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 Assignment 12.1: Case Study 3 

Case Study

L.P. is a 62-year-old woman with a history of hypertension and hyperlipidemia who presented to a primary stroke center with sudden onset weakness of the right side. On assessment, she had aphasia, left gaze preference, right hemianopsia, right facial droop, dysarthria, and right hemiplegia (Stroke Scale = 22). Head CT angiography showed a left middle cerebral artery occlusion. She was given Alteplase intravenous tPA at 2 hours from symptom onset and transferred to a comprehensive stroke center. She also underwent mechanical thrombectomy. Three months later she had no neurological deficits.

Assignment Instructions

Please complete the following case study analysis utilizing the following:

The Nursing Process:

A – Assessment

D – Diagnosis (Use NANDA nursing diagnoses)

P – Plan (Outcome with a specific short and long term goal)

I – Implementation

E – Evaluation

Additional Information to include if applicable: Medication (class, mechanism of action, dosage [standard if not provided], indication, side effects, contraindications)

See note attachment.

Requirements

  • Submit your answer as a word document or by typing your answer in the submission box below. 

*****Please see sample below*****

Running head: NURSING CARE FOR A PATIENT SCENARIO

Case Study: Nursing Care for Ms. Jones

Name

Academic Institution

NURSING CARE FOR A PATIENT SCENARIO 2

Case Study: Nursing Care for Mrs. Jones

Ms. Jones: Nursing Case Study

Assessment(A)

Ms. Jones has come to the hospital with the primary complaint of blurred vision which is not

amenable to relief by wearing glasses. Her disclosure of being hypertensive as well as diabetic serves to

induce the immediate suspicion of diabetic retinopathy. Ms. Jones is currently taking antihypertensive

medication that include the diuretic, Lasix, an ACE inhibitor Captopril, and the oral hypoglycemic drug

Glucotrol. Ms. Jones states she is a middle aged, 55 year old female, obese, with a family history of early

deaths of her father and brother due to heart attack are suggestive of genetic predisposition to

hypertension and obesity. She has high blood pressure and blood glucose levels upon presentation at the

clinic are suggestive of the chronic nature of her condition. She states that her mother’s diabetic status

also suggests an inherited link for diabetes mellitus. Important healthcare findings about Ms. Jones can be

listed as follows:

Subjective data. Ms. Jones is a, 55 year old female, with a family history of premature deaths of her

father and brother due to heart attack and that her mother’s had diabetic mellitus with a complaint of blurred

vision without relief with the use of glasses.

Objective data. Ms. Jones is 5ft.’ 2in’ tall hypertensive, diabetic female with obvious obesity

indicated by her currently observable 170 lbs. of body weight. Her history also reveals a positive diagnosis

of hypertension as well as type 2 diabetes mellitus in the past. Ms. Jones is already on an antihypertensive

regimen which includes the diuretic, Lasix, The ACE inhibitor Captopril in addition to the oral

hypoglycemic drug Glucotrol for controlling blood sugar.

Diagnosis (D)/Nursing Diagnosis (Berman et al. 2017)

The primary nursing diagnosis for Ms. Jones is that of “risk for disturbed sensory

perception” due to the immediate vision impairment from present and unstable diabetic state,

which has persisted (North American Nursing Diagnosis Association [NANDA].2017). History

NURSING CARE FOR A PATIENT SCENARIO 3

of long standing hypertension, diabetes and her obese condition are suggestive of this diagnosis.

Further confirmation can be obtained after evaluating the results obtained from retinal

examination and other eye tests if recommended. The major changes in type 2 diabetes are the

development of erratic blood glucose varying from hypo to hyperglycemia, increased

predisposition for infections, peripheral nephropathy/retinopathy sometimes leading to blurred

vision as well as blindness (Berman et al. 2017)

Plan (P)

Mrs., Jones needs to be put on a diet regimen which includes only the recommended

calorific intake and her diabetes needs to be controlled in order to keep her plasma sugar levels

at an optimum level of 80-120 mg/dL(Berman et al. 2017). If any abnormal changes in her

retina are detected, it needs an immediate surgical intervention to prevent further damage. She

needs to follow a more controlled lifestyle after the intervention which should include

appropriate control of diet, incorporation of a light exercise regimen to bring down her weight

and religious intake of antihypertensive and anti diabetic drugs with nursing education and

support.

Long-term goals/desired outcomes. Within the duration of care, Mrs. Jones will be able to:

• Demonstrate interest/behaviors and lifestyle changes to improve her well-being,

glycemic control, nutrition, hypertension, medication regimen and compliance, and

visual impairment.

Implementation/Interventions (I) (Berman et al. 2017)

Nursing care implementation and interventions include:

• Consult a dietician or nutritionist to cater for the client’s nutritional needs.

• Assessing and educating Ms. Jones concerning her diabetic and hypertensive medication

regiment and compliance.

• Assessment of the eye for any abnormal lesions in the retina suggestive of diabetic

NURSING CARE FOR A PATIENT SCENARIO 4

retinopathy and further examination, such as angiography if recommended by her

practitioner.

• Reviewing the comprehensive metabolic panel and fasting plasma glucose level and a

glucose tolerance test to further assess hypertensive and diabetic states.

• Evaluation of her diet habits for investigating the role of high calorie foods.

• Education, referrals, and option for health lifestyle practices to address her obesity and is

risk and health factors and complexities also involving her present diagnosis of diabetes

mellitus.

Evaluation (E)

Ms. Jones will require expert nursing concerning diabetic, hypertensive, and medication

education, as well as nutritional and psychological counseling to ensure compliance with the

health care recommendations and referrals after discharge from the hospital. She will also need

to visit the medical facility periodically for her health assessment to sustain her plan of care and

its effectiveness.

NURSING CARE FOR A PATIENT SCENARIO 5

References

Berman, A., Snyder, S. J., Kozier, B. & Erb, G. (2017). Kozier & Erb’s fundamentals of nursing:

Concepts, process, and practice (11th ed., p. 905 & pp. 1296-1298). Upper Saddle River,

New Jersey: Pearson Prentice Hall.

North American Nursing Diagnosis Association (NANDA) International Staff. (2017). Nursing

diagnoses: Definitions and classification, 2015-17. Hoboken: John Wiley & Sons,

Incorporated.

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