NR 226 RUA Fundamentals Patient Care

Student Name

Chamberlain University

NR-226: Fundamentals – Patient Care

Prof. Name

Date

Assessment

General Appearance

The patient is a well-nourished, well-developed 55-year-old male who appears consistent with his stated age. He demonstrates no signs of acute distress during observation.

Vital Signs

The patient’s vital signs are summarized in Table 1. While most parameters remain within normal limits, the blood pressure reading of 139/97 mm Hg is elevated, indicating ongoing hypertension that requires monitoring and management.

Table 1
Vital Signs

Parameter	Measurement	Interpretation
Blood pressure	139/97 mm Hg	Hypertensive (Stage 2 diastolic)
Pulse	79 bpm	Within normal range
Respirations	18 breaths/min	Normal respiratory rate
Oxygen saturation (O₂)	100% room air	Optimal oxygenation
Temperature (oral)	97.3°F	Normothermic

Neurological Assessment

The patient is alert and oriented to person, place, time, and situation (A&O ×4). Mild left facial drooping is present. Motor examination reveals weakness in the left upper and lower extremities, consistent with the patient’s history of cerebrovascular accident (CVA).

HEENT (Head, Eyes, Ears, Nose, Throat)

• Head: Normocephalic without visible or palpable abnormalities.
• Eyes: Visual acuity intact; disconjugate gaze noted. Pupils are equal, round, reactive to light and accommodation (PERRLA). Extraocular movements intact. Conjunctivae are pink and moist; sclera is clear.
• Ears: External auditory canals are non-tender, clear, and without discharge. Hearing intact to whispered voice.
• Nose: Nasal mucosa pink and moist; septum midline; nares patent bilaterally.
• Throat: Oral mucosa, lips, and tongue pink and moist; trachea midline with no palpable masses.

Cardiovascular System

The patient demonstrates a regular rate and rhythm with normal S1 and S2 heart sounds. No murmurs are auscultated.

Respiratory System

Breath sounds are clear bilaterally without adventitious sounds. Respirations are non-labored, and no accessory muscle use is observed.

Gastrointestinal System

Bowel sounds are present in all four quadrants. The abdomen is symmetrical, non-tender, and without masses or distention. Last bowel movement was on 1/30/2024.

Genitourinary System

Urination is normal with no dysuria or frequency. Urine is yellow in color, and there are no signs of incontinence.

Integumentary System

Skin is clean, dry, and intact without rashes, lesions, or pressure ulcers.

Musculoskeletal System

Weakness is observed in the left upper and lower extremities. The patient requires assistance from one person for positional changes, transfers, and ambulation with a rolling walker.

Psychosocial History

The patient is a Christian pastor, divorced, and father to six children. He recently relocated from New Jersey to North Carolina.

Laboratory and Diagnostic Findings

Laboratory results are within normal limits (Table 2), with no acute metabolic derangements.

Table 2
Laboratory Results

Test	Value	Reference Range	Interpretation
WBC	5.22	4.0–11.0 ×10³/µL	Normal
RBC	5.72	4.5–5.9 ×10⁶/µL	Normal
Hgb	16.5	13.5–17.5 g/dL	Normal
Hct	49	41–53%	Normal
Plt	215	150–450 ×10³/µL	Normal
Glu	92	70–99 mg/dL	Normal
BUN	9	7–20 mg/dL	Normal
Na	138	135–145 mmol/L	Normal
K	3.8	3.5–5.0 mmol/L	Normal
Cl	103	96–106 mmol/L	Normal
Creat	1.13	0.6–1.3 mg/dL	Normal
Ca	9.9	8.5–10.2 mg/dL	Normal

Pathophysiology

The patient is a 55-year-old male with a medical history of hypertension, transient ischemic attacks (TIAs), and dyslipidemia. Recently, he discontinued his antihypertensive therapy for two weeks under his primary care provider’s guidance in an attempt to manage his blood pressure through diet and holistic measures. While exercising, he developed sudden left-sided weakness. Imaging revealed a right pontine infarct, resulting in contralateral (left-sided) motor deficits and facial drooping.

The likely etiology of this cerebrovascular accident was uncontrolled hypertension, with reported systolic readings exceeding 200 mm Hg in the emergency setting. The patient’s history of recurrent TIAs further compounded his stroke risk. Post-event, he has residual left-sided weakness, gait instability, and facial drooping, placing him at high risk for falls.

NR 226 RUA Fundamentals Patient Care

Pertinent Medical Diagnoses and NANDA Priorities

Table 3
Primary and Psychosocial NANDA Diagnoses, Goals, and Interventions

NANDA Diagnosis	Short-Term Goals	Long-Term Goals	Short-Term Interventions	Long-Term Interventions
Impaired Physical Mobility	Patient can shower without assistance within 2 weeks	Patient performs physical activities independently by discharge	1. Use gait belt, wheelchair, and walker for mobility.2. Bed/chair alarms.3. Reposition every 2 hours.	1. Encourage proper nutrition and hydration.2. Active range-of-motion (ROM) exercises.3. Maintain safe environment.
Ineffective Tissue Perfusion	Maintain healthy blood pressure until discharge	Prevent recurrent stroke for at least 1 year	1. Blood pressure control via medications.2. Physical/occupational therapy.3. Anticoagulant therapy as indicated.	1. Medication adherence.2. Heart-healthy, low-cholesterol diet.3. Guided mental practice exercises.
Impaired Social Interaction	Patient expresses desire to interact socially within 2 weeks	Patient engages in group activities within 1 month of discharge	1. Encourage support group participation.2. Practice social skills.3. Provide stimulating environment.	1. Referral to therapy.2. Enhance coping skills.3. Facilitate ongoing socialization.

Rationale for Goals

These goals follow the SMART framework—specific, measurable, attainable, relevant, and time-bound (Shen, 2023). Short-term mobility goals (e.g., independent showering) foster confidence and promote self-efficacy, while long-term mobility goals target independence and safety. Blood pressure control and stroke prevention goals are vital in reducing recurrent events. Psychosocial goals address the patient’s isolation following relocation, mitigating depression risk and promoting reintegration into the community (Nursing Diagnosis, 2023).

Infection Control

Standard precautions were adhered to, including hand hygiene, glove use when indicated, mask use as required, and disinfection of high-contact surfaces. These measures were maintained as the patient was not on isolation protocols.

Safety Considerations

Due to left-sided weakness, the patient was considered a high fall risk. Safety strategies included one-person assist for mobility, the use of a rolling walker and wheelchair, and activation of bed and chair alarms to prevent unassisted ambulation.

Communication Strategies

Patient care involved active listening, maintaining eye contact, using empathetic language, and employing open-ended questions to encourage dialogue. Trust-building was prioritized to foster a therapeutic nurse-patient relationship.

References

Nursing diagnosis impaired social interaction. (2023, February 28). Nursing Diagnosis. https://nandadiagnoses.com/impaired-socialinteraction/

NR 226 RUA Fundamentals Patient Care

Shen, R. (2023, October 22). 13 smart goals examples for stroke patients. Success in Depth. https://successindepth.com/smart-goals-for-stroke-patients/