MS2 - Neurologic Disorder My Report

MS II - Advanced Health
Assessment
(NEUROLOGIC SYSTEM)
“Stroke”
ENGR. NEIL L. BALLOBAN RN., MS-MATH
MASTERAND
INTRODUCTION
The neurological, or nervous, system is a highly

organized system that directs all body functions
through both voluntary and autonomic responses.
Anatomically, the nervous system is divided into
two parts: the central nervous system (CNS) and
the peripheral nervous system (PNS). The central
division of the nervous system includes the brain
and the spinal cord, which direct coordinated
signals to other systems throughout the body.
INTRODUCTION
The PNS consists of 12 symmetrically arranged

pairs of cranial nerves and 31 symmetrically
arranged pairs of spinal nerves. Each nerve
contains a sensory (dorsal) root and a motor
(ventral) root, which are used to relay information
to and from the CNS.
Neurological system impairments include
changes in consciousness, altered mobility
(tremors, weak-ness, incoordination), altered
sensation (numb-ness, tingling), dysphagia,
dysphasia, and pain.
PATIENT’S PROFILE
Chief Complaint
“I have frequent headaches, keep losing my
balance, and sometimes have difficulty speaking.”
Information Gathered During the Interview

KW is a 48-year-old woman who presents to the
clinic accompanied by her husband. Mrs. W
reports that over the last 2 weeks she has
experienced frequent headaches and periods of
dizziness that resolved spontaneously.
PATIENT’S PROFILE
Mr. W states that early this morning he found his

wife unresponsive. Shortly thereafter, she regained
consciousness but had no recollection of the
morning’s events. She is currently having difficulty
speaking and is unable to ambulate due to left-
sided weakness and numbness. She denies a
history of seizures and dysphagia.
PATIENT’S PROFILE
Mrs. W denies a history of trauma. She states that

she was diagnosed with hypertension 10 years ago
but has been noncompliant with antihypertensive
medications because of their adverse effects. Mrs.
W also has a history of Hyperlipidemia; she has
been noncompliant with medication regimen
because of the cost. Mrs. W had a right carotid
endarterectomy 2 years ago.
PATIENT’S PROFILE
Mrs. W denies any family history of coronary artery

disease, diabetes, neurological disease, or cancer.
She is an only child. Her father, age 78, has hyper-
tension. Her mother, age 75, is alive and well. She
does not have any children.
PATIENT’S PROFILE
Mrs. W lives with her husband in a one-bedroom

apartment and has worked as a receptionist for the
past 20 years. Recently, she has had trouble
completing tasks at work. She reports that she
smokes one pack of cigarettes a day and has been
smoking since she was 18 years old. Other than an
occasional glass of wine with dinner, she does not
drink. Mrs. W denies recreational drug use. She
does not have a regular exercise regimen.
PATIENT’S PROFILE
Clues Important Points
Loss of balance upon ambulation Associated with disease of the motor
cortex and cerebellum and Parkinson’s
disease.
Difficulty speaking Suggests dysfunction of the frontal or
temporal lobes from tumor or stroke.
Left-sided weakness Associated with cerebellar and motor
cortex dysfunction.
Dizziness Suggests decreased cerebral blood flow or
problem with vestibular
apparatus such as an inner ear infection or
orthostatic
hypotension.
PATIENT’S PROFILE
Clues Important Points
Confusion Associated with multiple pathological
causes and requires
further investigation.
Headaches Associated with increased intracranial
pressure resulting from
hypertension, hemorrhage, tumor, or other
causes.
PATIENT’S PROFILE
Name: KW
Sex: Female
Date of Birth: June 10, 1967
Admitted: 2/17/2019
Time: 13:15
HISTORY OF PRESENT ILLNESS
Over the last 2 weeks, a history of frequent

headaches and periods of dizziness. Husband
found her unresponsive this AM. Regained
consciousness but does not remember the
morning’s events. Having trouble speaking and
cannot ambulate, due to left-sided weakness and
numbness. Denies seizures and dysphagia.
Medications
Novasc: 5 mg daily for HTN (Noncompliant due to
adverse effects)
Lipitor:20 mg daily for hyperlipidemia(Noncompliant
due to cost)
Allergies
NKDA ("no known drug allergies“)
Past Medical Illnesses

Denies history of trauma; history of HTN and
hyperlipidemia.
Hospitalizations/Surgeries
Right carotid endarterectomy 2 years ago.
Family History
Negative for CAD, diabetes, neurological disease,
and cancer; positive for HTN (father).
Social History
Employed as a receptionist; has had difficulty
completing work. 30 pack-year history of smoking.
Occasionally uses alcohol. Denies history of
recreational drug use. Denies exercise regimen.
GFHA
GENOGRAM
FATHE
R MOTHE
R
(HTN)
REVIEW OF SYSTEMS
General Ears
Denies fever or chills. Denies hearing loss.
Skin Nose/Mouth/Throat
Denies rash. Denies dysphagia.
Eyes Breast
Denies visual Denies lumps.
problems.
REVIEW OF SYSTEMS
Cardiovascular Genitourinary/Gynecological
Denies any problems. Denies any changes or
problems.
Respiratory
Denies any changes Musculoskeletal
or problems. Unable to ambulate.
Gastrointestinal Neurological
Denies any changes See HPI.
or problems.
PHYSICAL EXAMINATION
Weight: 178 lb Temp: 98.4 BP: 210/108

Height: 5'4" Pulse: 90 Resp: 18
Skin
Warm, dry
HEENT
Scalp intact and symmetric. No lesions, lumps, or tenderness.
Left ptosis. PERRL; EOM revealed left deviated gaze; visual
acuity revealed left hemianopia. Auricles aligned with eyes
without lesions, Tenderness, or masses. Hearing grossly intact.
Nose without discharge; nasal septum midline. No pain or
tender-ness upon palpation of the sinuses. Oropharynx is
benign with no mucosal lesion; tongue midline without lesions
or tremor. Gag reflex intact. Left-sided facial droop. Neck is
supple and without adenopathy or thyromegaly.
Cardiovascular
Apical pulse palpated; regular rate and rhythm. S1 and S2
auscultated. No murmurs, rubs, or bruits.
Respiratory
Respirations even and unlabored. Chest excursion symmetrical.
Vesicular breath sounds auscultated without adventitious breath
sounds noted.
Gastrointestinal
Abdomen soft, non tender, and not distended. Normal BS × 4
quadrants.
Genitourinary
Not examined.
Musculoskeletal
Left-side hemiparesis; left shoulder lower than the
right. Strength is 5/5 to upper and lower extremities on
the right side. Strength is 0/5 to upper and lower
extremities on the left side. No involuntary movements
noted.
Neurological
A J O 3 3; slurred speech; aphasic; follows commands;
GCS, 13. CNII, left homonymous hemianopia; CNIII, IV,
and VI, EOM, impairment in gaze to left; CNV,
decreased sensation to superficial pain and light touch
on left, intact on right; CNVII, left facial droop, lower
face; CNVIII, no abnormalities detected; CNIX and X,
no abnormalities; CNXI, left shoulder weak to shrug;
CNXII, tongue midline. Proprioception, absent on left
and intact on right.
Neurological cont.
Vibration sense, noted deficit on left and intact on right.
Stereoagnosis, graphesthesia, two-point discrimination;
extinction: intact on right and impaired on left.
Coordination (finger to nose, rapid alternating, heel to
shin), impaired on left side. Gait, not tested due to
hemiparesis. Meningeal irritation, negative. Cortical,
intact on right and impaired on left.
LABORATORY TESTS
Na: 140 mEq/mL Hgb: 13.6 g/dL Ca: 8.2 mEq/L
K: 4.1 mEq/mL Hct: 38% Mg: 1.4 mEq/L
Cl: 101 mEq/mL WBC: 7.2 3 103/mm3 Phos: 2.7 mg/dL
CO2: 37 mEq/L Neutros: 54% PT/INR: 13.0/1.3
BUN: 8 mg/dL Bands: 4% PTT: 34
SCr: 0.8 mg/dL Lymphs: 28% Platelets: 268
Glu: 90 mg/dL Monos: 5%

OTHER TESTS
Special Tests
Brain CT scan: suggested evidence of right frontal
lobe infarct. Cerebral angiogram: revealed embolus
and decreased perfusion to the right frontal lobe.
Carotid ultrasound: 92% stenosis right carotid, 79%
stenosis left carotid.
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
NURSING CARE PLAN

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MS II - Advanced Health

The neurological, or nervous, system is a highly

The PNS consists of 12 symmetrically arranged

Information Gathered During the Interview

Mr. W states that early this morning he found his

Mrs. W denies a history of trauma. She states that

Mrs. W denies any family history of coronary artery

Mrs. W lives with her husband in a one-bedroom

Over the last 2 weeks, a history of frequent

Past Medical Illnesses

Weight: 178 lb Temp: 98.4 BP: 210/108

K: 4.1 mEq/mL Hct: 38% Mg: 1.4 mEq/L

Cl: 101 mEq/mL WBC: 7.2 3 103/mm3 Phos: 2.7 mg/dL

CO2: 37 mEq/L Neutros: 54% PT/INR: 13.0/1.3

BUN: 8 mg/dL Bands: 4% PTT: 34

SCr: 0.8 mg/dL Lymphs: 28% Platelets: 268

Glu: 90 mg/dL Monos: 5%

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