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Nursing care plan

Nursing care plan

CC: Increased weakness and slurred speech

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HPI: The patient is a 61 yo gentleman with h/o CVA in September 2005, hypertension, hyperlipidemia, type 2 diabetes, seizure d/o, and cocaine abuse who presents with increased global weakness, slurred speech, and altered mental status. At approximately 4:00 AM, the patient was found by wife sitting on the couch, unable to stand up, respond appropriately to questioning, or speak clearly. The room was in disarray, possibly indicating a fall of some kind, and there was also evidence of urinary incontinence with a wet area on the couch. On presentation to the ED, the patient was found to have right upper and lower extremity weakness, slurred speech, and disorientation. The patient was unable to explain most of the night’s events but did state that he fell on his buttocks. He also thought he was speaking funny despite knowing what he wanted to say. Although patient did have some residual right sided weakness from the previous stroke that requires the use of a cane, wife noted that this episode was markedly worse in terms of lower extremity strength and ambulation. Patient endorses significant cocaine use and noncompliance with medications since May 2006. When seen in ED at 11:30 AM, patient at baseline per wife. Patient denies head trauma, headache, change in vision, nausea, and vomiting. No dizziness, SOB, chest pain, or palpitations. Patient denied urinary incontinence despite evidence described above.

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