Neurology Case Study PDF

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Neuro Case Study...

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Assessment & Reasoning Neurologic System

Peter Simpson, 55 years old

© 2019 Keith Rischer/www.KeithRN.com

Suggested Neurologic Nursing Assessment Skills to Be Demonstrated: Assessment: General • Mental status: assess speech, orientation, memory, and level of consciousness • Posture, position • Assess behavior, mood, and affect • Assess dress, grooming, hygiene Inspection: Neurological • Level of consciousness, orientation • Cranial nerves • Gait, balance, coordination Head: • Tongue-midline? • Symmetry in facial features • Grimace-big smile to assess facial droop • Sensation each side face • Pupils • Eyes: conjugate vs. disconjugate/extra ocular eye movements/visual fields ***Assess cranial nerve II (Optic) – Check PERRLA and visual fields • Evaluate posture, gait, balance, involuntary movements. • Assess light touch (to face and extremities), pain to extremities. • Fine motor coordination UPPER: finger to nose w/eyes closed (sobriety test) ***finger to nose then touch nurse’s finger ***fingers to thumb same hand in sequence • Fine motor coordination LOWER: Rub heel on opposite shin/calf downwards • Gross motor UPPER: bilateral hand grasp/pronator drift • Gross motor LOWER: dorsi/plantar flexion, bilateral leg lift, Babinski Inspection: Musculoskeletal • Observe posture – standing with feet together • Observe gait – weight-bearing, foot position, stride and length (and equality of stride), arm swing symmetry, and posture • Palpate muscles and joints for edema, heat, tenderness or crepitus • Assess muscle strength (0 to 5 scale) and joint range of motion FOCUSED/Frequent Neuro Assessment: Signs/symptoms: • Pupil changes of any kind (sluggish/change in size-EARLY ICP) • Assess LOC, orientation/new confusion, seizures, lethargic/unresponsive (LATE ICP) • Headache, nausea, vomiting VS changes: increased blood pressure, decreased HR, RR,

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Role play or go through the interview/body assessment process – student to student or as a group. Review the case study as an application exercise in small groups or together as a class. Depending on your program, some content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Use it to promote learning by having students identify what they do not yet know and guide where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!

© 2019 Keith Rischer/www.KeithRN.com

Present Problem: Peter Simpson is a 55-year-old Caucasian male with a past medical history of hypertension and hyperlipidemia who presents to the emergency department for evaluation of a slight right facial droop and slurred speech that began two days ago. Peter states that the right side of his face feels numb like when you go to the dentist. He became more concerned this morning when he began having difficulty walking and noticed that his right arm and hand were weak and had difficulty holding onto a pen when he tried to write a check. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: -hx hypertension -hx hyperlipidemia

-slight facial droop and slurred speech (started 2 days ago) -right side of face numb -weak right upper extremity with difficulty to hold a pen and write

Clinical Significance: -HTN can lead to aneurysms by increasing the pressure on blood vessel walls in the brain - Hyperlipidemia can lead to stroke by accumulation of fatty deposits in the arteries - recent symptoms of facial droop, slurred speech, numbness of right side of the face and weak upper right extremity indicates signs of possible tumor or hemorrhage of the brain

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. Class: Mechanism of Action (own words): Thiazide Increases the excretion of sodium in Hypertension Hydrochlorothiazide 25 mg PO daily Diuretic the kidneys through reabsorption of the distal convoluted tubule Hyperlipidemia

Atorvastatin 20 mg PO at HS

HMG-CoA reductase inhibitor (STATINS)

Prevents HMG-CoA from converting in order to lower cholesterol levels

You quickly collect the following assessment data:

Patient Care Begins: Current VS: T: 99.1 F/37.3 C (oral) P: 78 (regular) R: 16 (regular) BP: 158/90 O2 sat: 99% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Denies Quality: Region/Radiation: Severity: Timing:

© 2019 Keith Rischer/www.KeithRN.com

What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance)

Abnormal VS: BP elevated

Clinical Significance: -Elevated BP possible r/t history of hypertension – HTN can lead to trauma to the brain through narrowing of blood vessels or blood clotting in the arteries which lead to the brain.

Current Assessment: GENERAL SURVEY: Sitting upright in bed. Alert, oriented, pleasant, in a moderate amount of acute distress, dress appropriate for the season, hygiene and grooming normal for age and gender. Calm, body relaxed, no grimacing, appears to be resting comfortably RESPIRATORY: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally with equal aeration bilaterally ant/post, nonlabored respiratory effort with posture erect, sitting in bed, in no distress, on room air, AP diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2, noted over the five cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), right-sided facial droop present, speech slurred, paresthesia and drooping noted to right side of face, right upper/lower extremity weak (4/5) with impaired fine motor coordination of right hand ABDOMINAL: Abdomen flat, soft/symmetrical/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill...