NURS 121 Clinical Day 2 - Maybelle Morales by https://padlet.com/maybellemorales/yb9mmvs3qead7mr4 Patient: L.M., en-us 2021-02-11 23:08:02 UTC 2021-02-11 23:45:38 UTC hello@padlet.com About Patient maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194936519 - Lithia Monson, 93 years old, Caucasian female
- Code Status: FULL
- ADM: 02/07/2021; 1203 Resident Day #: 3
- ADM dx: subdural hematoma r/t head injury from fall
- Current Problem List: Subdural hematoma, head injury, dementia, falls risk, disorientation
- Allergies: NKA 
- Standard Precautions
]]> 2021-02-11 23:11:31 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194936519 Vitals maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194944764 Temp 97.2F
BP 96/74 mm Hg
P 82 bpm, RR 20 bpm, SaO2 97% on room air.]]> 2021-02-11 23:16:22 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194944764 About Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194945845 A subdural hematoma results from the rupture of a blood vessel—typically due to a physically traumatic brain injury—that redirects blood flow to pool between the dura mater and arachnoid layers of the meninges, formally known as the subdural space encompassing the brain. The brain then suffers from increased intracranial pressure and may not receive adequate amounts of oxygen. The product of a subdural hematoma may be loss of consciousness and or orientation, sluggish pupil reactions to light, cerebral edema, impaired mobility, and much more (1329, Lewis). ]]> 2021-02-11 23:17:03 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194945845 Neurological Effects of Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194947208 Due to the increased ICP, neurological dysregulation and coordination of signals to the rest of the body causes severe dysfunction such as aphasia, dysphasia, impaired judgment, deterioration of LOC, headache, drowsiness, confusion, unconscious ipsilateral pupil dilation and fixation, cerebral edema, aggressive personality changes, somnolence, memory loss, slurred speech, and changes in vision. ]]> 2021-02-11 23:17:48 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194947208 Musculoskeletal Effects of Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194948253 Effects on the musculoskeletal system due to impaired neuron transmission from the CNS include impaired balance and gait, general weakness, paralysis, seizures, motor deficit/impairment, palmar drift, spasticity, decorticate/decerebrate posturing, muscular rigidity or increased tone, flaccidity, and ataxia ]]> 2021-02-11 23:18:24 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194948253 Integumentary Effects of Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194949186 As for the integumentary, there may be lacerations from injury, contusions, abrasions, periorbital edema, ecchymosis, otorrhea, and even exposed brain matter due to irritated tissues lacking oxygen or where blood is pooling ]]> 2021-02-11 23:19:00 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194949186 Respiratory/Cardiac Effects of Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194949894 Since cardiac output begins to pool, the lungs attempt to compensate oxygenating the body by increasing breaths per minute. Respiratory quality declines with rhinorrhea, bradycardia, impaired gag reflex, inability to maintain a patent airway, and irregular respiratory rate and pattern. Blood pressure tends to raise to compensate for the pooled blood stasis in the brain, typically evidenced with an increased systole but extremely lower diastole, and bounding pulse ]]> 2021-02-11 23:19:24 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194949894 GI/GI Effects of Dx maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194950435 As for the GI/GU, patient’s experience nausea and vomiting due to ICP causing dizziness, and bowel/bladder incontinence. ]]> 2021-02-11 23:19:47 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194950435 Priority Assessment maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194951178 Neurological
Respiratory
Falls risk 
Vital signs
]]> 2021-02-11 23:20:14 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194951178 Expected Abnormal Priority Assessment Findings maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194952071 - Difficulty communicating or comprehending, ataxia (drunk-like behavior r/t pathophysiology), short-term memory,  disorientation to time, place, situation, or self, impaired judgment,  statements of headache, lethargic behavior, confusion, unconsciousness, ipsilateral pupil reaction, cerebral edema, aggressive personality changes, somnolence, memory loss, slurred speech, and changes in vision.
- Frequent nose bleeds, bradycardia, impaired gag reflex, inability to maintain a patent airway, and irregular respiratory rate and pattern.
- Overall motor control deficit, loss of balance and gait, general weakness, paralysis, seizures, muscular rigidity or increased tone, flaccidity
- A neurogenic fever may occur due to dysregulation of bodily functions from brain’s control center from the patient’s head/brain injury, hypertensive systolic blood pressure with significantly low diastole, and therefore bounding pulses to compensate, increased rate and irregular breathing pattern, decreased oxygen saturation
]]> 2021-02-11 23:20:49 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194952071 Typical Medications maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194965643 acetaminophen, levetiracetam, levetiracetam in D5W, oxycodone hydrochloride ]]> 2021-02-11 23:29:25 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194965643 Nursing Dx 1 maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194970158  Impaired verbal communication r/t subdural hematoma secondary to traumatic brain injury AEB increased ICP impairing CNS regulation and regular bodily functions.

Outcome: Pt will become alert and oriented x4, and be able to communicate without slurred speech by time of discharge.  ]]> 2021-02-11 23:32:27 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194970158 Evidence maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194970679 Neurological effects evident in pt left pupil sluggishly reacting to light. Pt is becoming more difficult to orient, even to self now. Their level of consciousness is getting harder to stimulate; pt will awaken to answer if spoken to, but immediately falls lethargic soon after. Speech is becoming more slurred and unclear, formulating sentences that do not make sense. Short-term memory is getting worse, as pt cannot recall events even 30 minutes prior.]]> 2021-02-11 23:32:47 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194970679 Nursing Dx 2 maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194973660 Disturbed sensory perception r/t subdural hematoma secondary to traumatic brain injury, AEB decreased LOC and orientation to time, place, and now self.
 
Outcome: Pt will at least maintain reality orientation and be able to follow directions and communicate clearly with others all the way until time of discharge.]]> 2021-02-11 23:34:47 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194973660 Evidence maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194974961 Psychosocial effects are evident in finding pt in room talking to self, stating they do not understand where they are, why they are here, and what time it is. Pt is becoming more lethargic, with slurred speech, and does not remember own son despite his recent visit yesterday. Pt exhibits more anxious behaviors, and frustration to understand circumstances leads to aggression.]]> 2021-02-11 23:35:38 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194974961 Nursing Dx 3 maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194977017 Risk for falls r/t increased ICP impairing neuron transmission from the CNS, affecting patient coordination, mobility, balance, and gait.

Outcome: Pt will not sustain any injuries of falls until time of discharge.  ]]> 2021-02-11 23:37:05 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194977017 Evidence maybellemorales https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194977946 Pt c/o chronic joint pain, has full ROM but generalized weakness, occasional involuntary muscle spasms, extreme dizziness and lethargic behavior, did not pass Romberg test, Morse Fall Scale score of over 50 meaning high fall risk]]> 2021-02-11 23:37:45 UTC https://padlet.com/maybellemorales/yb9mmvs3qead7mr4/wish/1194977946