SOLVED117

Nurses’ Notes 0820: Admitted to unit from emergency department. Admission assessment and vital signs obtained. Client and partner oriented to room. Grip absent on right, present on left. Unable to move right leg. Full range of motion to left leg. NPO pending swallow study. IV in right back hand infusing lactated Ringer’s. No redness or edema noted to IV site. Continuous cardiac monitoring in place. Client rhythm – atrial fibrillation with rate of 114/min. Call light within reach of client’s left hand. Seizure and fall precautions implemented and client education provided. All four side rails up. 0945: Client restless. No changes to cardiac rhythm noted on continuous cardiac monitor. Vital signs stable. Partner at bedside. 1020: Called to room by partner. Client experiencing seizure activity. Focal tonic seizures noted to client’s left side. Partner states the activity started right before they called out. Rapid response team notified; client placed in recovery position. 1025: Seizure continues. Provider in room. Vital Signs 0650: Temperature 37.2° C (99° F) Heart rate 123/min Respiratory rate 18/min BP 210/160 mm Hg Oxygen saturation 97% on 2 L via nasal cannula 0745: Temperature 37.3° C (99.1° F) Heart rate 118/min Respiratory rate 16/min BP 158/86 mm Hg Oxygen saturation 97% on 2 L via nasal cannula 0840: Temperature 37.3° C (99.1° F) Heart rate 116/min Respiratory rate16 breaths/min BP 136/76 mm Hg Oxygen saturation 98% on 2 L via nasal cannula 1025: Heart rate 118/min per continuous cardiac monitor Respiratory rate 14/min Oxygen saturation 96% on 3 L via nasal cannula Admission Assessment 0745: Client is awake but unable to speak or move right extremities. National Institutes of Health Stroke Scale score 23. Full range of motion to left extremities. Right homonymous hemianopsia noted. Lungs clear to auscultation to all fields. Heart regularly irregular. Rhythm atrial fibrillation. Abdomen soft, non-distended, non-tender, with active bowel sounds to all fields. Urine clear yellow draining per indwelling urinary catheter. Last bowel movement unknown. Historical information obtained from partner at bedside. Diagnostic Results 0725: CT: non-contrast head CT consistent with left MCA with noted areas of infarction INR 1.4 HbA1c 7.0% Blood
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