Answer key CVA unfolding reasoning 1[978] PDF

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Unfolding Clinical Reasoning Case Study: ANSWER KEY

Cerebral Vascular Accident (CVA)

I. Data Collection History of Present Problem: John Gates is a 59-year-old male who was at work when he had sudden onset of right-sided weakness, right facial droop, and difficulty speaking (dysarthric speech). He was transported to the emergency department (ED) where these symptoms persisted. During transport, he had increased agitation and became confused to place and time. It has been 30 minutes from the onset of his neurologic symptoms when he presents to the ED. Personal/Social History: John lives with his wife in their own home in a small rural community. He owns his own hardware store where he remains active and involved in the day-to-day operations. John’s wife is with him along with his son who also works in the hardware store. His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions. John has been trying to quit smoking over the past week and began using a nicotine patch. John has been complaining of pain on the right foot for the past week according to his wife. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Sudden onset of right-sided weakness, right All of these symptoms are reflecting acute neurologic changes that are facial droop, and difficulty speaking due to disruption in cerebral blood flow either because of embolism or (dysarthric speech) hemorrhagic event. The location of the affected area will determine the type and severity of symptoms. ASK…Are we are able to localize what side of the cerebral hemisphere this CVA is taking place on? It is clearly the LEFT cerebral hemisphere because of the right-sided motor deficits. This is a good time to highlight the relevance of A&P and remember the corpos callosum and what this does! During transport, he had increased agitation and confusion to place and time

It has been 30 minutes from the onset of neurologic symptoms when he presents to the ED

All of these symptoms are reflecting acute neurologic changes that are due to disruption in cerebral blood flow either because of embolism or hemorrhagic event and is a clinical RED FLAG because it is a change that is reflecting a worsening in status. Has been only 30 minutes since onset of neuro symptoms. Is now in ED and if not contraindicated, he is a candidate for thrombolytic therapy such as tPA that can re-establish cerebral blood flow and limit severity of CVA deficits dramatically. TIME IS NEURONS as it is estimated that millions of neurons are lost every minute that tPA therapy is delayed!

RELEVANT Data from Social History: His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions

Clinical Significance: The wife’s attitude MAY be a problem. Will need further assessment. Regarding his speech; is he expressive or receptive aphasia or both? This is reflecting EXPRESSIVE aphasia

Nicotine patch use

Is the patch still on him?…. May elevate BP and should be removed during the acute episode for now. The nurse needs to find it!

pain on the right foot for the past week

Be sure to take his shoes off and perform a skin and joint assessment. Think gout or potential for skin breakdown. He is a diabetic and clustering these 2 pieces of clinical data requires the nurse to assess this once the dust settles with his primary problem

© 2013 Keith Rischer/www.KeithRN.com

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: 1. Indomethacin (Indocin) Pharm. Classification Expected Outcome:  Diabetes mellitus type II25 mg tid 1. NSAID 1. Decrease inflammation poorly controlled 2. Aspirin 81 mg daily 2. NSAID 2. Prevent thrombus in  Hypertension 3. Lisinopril (Prinivil) 20 3. ACE inhibitor those at risk for CV disease  Hyperlipidemia mg daily 4. Anti-hyperlipidemic 3. Lower BP  Gouty arthritis 5. Hypoglycemic 4. Lower LDL and elevate 4. Simvastatin (Zocor) 40  Smokes 1 pack per day x mg daily 6. Nicotine replacement HDL chol. 40 years (40 pack years) 5. Metformin(Glucophage) 5.Lower blood glucose 500 mg bid 6. Smoking cessation 6. Nicotine patch 21 mg transdermal (Which medication treats which condition? Draw lines to connect) DM type II-poorly controlled>>>Metformin Hypertension>>>Lisinopril, ASA Hyperlipidemia>>>Simvastatin Gouty arthritis>>>Indocin Smokes 1 ppd>>>Nicotine patch One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life? Circle what PMH problem started FIRST

 DM-II o

This is where it all began! This is a direct contributor to the development of hyperlipidemia and eventual vascular complications. You will see this similar scenario repeatedly in practice!

Underline what PMH problem(s) FOLLOWED as domino’s  Hyperlipidemia  HTN o Domino that falls after development of hyperlipidemia as the arteries become stiff and noncompliant as a result of atherosclerosis. Hypertension is the end result!  Gouty arthritis o NO domino-isolated problem  Smokes 1 ppd x 40 years o Smoking is like adding gas to this fire of vascular complications with known diabetes! This will accelerate the progression of vascular complications including cardiac and neurologic complications. Knowing that he is poorly controlling his diabetes in addition to being a smoker, this current problem comes as no surprise!

II. Patient Care Begins: Current VS: T: 99.2 (oral) P: 118 (irregular) R: 20 (regular) BP: 198/94 O2 sat: 99% room air (RA)

WILDA Pain Scale (5th VS): Ache Words: 3/10 Intensity: Right foot Location: continuous Duration: Aggreviate: Walking/movement Rest Alleviate:

© 2013 Keith Rischer/www.KeithRN.com

What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS data: Clinical Significance: P: 118 (irregular) This is a clinical RED FLAG because it is reflecting the most common reason for embolic strokes…unrecognized/untreated atrial fibrillation. The irregular rate must be recognized for this likelihood and placing the patient on a cardiac monitor and obtaining a 12 lead EKG are essential standards of care to validate your initial clinical impression. BP: 198/94

An elevated BP after a CVA is not uncommon. However, when too high, it can actually impede cerebral blood flow and perfusion or lead to a hemorrhagic stroke., Managing BP closely is an essential standard of care. Goal is to have BP not too high or too low. Neurologists typically want to see SBP 150–180 to maintain optimal cerebral perfusion in the acute phase of a CVA. Specific goals and BP parameters are individualized for each patient.

O2 sats: 99% RA

Though normal, this is RELEVANT VS data in the context of confusion and agitation in this patient. Hypoxia can also cause the same symptoms, and knowing that sats are 99%, you can be confident that the confusion/agitation is being driven by the acute CVA not hypoxia.

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC:

Appears anxious–he is aware and concerned about changes in neuro status

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds irregular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Confused to place and why he is in the hospital, is notably anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light (PEARL), both right upper extremity (RUE) and right lower extremity (RLE) notably weak in comparison to left, which is strong, right pronator drift present, unable to hold right arm up, right visual deficit cut present

GI:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Able to swallow saliva Voiding without difficulty, urine clear/yellow Skin integrity appears intact, right foot not assessed at this time

GU: SKIN:

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT assessment data: Clinical Significance: GENERAL APPEARANCE: appears Anxiety will increase BP. Make it a priority to educate, comfort, and support anxious during this time in the ED to bring down naturally, and TREND this response to this intervention! CARDIAC: Rhythm: atrial fibrillation

SEE RHYTHM STRIP BELOW: This is confirming your suspicion of the rapid irregular rate that was present initially and may have precipitated the embolic stroke . At this time, the goal is not to change this rhythm, but to manage the complications of further embolic events related to atrial fibrillation.

As a whole all of these acute neurologic changes are reflecting a left NEUROLOGIC: Confused to place and hemisphere CVA that is likely significant in size based on the degree and why he is in the hospital, is notably scope of neurologic changes and hemiparesis. anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light © 2013 Keith Rischer/www.KeithRN.com

(PEARL), both right upper extremity (RUE) and right lower extremity (RLE) notably weak in comparison to left, which is strong, right pronator drift present, unable to hold right arm up, right visual deficit cut present GI: Able to swallow saliva

Any patient with a likely CVA is also at high risk for dysphagia and aspiration, therefore this normal assessment finding is clinically significant!

Cardiac Telemetry Strip:

Interpretation: Atrial fibrillation with RVR (rapid ventricular response; HR >100) Clinical Significance: Clinical RED FLAG as it is reflecting the most common reason for embolic strokes…unrecognized/untreated atrial fibrillation. AFib is common with the elderly, so it important to review medical history and see if they have had this in the past or not. In this case there is NO documented history. This clinical RELATIONSHIP must be recognized by the nurse

III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Acute CVA of the left hemisphere. Do not know yet if is embolic or hemorrhagic in origin, but more likely to be embolic based on assessment finding of new atrial fibrillation. 2. What is the underlying cause/pathophysiology of this concern? There are 2 major categories of stroke: hemorrhagic and ischemic. Hemorrhagic is too much blood within the cranial cavity due to a ruptured blood vessel. Ischemic is too little blood supply to parts of the brain. Ischemic stroke is caused by either a thrombus or embolus. A thrombotic stroke is often due to atherosclerosis developing over time in either the cerebral arteries or the main arteries that supply the brain (usually the carotid arteries). Because of the gradual occlusion, the onset of symptoms tend to occur gradually and slowly. An embolic stroke is caused by a thrombus that breaks off from one area of the body and travels to the arteries that supply blood to the brain. Because the sudden blockage of blood flow, the onset of symptoms tend to be abrupt and faster. Whether thrombotic or embolic, it It is ischemic tissue but is salvageable with timely intervention and reperfusion within 3 hours of onset (time extended to 4.5 hours in some cases). If reperfusion is not established in 3 hours (4.5 hours in some cases) or contraindicated, most of these neurologic deficits will be permanent, though the severity of motor deficits may be decreased over time with therapy.i In the context of atrial fibrillation, because the atria are fibrillating (quivering) and do not have a synchronized atrial kick, blood will not readily empty from the lower portion of the atria and will coagulate and form a clot that will eventually make its way into the ventricle and be pumped either into the lungs if in the right ventricle and cause a pulmonary embolus or if a clot makes it to left ventricle, will be pumped through the aorta and up to the brain causing an embolic stroke.

© 2013 Keith Rischer/www.KeithRN.com

3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY) It must be noted that in the context of a crisis, NANDA nursing diagnostic statements cannot capture the urgency of this critical situation! Though “ineffective tissue perfusion (neurologic)” does “fit” it does NOT communicate the URGENCY of this scenario! Therefore clinical reasoning that I use in practice is to simply state the problem as it is and the nursing interventions readily follow. Knowing that millions of neurons are being lost every minute that there is lack of perfusion to the brain, and since this patient was a witnessed change in symptoms, thrombolytic therapy is indicated if no contraindications. NURSING PRIORITIES right now are multifold…get to CT ASAP to r/o hemorrhagic CVA, continue to monitor and treat elevated BP to maximize cerebral perfusion. The following NANDA statements also have relevance in this scenario:  Ineffective tissue perfusion (neurologic)  Acute confusion  Risk for falls 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: 1. Will expedite transfer for head CT– make sure they are aware and obtain ASAP!

1. Time is neurons! Must r/o hemorrhagic CVA to determine if thrombolytic candidate

CT facilitated

2. Perform frequent neuro check–usually every 15–30" in the acute phase or per MD orders to trend for any changes

2. Status can change quickly, must assess for any subtle changes that could reflect a complication!

No change in neuro status

3. Frequent monitoring of BP of at least every 15minutes

3. Goal is to keep SBP 160–180. Do not want too high or too low to optimize cerebral perfusion 4. May need to slow HR if develops rapid rate and drops BP

SBP in range of 160180

5. At risk for possible seizures secondary to CV and an increase in intracranial pressure (ICP). A. Anticipate the most likely/worst possible complication! It is vital to situate your knowledge and ANTICIPATE vs. REACT!

No seizure activity

4. Continuous monitoring of cardiac rhythm. Afib can accelerate into the 130–150’s readily. Anticipate this possibility 5. Seizure pads on side rails

6. NPO so won’t aspirate until this is evaluated

5.

Expected Outcome:

HR remains...