Edson College of Nursing and Health Innovation - Arizona ...



|ASU Hospital | |

|Out Patient Stroke Clinic | |

|Registration Form | |

|Patient Name: Bertha Strong |Address: |

|DOB: 11/05/19XX |12470 N. Deer Valley Rd. |

|MRN: 3846196 |Glendale, AZ 85306 |

|SSN: 001240785 | |

|Next of Kin: |Insurance: Medicare and Veterans Benefits |

|Name: Jean Trimble |Policy number: 001240785 |

|Phone number: 602-555-1900 |Guarantor: Self |

|Address: 12470 N. Deer Valley Rd. | |

|Glendale, AZ 85306 | |

|Race: White |Advance Directives: |

|Religious preference: Not stated |Living Will No copy on chart No |

|Employer: Retired |Health Care Power of Attorney No |

| |Copy on chart _____ |

| |Patient Signature: |

| |Bertha S-.-..- |

| PROGRESS NOTES |

|DATE/TIME Today/0800 | |

|RN assessment |Background: Client is assessed today sitting in wheelchair with daughter at her side. This is their first visit to |

| |the Stroke Clinic following an ischemic embolic stroke two months ago, and was in the hospital for one week. The |

| |stroke was related to atrial fibrillation which is now controlled. She did not receive thrombolytic therapy at the |

| |time. She is prescribed anticoagulation medication and a beta blocker. She and her family refused rehab unit |

| |admission. During her hospital stay she was put on a mechanical soft diet with nectar thick liquids due to aspiration |

| |risk. She is a widow with two daughters and a son. She has always been the dominant matriarch and is used to |

| |controlling others. She is a Vietnam era veteran and a retired nurse. |

| |Physical Assessment: |

| |Respiratory: respirations even & unlabored @ 14 bpm, lung sounds clear throughout to auscultation, oxygen saturation |

| |95%, productive cough with deep breaths. |

| |Cardiovascular/Skin: skin pink warm, dry & intact, mucous membranes pink & moist, capillary refill < 3 seconds x 4 |

| |extremities heart sounds S1 & S2 with regular rhythm & rate of 82 bpm, blood pressure 138/78 mm Hg, radial pulses |

| |strong & equal bilaterally, pedal pulses strong & equal bilaterally, Temp 98.6 F orally. |

| |Neurological/Musculoskeletal: alert & oriented to person, place, time & situation, pupils equal round reactive to |

| |light @ 2 mm, no movement of right arm and leg noted. Daughter states that patient can transfer from bed to |

| |wheelchair to toilet with use of walker and full assistance on left side. Strong Grip on left, weak to none on right,|

| |Strong push on left, weak on right. Moves left toes easily and identifies which toe is being touched. No movement of|

| |right toes, looked at foot to try to identify which toe was being touched. |

| |Gastrointestinal/Genital/Urinary: abdomen soft round, active bowel sounds, denies nausea or vomiting. Daughter |

| |reports difficulty with constipation even though using stool softener and fiber supplements. Daughter states last |

| |bowel movement was 2 days ago with hard consistency. Urine has been dark yellow, denies difficulty with urination. |

| |Social: Currently daughter and her two children are living with the patient. Daughter provides most of the |

| |assistance needed with activities of daily living including help with transfers. |

| |Management at Home: Bertha is reluctant to use a walker, fearing that she will fall because she feels so weak and |

| |cannot control her muscles always. She is dependent in bathing, dressing, and most aspects of personal grooming |

| |although she tries to comb hair if encouraged. Bertha’s older daughter, Jean, is the caregiver. She has two |

| |teenagers and has lived with her mother for the past 3 years since her divorce. She is very devoted to her mother who|

| |supported her and her children (financially and emotionally) until she found a job after the divorce. Jean is now |

| |finding it difficult to balance care of her mother, work, and care of her teenagers. She fears her daughters are |

| |having difficulties at school but does not have the time/freedom to help them. She wishes there were more hours in |

| |her day. She thinks her mother deserves all of her time and cannot share that care with others “because she owes Mom |

| |so much.” Jean does not know about or use support services currently. She says she will have to quit her job to stay|

| |with her mother. |

| |Safety: Medication reconciliation completed. Daughter confirms discharge medications being given as ordered. Only |

| |addition medication was a one time use of Tylenol to assist with sleep. Daughter states that last INR was 2.6 and no |

| |change in Coumadin dose was required. |

| |A Murphy, RN |

|Clinical Speech and |Ms. Strong was given portions of the Boston Diagnostic for Examining Aphasia-Short Form to assess her language |

|Swallowing Evaluation |abilities. The following is a report of her data. |

| |Verbal Expression |

| |Simple social responses: 5/6 (83%) |

| |Picture Description for “Cookie Theft” : Girl…Boy…oh no. Stool…no.no…cookies and no. Mom.. bad…water. |

| |Automatic sequences: 3 / 4 (75%) |

| |Repetition: 4/7 (57%) - includes four single words and three from one short sentence |

| |Naming: 3/6 (50%) |

| |Auditory comprehension |

| |Word Comprehension: Body parts -1/2; Nouns – 5.5/8; colors ½; letters 2/2; numbers -1/2: Overall =10.5/16 (65%) |

| |Following commands: 3/15 correct (20%) |

| |Understanding Complex ideational Material (yes/no): 5/8 (63%) |

| |Reading |

| |Reading: Picture-word match: 3 / 4 (75%) |

| |Reading Comprehension- Sentence and paragraphs 2/4 (50%) |

| |Writing: |

| |Able to write name with non-dominant left hand. Significant perseveration on letters and simple words. Overall |

| |writing is laborious and partly malformed but legible. |

| |Speech assessment: |

| |Mild dysarthria characterized by imprecision. Speech production is limited due to language deficits but is |

| |approximately 95% intelligible. Articulation imprecision noted on repetition tasks and word finding tasks. Voice and|

| |fluency are within functional limits. |

| |Language assessment: |

| |Moderate non-fluent aphasia characterized by agrammatic language consisting of nouns and some social phrases. |

| |Significant lack of articles (the, a); verbs (fall, wash, etc), prepositions (in, on) and grammatical morphemes ( |

| |Verb tense - ing). Ms. Strong’s comprehension for simple, single words is moderately impaired and her ability to |

| |follow two step directions is severely impaired. She can read some simple words but her ability to read sentences is |

| |not functional. She can write some functional items such as her name but she exhibits perseveration during written |

| |tasks which was not evident during other testing. Her ability to write in response to questions rather than dictation|

| |should be assessed. |

| |Swallowing Assessment: |

| |Ms. Strong and her daughter report that the patient exhibits some coughing and choking after eating. In addition they|

| |report that food often gets pocketed and needs to be removed from her mouth. She has a history of weight loss. |

| |There is no history of pneumonia and no known aspiration. |

| |Ms. Strong is currently on a regular diet with thin liquids. Her daughter reports they need to cut things small and |

| |put a little extra gravy on some items. Ms. Strong was on nasogastric tube feedings for 2 days post CVA. Otherwise |

| |she has tolerated PO intake with modifications of mechanical soft texture and nectar thick liquids during her hospital|

| |stay. |

| |Ms. Strong needs minimal assistance with feeding as she is unable to cut her food. She is independent with getting |

| |the food to her mouth using her non-dominant hand. Her endurance for meals is fair and she is alert. |

| |Ms. Strong presents with weak buccal closure characterized by the inability to sustain a lip seal. Her tongue |

| |lateralizes to the right and she has limited strength, speed and range. Her jaw is symmetrical as rest and she is |

| |able to maintain jaw closure when pressure is applied. Her soft palate is symmetrical and appears WNL. No nasality |

| |is present in her speech. Her speech is limited but her voice was judged to be mildly breathy. Breath support is |

| |mildly compromised as she has some difficulty remaining full upright. |

| |Ms. Strong was given food and liquid trial to assess the quality and safety of her swallow. She was upright |

| |throughout the trials. She has difficulty following directions and each direction needed to be given one at a time. |

| |Models were also necessary. |

| |Thin Liquid Trial – Client was given 4 oz of water. She drank by herself from a cup. She drooled some of the water. |

| |The swallow duration (introduction of bolus to completion of pharyngeal stage was 3 seconds. She has adequate |

| |laryngeal excursion upon swallowing. She coughed immediately after the swallow. |

| |Nectar Liquid Trial – Client was given 4 oz of nectar thick juice. She drank by herself from a cup. She did not |

| |drool although her lip closure was limited. The swallow duration (introduction of bolus to completion of pharyngeal |

| |stage was 2 seconds. She has adequate laryngeal excursion upon swallowing. No coughing or overt signs of aspiration |

| |were noted. Client’s voice quality was good following the swallow. |

| |Pudding/Solid food Trial- Client was given vanilla pudding. She fed herself with a spoon. The examiner needed to |

| |hold the cup so it did not slide on the tray. The swallow duration (introduction of bolus to completion of pharyngeal |

| |stage was 4 seconds. She has adequate laryngeal excursion upon swallowing. No coughing or other signs of aspiration |

| |were noted. |

| |Moist Chicken/Solid food Trial- Client was given cut up chicken. She fed herself with a fork. The client chewed her |

| |food for 8 seconds prior to attempting to swallow. She struggled and produced an audible swallow. No coughing or |

| |other signs of aspiration were noted. Upon examination of the oral cavity, chicken remained in the left lateral |

| |sulci. She was unable to remove this with her tongue and was not aware that this food remained. |

| |Lettuce/Solid food Trial- Client was given some salad. She fed herself with a fork. The client chewed her food for |

| |8 seconds prior to attempting to swallow. She swallowed but immediately coughed and tried to clear her throat. She |

| |stated that a piece of lettuce got stuck. She was able to cough/clear and swallow a second time. |

| |Kelly Ingram, M.S. CCC-SLP |

|Nutrition Assessment |Age: 65 Gender: Female Height: 61 inches Weight: 162# |

| |Medical Diagnosis: Ischemic Embolic Stroke Consult: Consult for nutrition assessment |

| | |

| |ASSESSMENT |

| |Weight History: 18# unintended weight loss last 2 months |

| |IBW: 105 # + 11# %IBW: 154% |

| |Activity Level: Sedentary Medications: Coumadin, Colace, fiber supplements |

| |Past Medical History: Ischemic Embolic Stroke, HTN |

| |Lab Values (Date):albumin 3.8 mg/dl |

| |Current Diet Order: Regular with thin liquids Education Needs: Speech Therapist |

| |Energy Needs: 1700-1900 Kcal |

| |Protein Needs: 60-75 grams |

| |Fluid Needs: 2600 ml/day |

| |Energy Intake: minimal |

| |Protein Intake: minimal |

| |Fluid Intake: 720 ml/day |

| | |

| | |

| |Pt complains of unintentional 18# weight loss in the last two months. Pt has right side insufficiency unable to cut |

| |food but independent feeder. Pt complains of constipation, last bowel movement two days ago. Taking stool softener |

| |and fiber supplements. |

| | |

| |Sandra Mayol-Kreiser, PhD, RD, CNSC |

|Social Work Progress | |

|Notes Initial Visit with|Referral received from nursing re: patient’s appetite decline and reduced sleep since CVA with concerns re: patient’s |

|Bertha Strong |mood. Met with patient and her daughter, Jean, to assess further. Patient has communication deficits associated with |

| |CVA, yes/no response appears somewhat unreliable, but patient is able to communicate emotions such as sadness, worry, |

| |and concern via facial expression, gestures, and tone of voice; responds to humor with smile. Daughter provided the |

| |bulk of information due to patient’s communication limitations; reports patient has history of depression and PTSD |

| |associated with military service and received mental health intervention in the past. Daughter acknowledges patient’s |

| |lack of appetite and disrupted sleep; reports patient has difficulty falling asleep as well as staying asleep with |

| |early morning wakening. Daughter suspects patient’s worries, fears, and grief associated with changes accompanying CVA|

| |are contributing to mood changes; describes patient as “down” with episodes of tearfulness. Daughter reports some |

| |caregiver stress as well, trying to maintain employment as well as care for mother with no outside help; notes patient|

| |reluctant to accept in-home services due to fears of strangers in the home. Will discuss information with |

| |interprofessional team to further develop plan of care. |

| |[pic]PhD, MSW |

| |

|LABORATORY TEST RESULTS |

|DATE/TIME: Today/0800 |

|TEST |NORMAL VALUES |RESULTS |

|Comprehensive Metabolic Panel: | | |

| Sodium (NA) |136 – 145 mEq/L |136 mEq/L |

| Potassium (K) |3.7 - 5.2 mEq/L |4.5 mEq/L |

| Chloride (CL) |102 – 110 mmol/L |102 mmol/L |

| CO2 |22 – 30 mmol/L |30 mmol/L |

| Glucose |77 – 113 mg/dl |98 mg/dl |

| BUN |5 – 26 mg/dl |20 mg/dl |

| Creatinine |0.8 – 1.4 mg/dl |1.0 mg/dl |

| Calcium (Ca2+) |8.4 – 9.9 mg/dl |8.5 mg/dl |

| Total Protein |6.2 – 8.0 g/dl |6.8 g/dl |

| ALBUMIN |3.8 - 5 mg/dl |3.8 mg/dl |

| BILIRUBIN TOTAL. |0 – 1.2 mg/dl |1.0 mg/dl |

| AST. |8 – 40 IU/L |32 IU/L |

| ALT. |12 – 65 IU/L |55 IU/L |

| ALK PHOSPHATASE. |33 – 121 IU/L |102 IU/L |

| | | |

| | | |

|Complete Blood Count: | | |

| WBC |4,500-10,000 cells/mcl  |9,000 cells/mcl  |

| RBC | Male, 4.7-6.1 million cells/mcl;  |4.8 million cells/mcl;  |

| |Female, 4.2-5.4 million cells/mcl  | |

| Hemoglobin | Male, 13.8-17.2 gm/dcl;  |13.0 gm/dcl;  |

| |Female, 12.1-15.1 gm/dcl  | |

| Hematocrit | Male, 40.7-50.3%; |40.2% |

| |Female, 36.1-44.3%  | |

| Platelet count |150,000–400,000 mm3 |332,000 |

| MPV |7.4 – 10.4 fl |9.2 fl |

| MCV |80-95 femtoliter  |85 fl |

| MCH |27-31 pg/cell  |29 pg/cell  |

| MCHC |32-36 gm/dl  |34 gm/dl  |

| RDW |11% - 14.5% |12.5% |

| | | |

| | | |

|INR (International Normalized Range) |0.8-1.2 |2.8 |

| |2.00-3.00 with anticoagulation medication | |

| | | |

| | | |

| | | |

| | | |

ASU Hospital Discharge Summary

DATE OF ADMISSION:  One week before discharge

DATE OF DISCHARGE: Two months ago

ADMITTING DIAGNOSIS:  R/O CVA

CHIEF COMPLAINT:  Confusion and garbled speech for two days

DISCHARGE DIAGNOSES:

1. CVA—ischemic embolic stroke (left) with Right-sided weakness

2. Laryngeal penetration but no aspiration

3. Atrial Fibrillation—new onset

4. Hypertension

5. Hx of PTSD, depression, and anxiety disorder

CONSULT Obtained:  Speech Therapy

PROCEDURES Performed: 

CT scan of head: Axial noncontrast computed tomography (NCCT) demonstrated diffuse hypodensity and sulcal effacement involving the left anterior and middle cerebral artery territories consistent with acute infarction and atrophy with diffuse old ischemic changes. The patient is a 65-year-old female with history of garbled speech and increasing confusion for the past two days. Impression: ischemic embolic stroke.

Barium Swallow indicates laryngeal penetration but no aspiration

BRIEF HISTORY: The patient is a 65 year old female with history of hypertension, and PTSD, depression, and anxiety disorder related to Viet Nam war experiences. She came to the ED after daughter noted that her speech was garbled and she seemed confused at home. The patient was admitted to the neurology service for evaluation and treatment of a possible stroke.

PAST MEDICAL/SURGICAL HISTORY:  Positive for atrial fibrillation

FAMILY HISTORY:  Positive for atherosclerosis, hypertension

SOCIAL HISTORY:  Widow with two daughters and a son. Never smoked.  Alcohol socially.  No drugs.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

REVIEW OF SYSTEMS:  States no problems until time of the stroke except for hypertension being treated with Lisinopril.

PHYSICAL EXAMINATION:  

VITAL SIGNS:  Blood pressure 174/84, pulse 78, respirations 18 and saturation of 98% on room air.  

General Appearance:  Overweight (180#, 5’1”), appears stated age.

HEENT:  Conjunctivae are normal.  

PERRLA.  EOMI.  

NECK:  No masses.  Trachea is central.  No thyromegaly.  

LUNGS:  Clear to auscultation and percussion bilaterally.  

HEART:  Irregular rhythm.  

ABDOMEN:  Soft, nontender, and nondistended.  Bowel sounds are positive.  

GENITOURINARY:  Continent, Constipated

EXTREMITIES:  Right-sided Upper and lower limb weakness

SKIN:  Normal.  

NEUROLOGIC:  Cranial nerves are grossly within normal limits.  No nystagmus.  DTRs are normal.  Good sensation.  The patient is alert, awake, and oriented x3.  Speech is mildly dysarthric. Language is limited to 1-3 words. Mild confusion.

LABORATORY DATA:  WBC 8.6, hemoglobin 13.4, hematocrit 39.8, platelets 207,000, MCV 91.6, neutrophil percentage of 72.6%.  Sodium 133, potassium 4.7, chloride 104.  Blood urea nitrogen of 18 and creatinine of 1.1.  PT 17.4, INR 1.6, PTT 33. Glucose (fasting) 102, HbgA1c 5.6, Trig 146, Pre albumin 14.5,  

HOSPITAL COURSE AND TREATMENT:  

1. CVA—ischemic embolic stroke (left) with Right-sided weakness R/T new onset Atrial Fibrillation.

2. Laryngeal penetration but no aspiration requiring Level 2 Dysphasia diet

3. Hypertension treated with Lisinopril 10 mg po daily

4. Atrial Fibrillation—Anticoagulation with Coumadin established

5. Hx of PTSD, depression, and anxiety disorder

DISCHARGE DIAGNOSIS:  CVA—ischemic embolic stroke (left) with right-sided weakness

DISCHARGE DISPOSITION:  The patient is discharged to home after declining Rehabilitation Unit admission.

DISCHARGE MEDICATIONS:  The patient was discharged on the following medications:

Coumadin 5 mg by mouth every evening

Lisinopril 10 mg by mouth once daily

Metoprolol XR 50 mg. by mouth once daily

Colace 100 mg by mouth once a day

Fiber supplement of choice 5 grams twice a day with 4-8 ounces of water

DISCHARGE DIET:  Level 2 Dysphagia

DISCHARGE ACTIVITY:  Resume activity as tolerated.

FOLLOWUP:

1. Follow up with primary provider in 2-3 days for hypertension control and anticoagulation evaluation.

2. Appointment made for Stroke Clinic in 4 weeks.

Ticket in: Please complete this page and bring it with you to the Interdisciplinary Meeting.

Impressions (Statement of issues for the client and family)

Recommended Interventions

Your signature: ______________________________________________________

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NAME: Bertha Strong MRN: 3846196

AGE: 65 yrs DOB: 11/05/19xx

ADM: Today Service: Stroke Clinic

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