Case Study Neurologic Disorders PDF

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Clinical practice focused on care of adults, experiencing acute and chronic illnesses with stable or predictable outcomes, throughout the care continuum and across settings (simulation and health care)....

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03/04/2020

Case Study: Neurologic Disorders Scenario N.T., a 79-year- old woman, arrives at the emergency room with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0600, she stayed in bed, complaining of a mild headache over the right temple and feeling slightly weak. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed a left- sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure (BP) has been well controlled. N.T. is currently taking flecainide (Tambocor), hormone replacement therapy, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). The physician suspects N.T. has experienced an acute cerebrovascular accident (CVA). Questions 1. What role do diagnostic tests play in evaluating N.T. for a suspected CVA? When symptoms of a stroke occur, diagnostic studies are done to confirm the stroke and identify the cause. CTs scan and MRI’s can be used. CT scan is the primary diagnostic test for a stroke because it is fastest, it can indicate the size and location of the stroke and determine what type it is. A repeat CT scan should be done between 24-72 hours to monitor because peak cerebral swelling of the brain occurs around 48 hours post stroke. 2. Explain how knowing the type of CVA is an important factor in planning care. We need to know whether the stroke is ischemic or hemorrhagic because that can help determine the type of treatment. If the stroke is hemorrhagic, it is the most serious and neurosurgery needs to be contacted right away. Medications to manage blood pressure need to be given to control bleeding because the body compensates immediately by increasing blood pressure and cerebral perfusion pressure. If it was an ischemic CVA, then we can administer tissue plasminogen activator (tPA) within 4.5 hours for the stroke and avoid other antiplatelets/anticoagulants 24 hours post tPA to prevent intracranial hemorrhage. A major contraindication for administering tPA is if it were a hemorrhagic stroke because it could be fatal. Thus, it is very important to know what type of CVA it is in order to implement the appropriate treatment. 3. Which factor in N.T.’s history is the most likely contributor to her having experienced a CVA?

N.T.’s past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. It was also mentioned that her blood pressure (BP) has been well controlled. Thus, while all of her past conditions can be risk factors to CVA, the main risk is atrial fibrillation. Atrial fibrillation is an irregular heart rhythm that can interrupt blood flow/cause stasis and can also result in an ineffective cardiac output. This can lead to a clot formation that can travel to the brain and result in a CVA. Furthermore, N.T’s history of atrial fibrillation puts her at an increased risk for CVA. Case Study Progress After a non-contrast CT scan, she is diagnosed with a thrombolytic CVA. The physician writes the orders shown in the chart. Physician’s Orders - IV 0.9% NaCl at 75 mL/hr - Activase (tPA) per protocol - Stat CBC, PT/INR, CPK isoenzymes - Neurologic assessment every hour - Obtain patient weight - Vital signs every hour - Oxygen at 2 L per nasal cannula (NC) - NPO until swallowing evaluation Questions 4. Outline a plan of care for implementing these orders. - Monitor vital signs every hour to manage ICP → ensure breathing, blood pressure, bleeding, swallowing, heart, and other symptoms are are managed - Obtain patient weight to get baseline data - Neurologic assessment every hour - Send blood work → CBC, PT/INR, CPK isoenzymes - Administer Oxygen at 2 L per nasal cannula (NC) - Start IV 0.9% NaCl at 75 mL/hr - Administer Activase (tPA) per protocol 5. Which interventions can you delegate to the Personal Support Worker (PSW)? Select all that apply. a. ** Obtaining N.T.’s weight b. ** Assisting N.T. in repositioning every 2 hours c. Initiating oxygen therapy by nasal cannula d. Performing N.T.’s neurologic checks every hour

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e. Obtaining a manual BP per protocol 6. What is the purpose of monitoring the CK isoenzyme levels? Creatine kinase (CK) is an enzyme found in major muscles. It is required for muscles to function and help facilitate chemical reactions in the body. Monitoring the CK isoenzyme levels is used to identify if there is damage to the muscles in the body. The CK isoenzyme level provides information about any injury/diseases in the brain, heart, lungs, and skeletal muscles. The level of CK isoenzymes are elevated in the blood when there is damage to muscle cells. The elevated levels of CK-1 isoenzyme, which is primarily in the lungs and brain, indicate a possible brain injury, formation of clot, seizure, or sudden death of brain cells. 7. The instructions on the tPA vials read to reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. N.T. weighs 143 pounds. What is the amount of the bolus dose, in both milligrams and milliliters, you will administer in the first minute? What is the amount of the remaining dose that you will need to administer? Tissue plasminogen activator (tPA) is a recombinant drug that breaks up clots to reopen blocked arteries in ischemic strokes. Recommended → 0.9 mg/kg 1mg is constituted in 1 ml → 1 mg = 1 ml Patient weight = 143 lb Convert patients weight into kg by dividing by 2.2 → 143 lb / 2.2 = 65 kg 0.9 mg x 65 kg = 58.5 mg or 58.5 ml Therefore, the total dose to be given the the patient is 58.5 mg or 58.5 ml 10% of the dose is administered as bolus over 1 minute The rest of the dose is given over 60 minutes 58.5 mg x 0.1 = 5.85 mg or 5.85 ml Therefore, 5.85 mg or 5.85 ml is the amount of bolus to be administered over 1 minute. 58.5 mg x 0.9 = 52.65 mg or 52.65 ml Therefore, 52.65 mg or 52.65 ml is the rest of the dose to be administered over 60 minute.

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8. Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply. a. ** Currently on Coumadin with an INR of 2.4 b. ** Major surgery in the last 14 days c. Systolic BP of 150 d. ** Platelet count of less than 100,000 e. ** Blood glucose of less than 50 mg/dL f. ** History of myocardial infarction 1 year ago g. Improving neurologic status 9. What are your responsibilities during the administration of Activase (tPA)? During the administration of Activase (tPA), I am responsible to know the weight of the patient to ensure proper dose calculation. I must also know when the first symptom of CVA occurred because it should be administered within 4.5 hours. I also need to know if there are any contradictions for it and verify that it is an ischemic stroke rather than hemorrhagic. I am also responsible for ensuring that no additional anticoagulants or antiplatelets are given for 24 hours post tPA in order to prevent intracranial hemorrhage. Because tPA increases the risk of bleeding, I need to monitor if bleeding problems occur such as blood in cough, stool, emesis, or headaches.

Case Study Progress N.T. is admitted to the neurology unit. A second CT scan (18 hours later) reveals a small CVA in the right hemisphere. She is placed on flecainide (Tambocor), amlodipine (Norvasc), clopidogrel (Plavix), aspirin, simvastatin (Zocor), and lisinopril (Zestril). 10. If N.T.’s deficits are temporary, how long might it take before they completely reverse? If N.T.’s deficits are temporary, it may take 6 months up to 1 year for mild deficits to resolve. 11. During the first 24 hours after receipt of Activase (tPA), the primary concern is controlling N.T.’s: a. Cardiac rhythm b. ** BP - Blood pressure is the primary concern during the first 24 hours after the

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patient receives tPA. Patients experience elevated blood pressure levels post-CVA. Blood pressure needs to be lowered to reduce the risk of hemorrhage and increased cerebral edema. Although, the blood pressure should not be lowered rapidly to decrease the risk of cerebral blood flow. c. Glucose level d. Oxygen saturation 12. While assessing N.T., you note the following findings. Which one is unrelated to the CVA? a. Headache b. ** Lethargy - Lumbar pain is a neurological finding unrelated to the CVA. Headaches, lethargy, blurred vision, decreased level of consciousness and other motor deficits are more common symptoms of a CVA. c. Lumbar pain d. Blurred vision 13. Why was N.T. placed on clopidogrel (Plavix) post-CVA? Clopidogrel plus aspirin is currently recommended to prevent platelet aggregation and thereby prevent primary and secondary CVA. Clopidogrel is an antiplatelet medication that keeps blood vessels open and prevents blood clots to reduce the risks of cardiovascular diseases . 14. Because N.T. had a thrombolytic infusion, how many hours should you wait before beginning administration of any anticoagulant or antiplatelet medications? Since N.T. had a thrombolytic infusion the nurse should wait 24 hours to begin administration of any anticoagulant or antiplatelet medications. If the nurse did not wait 24 hours this puts the patient at a very high risk of experiencing a hemorrhagic stroke. 15. Is there any benefit from continuing simvastatin (Zocor) after her CVA? Since the patient has hyperlipidemia, the patient has a greater risk for plaque buildup, thus blocking the arteries and preventing blood flow. Statins help decrease cholesterol levels and prevent the buildup of plaque and stabilizes the endothelial wall. 16. As you walk into the nurses’ station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallow study and referral for a speech-language pathologist (SLP). Give the rationale for these orders

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Following a stroke, the patient is at a high risk for experiencing dysphagia. A barium swallow would be done to see how the patient is intaking the food, as well as swallowing. The SLP will make a diagnosis of dysphagia, and instruct the safest way for the patient to position their head while eating, as well as what texture and consistency of food the patient should eat in order to prevent aspiration.

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