Nursing Assignment: Case Scenario of a Patient with Stroke

This nursing assignment focuses on the case scenario of a patient, Mr Orkins, who was 84 years old and was admitted to the emergency department (ED) due to collapse. The essay discusses the complete evaluation of the patient's condition, identification of relevant cues, and effective nursing interventions for treating the health issues of the patient.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
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Introduction
The essay will focus on the case scenario of a patient, Mr Orkins, who was 84 years
old and was admitted to the emergency department (ED) due to collapse. The complete
evaluation of the patient condition and identification of the relevant cues or information will
be beneficial for identifying his deteriorating health condition associated with primary,
secondary and focused valuations of the patient health (Odell 2015). Effective nursing
interventions or strategy is included in the study that will be useful for treating the health
issues of the patient.
Part 1:
The patient was admitted to the emergency department as he collapsed and was
unresponsive for a short span of time. A complete handover including the patient’s primary,
secondary and focused assessment was completed that would be beneficial for identifying the
issue of the patient of the patient. According to the primary assessment, it was identified that
he was suffering from stroke that is defined as the condition, where the brain does not receive
adequate amount of blood that further result in death of numerous cells. There are two types
of stroke and based on the initial symptoms of the patient it was clear that he was suffering
from ischaemic stroke as no symptoms of bleeding was evident form the scenario. The major
issue identified from the primary assessment was the drooping of face towards his right side
associated with drooping of saliva from his mouth on the right side that was mainly due to
paralysis of face that is considered as the major symptom of stroke. His speech was also
slurred and he was facing trouble in speaking fluently (Volk et al. 2016). The patient also
exhibited the symptom of urinary incontinence, where the patient could not control his stool
and urine as the muscle controlling the release of stool and urine were weakened due to
stroke.

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The secondary assessment was performed that focused on evaluating the vital signs of
the patient. The blood pressure of the patient was high (150/98), which was due to his
hypertension condition that can possibly lead to blood clot in the arteries thereby not allowing
the blood to flow adequately to the brain and therefore resulting in stroke. The heart rate was
98 bpm that is considered as normal in older adults as the heart rate (HR) range between 60-
100 bpm. Similarly the SpO2 and respiratory rate was normal in the patient as identified from
the secondary assessment of vital signs. The blood sugar level was high (10.4 mmol/mL) as
the patient was suffering from type 2 diabetes and he can further develop the condition of diabetic
stroke as the patient suffering from stroke need to manage their blood sugar level under 10
mmol/L (Pepper and Witherow 2019). The people suffering from diabetes are more prone
towards developing stroke as compared to normal people.
Neurological assessment was done that involved few significant symptoms leading to the
bad health condition of the patient. The GCS score of the patient was 13, which indicated that the
patient was suffering from mild head injury after falling that could possibly be the reason for
stroke. The size of the patient pupil was different, which exhibited that he might have developed
the condition of Anisocoria, due to lack of blood flow that is considered as the common
symptom in older patients (Sabarigirish et al. 2016).
Part 2:
The patient current health situation was assessed using primary, secondary and
focused assessment procedure. Primary assessment is considered as the initial assessment that
is conducted for identifying any life threating situation of the patient. The patient was
admitted to the emergency department due to stroke and was immediately taken under
primary assessment that helped the doctor to identify what was the possible reason or issues
that lead to stroke (Banks et al. 2015). From his physical symptom, the doctors could identify
the risk and what was the major health issue. In primary assessment the patient is assessed

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under the acronym ABCDE, which typically stands for Airway, Breathing, Circulation,
Disability and Exposure. The patient was evaluated on the basis of each parameter and any
threat or issue that was highlighted from any parameter was evaluated and noted. Secondary
assessment is done only after the conduction of primary assessment where all life threatening
issues are identified including the respiratory rate, heart rate, blood pressure and oxygen
saturation (Rozen and Saba 2017). The primary objective of secondary assessment is to
discover the medical condition of the patient and asses the viral signs of the patient that will
provide a detail analysis of the patient’s health condition. The last assessment that was
conducted for the patient was neurological assessment that is critically done for evaluating
the motor and sensory response of the patient body and identify if any neurological disease is
present in the patient (Spencer and Irving 2016).
Part 3:
To treat or prevent the bad health condition it is essential that appropriate nursing
intervention is selected that will assist the patient in overcoming from the condition of stroke.
The nursing interventions that is culturally safe, holistic and derived from evidence-based
practice with rationale are stated as follows:
Intervention Rationale
Monitoring of vital signs like change of
blood pressure, heart rate and respiratory
rate.
Any irregularities in the vital signs of the
patient can help the doctor to identify if the
change is happening due to stroke or not.
The fluctuation in the blood pressure might
happen due to cerebral injury as the
condition of hypertension is considered as
the precipitating factor.
Evaluating the size, shape and activity of the
pupil.
Effective pupil reaction is managed by the
cranial nerves that is crucial for identifying
if the brain stem is integral and also identify

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the balance among the sympathetic and
parasympathetic innervations.
Support extremities in managing the
functional position of the patient in case of
spastic paralysis. Uphold the head neutral
position.
Prevent footdrop and contractures and
regain of activity after the body function
properly as spastic paralysis result in head
deviation to one sideways.
Refer and consult the patient to a speech
therapist.
Assesses the patient verbal competences and
motor, cognitive and sensory functioning in
order to identify the therapy needs
Conclusion
It can be concluded that the essay had focused on the condition of facial palsy and
what are the risk factors or issues identified in such condition after complete assessment of
the patient. The primary, secondary and focused assessment was explained in the essay and
how this assessment are performed was also highlighted. The essay concludes by exhibiting
the effective nursing interventions, which will help the patient to recover from their illness.

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References
Andresen, N.S., Sun, D.Q. and Hansen, M.R., 2018. Facial nerve decompression. Current
opinion in otolaryngology & head and neck surgery, 26(5), pp.280-285.
Banks, C.A., Bhama, P.K., Park, J., Hadlock, C.R. and Hadlock, T.A., 2015. Clinician-graded
electronic facial paralysis assessment: the eFACE. Plastic and reconstructive surgery,
136(2), pp.223e-230e.
Madhok, V.B., Gagyor, I., Daly, F., Somasundara, D., Sullivan, M., Gammie, F. and
Sullivan, F., 2016. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane
Database of Systematic Reviews, (7).
Odell, M., 2015. Detection and management of the deteriorating ward patient: an evaluation
of nursing practice. Journal of clinical nursing, 24(1-2), pp.173-182.
Pepper, T. and Witherow, H., 2019. Not just a pretty face–face lift as a treatment for
dysarthria secondary to facial palsy. International Journal of Oral and Maxillofacial Surgery,
48, p.126.
Rozen, S. and Saba, S.C., 2017. Nerve Transfers in Facial Palsy. In Operative Dictations in
Plastic and Reconstructive Surgery (pp. 333-335). Springer, Cham.
Sabarigirish, K., Lohith, B.R., Saxena, S., Swami, H. and Dutta, A., 2016. Bilateral Temporal
Bone Fractures with Bilateral Facial Nerve Palsy. Indian Journal of Neurotrauma, 13(03),
pp.168-170.
Spencer, C.R. and Irving, R.M., 2016. Causes and management of facial nerve palsy. British
Journal of Hospital Medicine, 77(12), pp.686-691.
Volk, G.F., Granitzka, T., Kreysa, H., Klingner, C.M. and Guntinas‐Lichius, O., 2016.
Nonmotor disabilities in patients with facial palsy measured by patient‐reported outcome
measures. The Laryngoscope, 126(7), pp.1516-1523.

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