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A 67-year-old male client was admitted with a hemorrhagic stroke to the Emergency Department and is unresponsive to voice or painful stimuli upon arrival.

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Click to highlight the assessment findings (below) that demonstrate cues of Embolic Stroke & Related Assessment findings.


 

Body System Assessment Findings
Neurological unresponsive to voice or painful stimuli upon arrival. After 3 minutes the client opens her eyes and looks around. The client is confused and initially combative. Pupils 4 mm PERRLA bilaterally. Speech slow. Having delayed responses to questions.
Cardiovascular Heart sounds auscultated are S1 and S2. HR irregular. Atrial Fibrillation on the monitor without ectopy. Heart rate 120. No edema. +2 radial pulses. Cap refills in less than 3 seconds.
Respiratory The patient currently has respirations of 22/min and SpO2 is 94% on room air. Equal chest rise and fall. Lung sounds fine crackles.