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NURS 4581 ADULTS WITH COMPLEX NEEDS Cerebrovascular Accident Case Study Assignment You are to complete all of the critical thinking questions for each stage and embed typed answers into this document. STAGE 1: William Edwards 64 year old African American male admit: 02/01/2021 Height: 72in Weight: 120 kg Allergies: NKDA Chief Complaint- presented to the emergency department accompanied by his wife via EMS for c/o severe headache, right sided weakness, facial drooping, slurred speech, and nausea. The client developed status epilepticus (seizure activity) in route to the hospital which resolved with two doses of Ativan. His initial BP was 220/109 (146). Past Medical History- HTN, CAD, obesity, hyperlipidemia, atherosclerosis, trans-ischemic attacks with documented non-compliance with medical plan of care. Home Medications: Metoprolol 50 mg PO daily Famotidine 20mg PO daily Atorvastatin 20mg PO daily ASA 81 mg PO daily Past Surgical History- R carotid endarterectomy 2018 Past Social History- 1 PPD current cigarette smoker, no ETOH or illicit drug use. History of Current Illness02/01/2021- On arrival to the ED, Mr. Edwards was placed on 2L NC, O2 Sats of 96% with anxiety, c/o HA, with marked R sided weakness. His current B/P is 220/109 (146). Onset of symptoms was 1.5 hours prior to arrival. He was loaded with 1200mg Dilantin IVPGBK. Assessment: Pain: 6/10 Headache- pounding all over. Neuro: Asleep, easily arousable, Ox4, follows simple commands. GCS 14. PERRLA 3mm brisk. Upper/lower motor strength is unequal with L strong & R weak. Gross motor intact, fine motor NOT intact on R side (upper & lower) with good coordinated effort noted on L side. Slurred speech; drooling, tongue midline, no numbness/tingling or seizure like activity noted; evaluated as 7 on the NIH stroke scale. Cardiac: S1 & S2 auscultated no extra sounds. Continuous ECG monitoring. Rhythm: sinus tachycardia HR 112. Peripheral pulses 2+/3+. Trace non-pitting peripheral edema in bilaterally lower extremities. BP remains 220/109 (146). Respiratory: RR 22 even and unlabored, BBS- CTA but diminished in the bases. O2 sat 94% on 2L NC. Gastrointestinal (GI): abdomen obese, soft, with NO tenderness, guarding, masses or pulsations noted. BSactive x 4 quads. Nausea present without vomiting. Diet: NPO. Last BM 2 days prior to arrival. Genitourinary (GU): has not yet voided. Urinal at bedside. Musculoskeletal (MS): High fall risk; Seizure precautions in place. Activity observed- bedrest. Integumentary: Skin is dark brown, warm, dry and intact. Temp 98.5 orally. PIV- R FA 20g CDI with 0.9% sodium chloride infusing at 50 mL/hour.

Critical thinking exercises 1. What is the pathophysiology of a trans-ischemic attack vs thrombotic ischemic stroke? 1. Trans-ischemic attack - A transient ischemic attack (TIA) is a neurologic deficit typically lasting 1 to 2 hours. A TIA is manifested by a sudden loss of motor, sensory, or visual function. 2. Thrombotic ischemic stroke - is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. Caused by disruption of the cerebral blood flow due to obstruction of a blood vessel 1

2. List possible signs and symptoms of an acute ischemic stroke? 1. 2. 3. 4. 5. 6.

Numbness or weakness of the face, arm, or leg, especially on one side of the body Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination Sudden severe headache

3. For stage 1, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why? 1. Main priority is to determine if the stroke is hemorrhagic or ischemic in order to properly treat it! 2. The patient is presenting with facial drooping, nausea and slurred speech. This symptoms put a red flag for aspiration precautions. 3. Safety is another main concern, pt has developed status epilepticus in route to the hospital and his bp remains high which can lead to more seizures. 4. What priority medications would you expect to be ordered for this patient and why? 1. Platelet inhibiting meds – decrease incidence of cerebral infarction in pts who had TIAs 2. Thrombolytic therapy ( t-PA) Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain. 3. Antihypertensive meds : pt bp needs to be lowered and controlled, ( carvedilol, nicardipine (titrate) ) 4. Anticonvulsants: Keppra,

5. What priority lab/diagnostic tests would you expect to be ordered for this patient and what results would you anticipate being abnormal and why? 1. CT – expected results would be the present of ischemia in the brain. 2. 12-lead- EKG to make sure. There is no cardiovascular involvement, results may show normal or abnormal. 3. Routine CBC, chemistry , lipid, metabolic. 6. What patient and family teaching is important? Be specific. 1. Its important to educate family and patient about signs and simptoms of TIA and stroke. Also its important to educate patient on medication compliance and management of hypertension. STAGE 2: Mr. Edwards is sent for a CT scan of his head and then admitted to the ICU with the following orders: Neurology consult for suspected ischemic stroke Neuro Assessment q1h Vital Signs q15 min Activity: Bedrest Diet: NPO 2

Place central line and get Chest X-Ray for placement. NS at 50ml/hr Labs: CBC, PTT/PT, INR, Chemistry, Lipid & Liver Panels, Troponin Diagnostics: 12Lead EKG, Repeat Non-contrast Head CT in am O2 at 2 1iters/min per NC—titrate for SpO2>91% Labetalol 5 mg IV-Push PRN Q 10 min SBP > 180 mmHg After SBP maintained under 180, administered t-PA per protocol

Lab & Diagnostic Results: CBC: WBC- 8 RBC- 4.5 Hgb- 14 Hct- 42 Plt- 130 Coags: PT 13.0 PTT 32.0 INR 1.0 Chemistry Panel: Na 136 K 3.9 Cl 100 Ca 9.0 Mg 1.2 Phos 3.8 Glu 158 BUN 18 Creat 1.0 Total Protein 5.8 Albumin 3 GFR >60 Serum Osmo 305 Lipid panel: HDL 30 LDL 140 Total cholesterol 250 Triglycerides 300 Liver Panel: AST 20 ALT 24 Total Bili 1.0 Alk Phos 50 Cardiac: Troponin 0.01 12 lead ECG- Sinus Tachycardia Chest X-Ray: All lung fields clear with mild atelectasis in the bases. Central line noted in R SCV. CT head without contrast- diffuse cerebral edema noted, no evidence of intracranial bleeding or other abnormalities. Critical thinking exercises 1. What is your rationale for each of the admitting orders? List out each order and explain why you think they are ordered for this patient. a. Neurology consult for suspected ischemic stroke- patient is presenting signs and symptoms of stroke, which is a neuro issue and requires neuro consult. b. Neuro Assessment q1h- its necessary to monitor the patient closely in order to asses for changes in LOC. c. Vital Signs q15 min- important to monitor the effectiveness of medications and deterioration of status d. Activity: Bedrest- patient is at fall risk and has seizure precautions, bedrest is the most appropriate for the patient. e. Diet: NPO- patient is exhibiting dysphagia which increases the risk for aspiration. f. Place central line and get Chest X-Ray for placement. - Central line for fluid administration, chest X-ray needed for verification of placement. g. NS at 50ml/hr- Needed to maintain fluid volume. h. Labs: CBC, PTT/PT, INR, Chemistry, Lipid & Liver Panels, Troponin- needed for baseline values of patient i. Diagnostics: 12Lead EKG, Repeat Non-contrast Head CT in am- EKG is needed for cardiac rhythm and assess for any cardiac disfunction and abnormality. j. O2 at 2 1iters/min per NC—titrate for SpO2>91%- good perfusion is needed for patient, to prevent tissue death. k. Labetalol 5 mg IV-Push PRN Q 10 min SBP > 180 mmHg- blood pressure needs to be reduced in order to administer t-PA l. After SBP maintained under 180, administered t-PA per protocol – t-PA therapy requires the patient to have BP less than 180 systolic and less than 110 for diastolic. This medication after an ischemic stroke can help reverse effects of a stroke. 2. What is your rationale for EACH of the abnormal physical assessment parameters in stage 1, the abnormal laboratory and diagnostic tests from stage 2? List each abnormal result out by section (physical 3

exam, lab results, diagnostic tests) and provide abnormal result and explain rationale for why you believe they are abnormal. Pain: pt reports headache pain 6/10 which is one of the symptoms of ischemic stroke Neuro: Right sided weakness is a stroke symptom and its indicative of an ischemic incident in the left side of the brain. Slurred speech and drooling may be indicative of stroke . Score of 7 on NIH Stroke Scale indicative of a minor stroke. Cardiac: HR 112 and BP 200/109 are both abnormally high results. Respiratory: diminished lung sounds in bases bilat is an abnormal result. Possible consolidation. GI: presence of nausea symptom of stroke. Last BM 2 days prior possible normal result MS: status epilepticus Labs: a. PLT 130 L b. Glu 158 H possibly following a meal c. HDL 30 L, LDL 140 H, Total Cholesterol 250 H, Triglycerides 300 H – hx of hyperlipidemia with medication nonadherence d. CXR mild atelectasis in bases, possible pneumonia 3. tPA administration a. What are contraindications for administering tPA? i. Trauma, intracranial hemorrhage ii. PT>15 iii. Pregnancy iv. Current use of anticoagulant with INR greater than 1.7 or PT greater than 15 seconds

b. What are the risks when giving tPA? i. Bleeding ii. Cardiac dysrhythmias

c. How do you monitor for these? i. Monitor VS and neuro status ii. Hematocrit, hematocrit d. How is tPA administered? Be specific i. 10% bolus, 90% iv in 1hr 4. What patient and family teaching is important in this stage? Be specific. a. Patient requires medication teaching. b. Bleeding precautions

STAGE 3: Day 1 post t-PA administration. Mr. Edwards BP remained elevated during the night despite the labetalol and is currently 185/100(128). No S&S of bleeding noted. His HA is now at a 2/10 “tension”, still with R sided weakness, facial drooping, and slurred speech. Enteral tube in his R nare is CDI and running Glucerna at 10ml/hr. He is voiding via urinal with assistance, averaging 120ml/hr clear yellow urine. Triple lumen central line in R SCV CDI. No other changes noted from initial assessment.

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The following orders were written by the Intensivist: Speech therapy consult for swallow study; if fails place enteral feeding tube and get a KUB for placement; Start Glucerna 10ml/hr if client fails swallow study. Repeat Head CT without contrast. Carotid Doppler study. Consult PT for assessment and treatment plan. Obtain Dilantin Level Nipride 0.5-8 mcg/kg/min continuous IV infusion: Titrate by 0.5 mcg/kg/min every 10min to maintain a SBP < 180 Mannitol 12.5gm IVPGBK Q12hrs Dilantin 100mg IV push Q8 hrs Lipitor 80mg PO Daily Lovenox 40mg Sub Daily

Lab/Diagnostic results: Drug Levels: Total Dilantin level 7.8 (normal range 10-20). Carotid Doppler- R common 40% and L common 80% occluded. Swallow Study: failed. Abdominal x-ray(KUB)- DHT tip noted in duodenum just past pyloric sphincter. CT scan Head: mild to moderate increase of cerebral edema noted on prior scan, no evidence of intracranial bleeding or other abnormalities. Critical thinking exercises 1. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient. a. Speech therapy consult – assessment has to be done for swallowing problems which may lead to aspiration, if negative results then pt will have a feeding tube. b. Repeat Head CT – needed to assess intracranial bleeding and edema c. Carotid Doppler – identifies abnormalities in the carotid, like build up plaque d. Consult PT . – physical therapy will help patient gain some strength back and work on ADLs e. Obtain dintalin level- verify for therapeutic dose f. Nipride – helps lower BP g. Mannitol – helps reduce cerebral edema h. Dilantin – ordered for seizure precautions, prevent seizures i. Lipitor – to reduce cholesterol levels j. Lovenox – to prevent PE and DVT from developing 2.

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What is your rationale for EACH of the abnormal lab/diagnostic results in Stage 3? List each out and explain rationale for why you believe they are abnormal. a. For stage 3, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why? a. Cardiovascular – pt is still having elevated BP b. Respiratory- pt is at risk for aspiration, swallow test failed c. Neuro- there is an increased level of cerebral edema The Dilantin level needs called to the provider. Write the SBAR report you would give. a. WE, 64 y/o African American male presented to the ED with severe headache 6/10, right-sided weakness, facial drooping, slurred speech, and nausea. b. BP on arrival 220/109. Admitted to ICU where he was central line was placed and he was administered labetalol and tPA per protocol. Today, has no S/S of bleeding. Reports headache 5

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2/10. Still slurs speech, R sided weakness, and facial drooping. Failed swallow test and is on enteral feeds of Glucerna 10mL/hr. Currently Dilantin 120mg q 8 hours dintalin levels obtained Last Dilantin trough 7.8. c. Therapeutic levels of dintalin 10-20. I recommend increasing dosage to achieve therapeutic levels. After reporting the Dilantin level to the provider, what orders do you anticipate receiving and why? a. I anticipate an order for increased Dintalin dose, and obtain new levels. What patient and family teaching is important? Be specific. a. Importance of therapeutic range of medications such as Dintalin. b. Failed swallow test = NPO status

STAGE 4: Day 2 post t-PA administration. Mr. Edwards BP is stable at 160/90 (113) on the Nipride drip currently running at 6mcg/kg/min. No S&S of bleeding noted. His neurological status has declined. He is lethargic and arouses only to painful stimuli with a blank stare, slight purposeful movement (localizes to the painful stimuli) and is nonverbal. Pupils: PERRL 3mm and sluggish. He has generalized non-pitting edema to all extremities. His abdomen is slightly distended and Glucerna is now running at 40ml/hr. He has not voided since last evening. No other changes noted from prior assessments. The following orders were written by the Intensivist: Stat repeat Head CT without contrast. Stat Serum Osmolality Increase Dilantin 100mg IV push Q6 hrs Stat Bladder Scan Lab/Diagnostic results: Serum Osmolality: 316. CT scan Head: substantial increase of cerebral edema noted from prior scan, new 3mm left to right midline shift with narrowing of the ventricles noted. Critical thinking exercises 1. Calculate this patient’s GCS score and provide your priority nursing interventions and rationale for them. a. 8 b. Rom exercises, turn pt and maintain skin integrity, assess residuals, monitor I&O 2. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient.

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a. Stat repeat Head CT without contrast. – pt is showing neuro decline b. Stat Serum Osmolality – to assess for fluid imbalance c. Increase Dilantin 100mg IV push Q6 hrs- prevent seizure activity, pt levels are lower than the therapeutic levels. d. Stat Bladder Scan- pt has distended abdomen, need to assess for urinary retention. Pt has not voided sine last evening. What is your rationale for EACH of the abnormal lab/diagnostic results in stage 3? List each out and explain rationale for why you believe they are abnormal. a. Serum osmolarity 316b. CT scan head- increased swelling in the brain For stage 4, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why? a. Neuro – pt continues to have decreased level of consciousness

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b. Respiratory – as pt neuro status decreases we worry about his breathing being impaired also, and needing ventilatory support. c. GU- pt has not voided and his stomach is distended. The lab/diagnostic results from stage 4 needs called to the provider. Write the SBAR you would give. a. WE, 64 y/o African American male presented to the ED with severe headache, right-sided weakness, facial drooping, slurred speech, and nausea, pt was admitted in the ICU. b. Pt is 2 days post tPA admin, his BP is 160/90 (113). Neuro status has declined, nonverbal and arouses to painful stimuli. c. CT shows increased cerebral edema , and a new 3mm left to right midline shift with narrowing of the ventricles noted. Recent serum osmolarity 316. d. I recommend neuro and ICP assessment and foley catheter to drain urine after obtaining bladder scan. After reporting the lab/diagnostic test results, what orders do you anticipate receiving and why? a. Urinary catheter b. Ventricular catheter to drain CSF and control ICP What patient and family teaching is important? Be specific. a. Urinary catheter may be inserted to drain urine from pts bladder. An ventricular catheter may be needed as well to drain CSF and control the ICP of the pt.

STAGE 5: Neurosurgery was consulted and an External Ventriculostomy Drain (EVD) with Intracranial Pressure (ICP) Monitoring had been inserted. There is no change in neurological status. Bladder Scan showed 700ml. The following orders were written by the Neurosurgeon: Level EVD to EAC open to drain at 13cm H2O and call if output 30ml per hour Q1 hr ICP/CPP measurements and call if ICP >20 or CPP 300 ml per hour Start Docusate Sodium 150mg PO/Gastric Daily Critical thinking exercises 1. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient. a. Level EVD to EAC open to drain at 13cm H2O and call if output 30ml per hourCSF needs to be drain in order to control ICP b. Q1 hr ICP/CPP measurements and call if ICP >20 or CPP 300 ml per hour- pt needs to void, bladder scan shows 700mls f. Start Docusate Sodium 150mg PO/Gastric Daily- stool softener to help patient have BM 2.

What are your nursing responsibilities when caring for a patient with an EVD/ICP? a. Monitor ICP , assess patients LOC, vitals b. Describe drainage characteristic and document amount. c. Maintain patent airway , ensure adequate cerebral perfusion, fluid balance and absence of infection. 7

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What are the complications associated with an EVD? a. Infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue of blood and problems with the monitoring system List the nursing interventions that can be implemented to decrease ICP? a. HOB 0-60 to promote venous drainage b. Calm, quiet atmosphere c. Drain CSF as ordered d. Level EVD properly What patient and family teaching is important? Be specific. a. Teach about the function of EVD. Pt needs to stay HOB elevaled to 30, and the need for calm environment.

Mr. Edwards became more alert over the coming days, his stroke symptoms improved and the EVD was removed. On day 14 of his hospital stay he was successfully transferred to a neuro rehab center for further management and care. Final critical thinking exercise 1. How would the plan of care have change for a patient having a hemorrhagic stroke? a. Plan of care would essentially be the same, pt would not have any anticoagulant therapy. b. ABCs c. Bp lowering meds 2. What is Cushing’s triad? Why is important to know how to assess for this? a. Medical emergency, its when the ICP increases leading to bradycardia, irregular respirations and a widened pulse pressure. b. When ICP>MAP the brain cannot receive enough O2 3. What additional information would you like to have seen covered in this evolving case study? a. All the information covered has been great and provided me with an image of how patients evolve during ICU care. 4. As you watched this case unfold, how did it make you feel? a. It make me stress a little bit because I some instances I doubted myself and didn’t know enough of the subject. However, I do feel better informed and more confident on my knowledge. Prov...