Mrs. Brown a 54-year-old African American woman was presented to the clinic
for hypertension and severe headache that she claims has lastly for few hours.
Mrs. Brown have a past medical history of hypertension, history of stroke 3
years ago (she has right sided weakness from the stroke). She is allergic to
aspirin. She reports severe headache as 9/10 on a pain scale of 1-10. Her vital
signs were taken. Temp 98.2 F, BP 169/92, RR 22, HR 88 BPM. She’s oriented
to person, place, and time. Her speech is appropriate. Client CN II (Visual) is
impaired on the Snellen chart and her CN VII (facial nerve) is impaired, right
lower facial droop present. CN XI (accessory nerve) is impaired, right sided
weakness due to stroke.
Subjective data
Client is a 54-year-old African American woman
Client present to the clinic for hypertension and severe headache
Past medical history, hypertension, stroke (right sided weakness from
stroke)
Allergic to aspirin
Client reports Severe headache as 9/10 on a pain scale of 1-10
Objective data-
Client vial signs temp 98.2 F, BP 169/92, RR 22, HR 88 BPM
Client is oriented to person, place, and time
Client speech is appropriate
Client CN II is impaired on the Snellen chart
Client CN VII is impaired, right lower facial droop present
Client CN XI is impaired, right sided weakness due to stroke
Potential or actual risk factors
Mrs. Brown is at risk for bell’s palsy. Bell’s palsy is a disorder of the nerve that
controls movement of the muscles in the face. Mrs. Brown CN VII is impaired
due to stroke and the assessment finding indicate that her CN VII is impaired,
right facial droop present.
Mrs. brown is also at risk for acute pain due to severe headache.
