working due to health conditions. 

• Source of data: Chart, Kardex, patient, nurses, physiotherapist. 

• Reason for seeking Care/Presenting Problem: Subarachnoid hemorrhage (SAH): “this is a life-threatening type of stroke caused by bleeding into the space surrounding the brain” (Ringer Andrew, 2020) 

• Present Health Status:

  • Current medical conditions/chronic illnesses: Hypertension (HTN)

  • Current medication: ASA, Bisacodyl, Diltiazem, Pantoprazole, Ramipril

  • Medication / food allergies: NKAD

  • Current medical treatments: Post CVA (Rehab)

• Past Health History 

  • Childhood illnesses: Data gap

  • Previous medical condition: Hypertension

  • Previous hospitalization: Spinal Sternosis

  • Accidents/injuries: Data gap

  • Surgeries: Coiling, cerebral angiostent + embolization. 

  • Immunization: Up to date

  • Date of last examination: Data gap

• Family history: she has support from her daughter. 

• Personal and psychosocial history:

  • Personal status: Low self-esteem due to inability care for self fully due to the aftermath of the stroke. 

  • Family and social relationships: She has a relationship with her daughter.

  • Diet:  Regular diet

  • Functional ability: Requires one-person assistant, able to assist with some ADLs

  • Mental health: Oriented to person, place and time

  • Personal Habits: 

    • Tobacco use: No

    • Alcohol: No

    • Street drugs: No

  • Health promotion: 

    • Exercise:  Activity as tolerated 

    • Self-examination: Data gap

    • Oral hygiene practice: Able to provide morning care with assistance, client brush her teeth every morning before breakfast. 

    • Screening examination: Ultrasound, X-ray

    • Environment: 

• Review of systems:

  • General symptoms: Pain in the left shoulder, vital sign within normal limit.

  • Integumentary system: Skin is consistent with genetic background, presence of bruises on the stomach and on the leg, which might be the effect of blood thinners. 

  • Head: No unusual frequent or severe headache, no head injury, no dizziness 

  • Eyes: Eyes, equal round, are reactive to light and accommodate

  • Ears: Same shape and size bilaterally, has good hearing, no ear infection or discharge.

  • Nose, nasopharynx, Sinuses: No nasal discharge, no pain, no nose bleeds. 

  • Mouth: Not dry so she is hydrated

  • Neck: No distended JV, no pain, no swelling, patient has no limitation of motion, head position is centered in the midline. 

  • Breast: No pain, no lump, no nipple discharge, no history of breast disease.

  • Cardiovascular system: No precordial pain, no dyspnea on exertion, no edema. 

  • Respiratory system: No history of lung disease, no wheezing crackles, no shortness of breath.

  • Gastrointestinal system: No dysphagia, no pain, no abdominal pain. 

  • Urinary system: Sometimes incontinent, wears adult briefs, uses bathroom, no discomfort when voiding.  

  • Reproductive system: 

  • Musculoskeletal system: No history of arthritis, no back pain, no muscle pain

  • Central nervous system: Lack of coordination due to CVA

• Examination:

  • Vital signs: T= 36.3, P= 87, RR= 22, O2= 95 BP= 126/ 70

  • Pain: 6 out of 10 when moving

  • Height: Data gap

  • Weight: Data gap

  • General inspection: Data gap 

  • Oriented: Fully oriented to person, place and time

  • Skin: Consistent with genetic background.

  • Upper extremities:  All body parts are equal bilaterally

  • Head and neck: The head is normocephalic, the head position is centered in the midline, no palpable lymph nodes

  • Chest: symmetrical chest expansion, shape is elliptical, clear sounds heard throughout lung field. 

  • Breast: Same size bilaterally, no nipple discharge, no swelling. 

  • Abdomen: Flat, presence of hyperactive bowel sounds heard in all four quadrants, umbilicus is midline with no discolouration, no pain.

  • Bowel sound: Hyperactive bowel sounds heard in all four quadrants

  • Lower extremities: Presence of +1 pitting edema in both feet

  • Genitalia, rectum: Intact skin, no discolouration, no pain or swelling

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