Age/Sex: 68years old woman.

Mrs J.O.

Primary diagnosis: Acute Ischemic stroke. Secondary diagnosis: Hyperlipidemia, Hypertension.

Inpatient admission.

MR# : Q600645865.

Acount # :Q000000005.

Attemding doctor: Don’thate,Big.

Code Status: Full Code.

Isolation Status: Standard precautions.

Is patient at risk for falls: yes.

Did patient signed the advanced Directive.NO.

Copy of advanced Directive on the chart.

02@2L NC at 94 % .

Method of transportation: Bed.

Patient is confused, combative,right side face drooping. Moves all extremities.

CT Scan /MRI done.

Head CT Scan stable.

Delay in receiving Thrombectomy Treatment.(Delay in bringing patient to the hospital.With stroke patients, there should be no delays with treatment. )

Neursurgery Consultation :no intervention.

Medical management.

Left middle cerebral artery infarction.On Nacl at 140. No evidence of vegetation.

Ejection fraction of 55 to 60%.

Alert and oriented ×1,nonverbal, follows simple commands.

Upon the chair with Physical therapist.

Feeder. Pureed diet.Thin liquid. 1: 1 with feeding discourage straw,let patient take small sips.Sit patient in upright position. Abdomen soft and nontender.

Right side flaccid .

Excoriation right buttocks, abrasion lateral torso, ointment applied.


Resumed :Heparin 5000unit SubQ Q8hours, Aspirin 81mg Q24hours.

Antibiotics as ordered.

0.9NS @50ml/hour.

Bilateral lower extremities with SCD in place. Follow doctor orders and comply with your facility policy and procedures.

Discharge Plans:

Doctor orders case manager and social worker consult. Discharge plan includes patient daughter, Nurse,Case manager consulted, Social worker, Patient needs.Medical records, patient medications review.It is decided that patient will be discharged to rehabilitation hospital to help her to recover. Case manager sent out a referral to various nursing facilities. Awaiting responses. Daughter said that she want a place close to home so that she can easily visit her mother .Daughter can be reached at 5100000000.

Patient will be transferred to rehabilitation hospital when bed is available.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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