RVCC Virtual NCP Case 64 CVA PDF

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Raritan Valley Community College NURSING PROGRAM Willingham Case Study 64: Acute Cerebrovascular Accident STUDENT: Catherine Espinosa AGE: 79 years SEX: female

Instructor: Professor Giffin Virtual clinical Date 9/8/2020

___________________________________________________________________________________________________________ PRESENT HEALTH AND/OR HISTORY OF PRESENT ILLNESS: (Write a narrative about the symptoms the patient was having and why they went to the hospital. Include medical history.

N.T. is a 79 year old woman who arrives at the emergency room with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. At 0600 she complained of a mild headache over her right temple feeling slightly weak. Her husband went to check on her after getting coffee and found that she was having difficulty saying words and has developed a left sided facial droop. When helping her to the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department.

PAST MEDICAL HISTORY: (Look at your patient’s home medications and document the medical diagnosis that would be related to the medications listed) N.T. has a hx of *paroxysmal atrial fibrillation (PAF)*, HTN, and hyperlipidemia. A recent cardiac stress test dictates normal findings and her BP has been well controlled. N.T. is currently taking flecainide (Tambocor), hormone replacement therapy, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). *PAF in relation to the current medical dx: CVA

ADMITTING MEDICAL DIAGNOSES: What is the patient being admitted for, write the medical diagnosis here)

Acute Cerebrovascular Accident PATHOPHYSIOLOGY: Use Lewis for this information, it must be scientific An Acute cerebrovascular accident (also known as stroke or brain attack) occurs when there is (1) ischemia (inadequate blood flow) to part of the brain or (2) hemorrhage (bleeding) into the brain that results in death of brain cells. Functions such as movement, sensation, thinking, talking, or emotions that were controlled by the affected area of the brain are lost or impaired. The severity of the loss of function varies according to location and the extent of brain damage. If blood flow to the brain is totally interrupted, neurological metabolism is altered in 30 sec, metabolism stops in 2 min, and cell death occurs in 5 min. SIGNS AND SYMPTOMS: What signs did the patient report? The patient reported of a mild headache over her right temple and feeling slightly weak. She presents with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. She has developed a left sided facial droop and has weakness in her left hand and leg. APPROPRIATE ASSESSMENTS: Your clinical instructor will provide specific information for the health interview at your clinical virtual meeting.

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Health History: Write the patient’s response to the health history questions discussed at the virtual session below Record 8am Admission weight here: 143lbs = 65kg Record 8am admission vital signs here: BP 140/86, heart rate 116 and irregular, respiratory rate 20/min, O2 sat 95% on room air Record 8am blood sugar upon admit: 106 mg/dl Record which medications the patient reported taking at home before coming to the hospital: list the 5 medications presented in the case study: flecainide (Tambocor), amlodipine (Norvasc), clopidogrel (Plavix), aspirin, simvastatin (Zocor), lisinopril (Zestril),

Describe your findings when her lower extremities were assessed: no edema, pedal pulses palpable ABOVE INFORMATION MAY BE COMPLETED DURING YOUR VIRTUAL CLINICAL EXPERIENCE

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RVCC Adult Health Laboratory and Diagnostic Testing Your clinical instructor will provide the labs to be used below

Diagnostic Test Normal Adult Patient’s Ab- Medical Diagno- Nursing Implications Value(s) normal Value sis (Associated with (Actions the nurse should take in rethis abnormality in sponse to this abnormal finding.) this patient.)

CBC WBCs

5,00010,000

Band WBC differential neutrophils 0-8%

15,000

12%

Stress and inflammatory response to CVA Stress and inflammatory response to CVA

Maximize relief and comfort. Administer anti-inflammatory and analgesic as needed. Monitor WBC and for any signs of bleeding, infection, and IICP. Maximize relief and comfort. Administer anti-inflammatory and analgesic as needed. Monitor WBC and for any signs of bleeding and infection, and IICP.

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Urinalysis WBCs

≤ 2-5/per high power field (hpf)

CMP Sodium

136145mEq/L

Too numer- Inflamma- Obtain patient weight. Administer activase (tPA) as per proous to count tory re(TNTC) sponse due tocol. Wait 24 hrs before givto occlusion ing anticoagulants. of arterial Monitor urinalysis for continued elevation. supply in kidney as a result from thromboembolism Could be Monitor for signs and sympdue to the toms of hyponatremia. Administer IV fluid cautiously. No132 mEq/L lisinopril which is an tify HCP about decreased sodium level. ACE inhibitor that blocks the conversion of angiotensin. Angiotensin stimulates aldosterone production and causes the body to retain sodium.

List the diagnostic tests that were completed on this patient: CT scan of head- include results…… EKG- Atrial fibrillation with ventricular rate of 116; occasional premature ventricular contractions (PVCs)

Non contrast CT scan in which patient was diagnosed with a thrombolytic CVA. A second CT scan was administered 18 hrs later and revealed a small CVA in the right hemisphere.

Having a CT scan is pertinent in N.T.’s care because it quick and efficient and will distinguish between ischemic & hemorrhagic stroke. Distinguishing what kind of stroke the patient has will determine the next step in her care.

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Summarize what these tests indicate for this client: These tests indicate that the client may recover within 6 mo to 1 year if stroke deficits are temporary. Because of the patient’s symptoms of dysphagia and diagnosis, confirmation of thrombolytic CVA, a referral to the speech pathologist would be appropriate to confirm dysphagia and decide the next step in the patient’s plan of care. A physical and occupational therapist would also be recommended to help strengthen the patient and adapt to functioning with her current physical disability. The patient has inflammatory responses as a result of the thromboembolism so it would be appropriate to administer an analgesic or antiinflammatory as needed. Monitor for signs and symptoms of bleeding and infection, daily weight and I&Os to ensure adequate renal perfusion and circulation. Monitor for S&S of IICP.

Expand this section to include the following information on each drug mentioned in this case study Must Include All Medications, submit one form for each medication.

DRUG STUDIES ARE UPLOADED AS SEPARATE DOCUMENTS

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Priority # 1 of 3 NURSING DIAGNOSIS: Risk for Aspiration RELATED TO (Include all the reasons for this diagnosis): Mild dysphagia AS EVIDENCED BY (include all the assessment data to support your diagnosis): left sided facial droop, mild dysphagia, neuromuscular impairment GOAL: Patient will demonstrate feeding methods appropriate to individual situation with aspiration prevented within 24 hrs. OUTCOME CRITERIA

NURSING ORDERS

RATIONALE

Prevent risk of aspiration 1. Patient will be posi1. Patient will maintain tioned upright, elevated at from impaired swallowing patent airway and clear lung sounds within the next30 degrees and midline for feeding 8-12hrs. 2. Patient will be suctionedPrevent risk of aspiration from impaired swallowing as needed if secretions, vomiting, and aspiration occurs.

2. Patient will swallow and 1. Patient will eat foods Prevent risk of aspiration digest oral, nasogastric, or according to swallowing from impaired swallowing gastric feeding without as- ability and select piration within the next 8- foods/fluids of proper consistency within the next 412 hrs. 8 hrs 2. Patient will be assisted Prevent risk of aspiration in an upright position of from impaired swallowing 30 degrees and will be instructed not talk while eating, if appropriate.

DOCUMENTATION/ EVALUATION Document lung sounds on evaluation, what position the patient needs to be in, and the HOB setting. Document patient’s status before suctioning, how the patient tolerated the procedure, COCA the secretions, and the patient’s status post procedure Document patient’s swallowing ability, what diet the patient’s been prescribed, and I&O’s

Document what position the patient needs to be in and the HOB setting.

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3. Patient will maintain oral1. Patient will brush her Good oral care can prevent Documentation of when oral hygiene within the next 4 teeth at least 2-3 times per contamination in the mouth care was performed which can be aspirated. day. hrs.

2. Patient will understand Patient will be more mindful Documentation of when oral care was performed and that paand acknowledge that lack to reinforce preventative tient understood teaching. of oral hygiene puts the measures to aspiration patient at risk for aspiration and pneumonia

EVALUATION: Patient suffers from mild dysphagia as a result of the acute CVA and is at risk for aspiration. Speech language pathologist will confirm results. Patient is to continue dysphagia diet until further notice. Confirm diet with dietician. Ensure that the patient is positioned at 30 degrees and midline to prevent aspiration and IICP. Patient will be suctioned as needed and will continue to maintain adequate oral hygiene within the next 4 hrs. Maintain patient at an adequate caloric weight and ensure adequate supplemental nutrition.

Priority # 2 of 3 NURSING DIAGNOSIS: Impaired Physical Mobility RELATED TO (Include all the reasons for this diagnosis): Left sided hemiparesis AS EVIDENCED BY (include all the assessment data to support your diagnosis): Weakness in left hand and left leg, perceptual impairment, reduced muscle/eye coordination GOAL: Patient will maintain/increase strength and function of affected or compensatory body part within 7 days or less. OUTCOME CRITERIA

NURSING ORDERS

RATIONALE

1. Patient will perform ex- Increases patient strength 1. Patient will describe feeling stronger and more ercises, focusing on the mobile in the next 1-3 days left side as directed by PT and OT

2. Patient will perform flexibility exercises

2. Patient will demonstrate 1. Nurse will educate pause of adaptive equipment tient on how to use the 1-2 days before the time of equipment discharge

DOCUMENTATION/ EVALUATION Document what exercises have been implemented, how the patient was able to tolerate the exercise, and whether or not the patient tolerates the exercise.

Improves patient’s range of Document what exercises have motion been implemented, how the patient was able to tolerate the exercise, and whether or not the patient tolerates the exercise. Will help patient understand Document what device the patient will be using and if the pahow to use equipment in tient understood how to use it. If order to be mobile not, instruct for further teaching. independently

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2. Nurse will assist and Will help patient understand Document what device the patient will be using and if the pahelp the patient practice how to use equipment in tient understood how to use it. If using the equipment so the order to be mobile not, instruct for further teaching. patient can become more independently familiar and comfortable with the assistive device 3. Patient will increase and 1. Encourage patient to Ambulation will help Document how long patient was tolerate 9-10 more min of ambulate 3 more min each improve the patient’s able to tolerate ambulating and exercise/ambulation within day as tolerated strength and mobility if condition has improved the next 3 days

2. Set a daily goal for hav- Ambulation will help ing a certain amount of improve the patient’s steps a day and keep track strength and mobility of steps by using pedometer

Document how long patient was able to tolerate ambulating and if condition has improved

EVALUATION: Patient has suffered from an acute cerebrovascular accident resulting in left sided hemiparesis. This may result in altered proprioception, altered sensation, and perceptual deficits. Patient requires assistance x 1 from bed to chair. Administer non-slip footwear and reorient patient to surroundings. Instruct patient to press the call bell to request for help prior to getting up and educate the patient why. Ensure that table and call bell are within reach. Turn bed alarm and chair alarm on. Continuously assess for improvement in muscle tone and function.

Priority # 3 of 3 NURSING DIAGNOSIS: Impaired Verbal Communication RELATED TO (Include all the reasons for this diagnosis): Expressive aphasia AS EVIDENCED BY (include all the assessment data to support your diagnosis): Difficulty forming words GOAL: Patient will establish method of communication in which needs can be expressed within 24 hrs OUTCOME CRITERIA

NURSING ORDERS

RATIONALE

DOCUMENTATION/ EVALUATION 1. Patient will use effective 1. Patient will be properly Language barriers, low liter- Document what language the communication techniques assessed with comprehen- acy, and lack of understand- patient speaks, cultural considersive learning assessment toing are barriers to effective ations, literacy level, cognitive within the next 24 hrs. level, and the use of communication. determine the language glasses/hearing aids spoken, cultural considerations, literacy level, cognitive level, and the use of glasses/hearing aids 2. Patient will receive con- Consistent nursing care will sistent nursing staff to in- increase patient-care comcrease patient-nurse com- munication and decrease powerlessness. munication

Document what language the patient speaks, cultural considerations, literacy level, cognitive level, and the use of glasses/hearing aids and if possible, will be paired with the same nursing staff.

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2. Patient will demonstrate understanding even if not able to speak within the next 24 hrs

1. Obtain patient’s attention before speaking and face towards her unaffected side and using gestures as appropriate to aid in communication.

Correct positioning and an Document affected side utilize optimal listening environ- unaffected side for maximum communication ment increases patient’s awareness of interaction and enhance the patient’s ability to communicate.

Document the patient’s under2. Explain healthcare pro- Effective communication cedures, be persistent in entails involving patients, standing of the procedures and means of enhancing communideciphering what the pa- being sensitive to patient tient is saying, and do not needs, and ensuring patient cation. understanding. pretend to understand when the message is unclear. 3. Patient will use alterna- 1. Patient will utilize writ- Enhancement of effective Document what tools and methtive methods of communi- ten and if possible, spoken communication between pa- ods can be used for enhanced cation effectively within language to exchange mes-tient and receiver. and effective communication. the next 24 hrs sages effectively with others 2. Validate verbal and non- The Critical Pain Observa- Document the patient’s level of verbal expressions espe- tion Tool and the Behavioral pain, what interventions have cially when dealing with Pain Scale are valid and reli- been done to treat the pain and if pain and use appropriate able options if patient has the pain management has been scales of pain when appro- difficulty communicating. effective. priate.

EVALUATION: Patient is diagnosed with expressive aphasia as a result from the acute CVA. Patient will use resources as effective means for communication (i.e. writing board, general pictures of requests such as bathroom, hungry, food). Speak to patient on unaffected side to ensure enhanced communication. Use family members if appropriate to help facilitate communication and understanding. Patient will validate verbal and nonverbal responses with pain scale and will receive consistent nursing care to increase patientcare communication

Summarize what you have learned in caring for this patient

What I have learned in caring for this stroke patient is that time is of the essence and it is important to differentiate whether or not if the stroke is ischemic or hemorrhagic. That will determine what will go forth in the patient’s plan of care, i.e. tPA can only be administered within 3 hrs (4.5 in some patients) and only for ischemic strokes. I’ve also learned that it is important to be mindful of the patient’s positioning in order to prevent aspiration and IICP. It is also important to also establish an effective means of communication in order to address patient needs. Fall risk measures should be implemented as well due to the left sided hemiparesis. Circulation, cerebral perfusion, renal perfusion, and I&Os should also be assessed regularly to prevent any future emboli from forming and that the patient is perfusing adequately. I’ve also learned that because of the mild dysphagia and the left sided facial droop that it is important to monitor the patient’s nutritional intake due to the lack of caloric intake.

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Nursing Care Plan: Grading Rubric Passing Score for Nursing of Adults II = 90% Content to be evalu- Content addressed for maxi- Content lacking for medial Content lacking for low score ated mum score score Admission assessment All information included, de- Vague short responses, one Does not include pertinent infortailed explanation, textbook to two missing information mation, missing three or more consulted for scientific expla- 5 pieces of information, does not nations 10 use medical jargon 0 Laboratory and diag- All information provided with Missing information, in- Does not fill in the required innostics data explanation of abnormal labs complete explanations 10 formation 0 15 Radiology data Include radiology test ordered One sentence response, Missing data, does not mention as discussed at the virtual does not completely explainthe purpose for the test, provide a clinical, provide results and the relevance of the test. 5 one-word answer 0 discusses how the radiology test is pertinent in the patient’s care 10 Drug Study All drugs and required infor- Two or less missing drugs, Missing all drugs, or missing mation included in drug sheet missing parts of the drug most of the information about the 15 sheet 10 drugs 0

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Incorrect nursing diagnosis, Does not use medical terms, Nursing care plan #1 Correct nursing diagnosis, nursing interventions with ra- no related to factor, incor- nursing diagnosis not correctly rect goal and outcome, written, missing information, tionales and citations 15 most of the interventions provide a combination of two are incorrect except for nursing diagnosis e.g respiratory two. 10 and pain in one care plan. 0 Nursing care plan #2 Correct nursing diagnosis, Incorrect nursing diagnosis, Does not use medical terms, nursing interventions with ra- no related to factor, incor- nursing diagnosis not correctly tionales and citations 15 rect goal and outcome, written, missing information, most of the interventions provide a combination of two are incorrect except for nursing diagnosis e.g respiratory two. 10 and pain in one care plan. 0 Nursing Care Plan #3 Correct nursing diagnosis, Incorrect nursing diagnosis, Does not use medical terms, nursing interventions with ra- no related to factor, incor- nursing diagnosis not correctly tionales and citations 15 rect goal and outcome, written, missing information, most of the interv...