A patient with a confirmed large infarction in the left middle cerebral artery territory presents with worsening neurological symptoms, including complete right-sided hemiplegia and inability to speak coherently. Which nursing intervention is most appropriate to prioritize in this situation to address the risk of increased intracranial pressure?

A) Elevate the head of the bed to 30 degrees and ensure the neck is in a neutral position.

B) Administer a rapid intravenous push of mannitol to immediately reduce intracranial pressure.

C) Place the patient in a supine position to promote cerebral perfusion.

D) Encourage oral fluid intake to maintain hydration status.

A patient with an acute ischemic stroke in the left middle cerebral artery territory is experiencing worsening neurological symptoms and elevated intracranial pressure. Which nursing intervention is most important to implement first to address the patient's current condition?

A) Administer mannitol to reduce intracranial pressure.

B) Start an insulin infusion to lower blood glucose levels.

C) Elevate the head of the bed to 30 degrees.

D) Initiate continuous cardiac monitoring.

A patient with an acute ischemic stroke is showing signs of increased intracranial pressure (ICP) and a declining Glasgow Coma Scale (GCS) score. What is the most appropriate initial nursing intervention to reduce the risk of further neurological deterioration?

A) Elevate the head of the bed to 30 degrees

B) Administer additional doses of mannitol

C) Apply restraints to prevent agitation

D) Increase IV fluids to improve cerebral perfusion

A patient with an acute ischemic stroke is experiencing a decline in neurological status despite medical interventions. The nurse notes a decrease in the Glasgow Coma Scale (GCS) score from 10 to 7, increased pupil asymmetry, and a drop in oxygen saturation to 88%. Which nursing intervention should be prioritized at this time?

C) Elevate the head of the bed to 30 degrees to promote venous drainage

A) Increase the rate of intravenous fluids to improve cerebral perfusion

B) Prepare the patient for immediate surgical intervention to relieve intracranial pressure

C) Elevate the head of the bed to 30 degrees to promote venous drainage

D) Administer additional antihypertensive medication to control blood pressure

A patient with acute ischemic stroke exhibits significant cerebral edema with a midline shift, hyponatremia, and elevated blood pressure. Which nursing intervention is the priority to address the patient's current condition?

C) Prepare the patient for urgent decompressive craniectomy.

A) Administer antihypertensive medication to lower blood pressure.

B) Initiate a slow infusion of hypertonic saline to correct hyponatremia.

C) Prepare the patient for urgent decompressive craniectomy.

D) Start broad-spectrum antibiotics to address potential infection.

A nurse is caring for a patient with a recent diagnosis of acute ischemic stroke, who presents with significant cerebral edema and a midline shift. The patient is scheduled for a decompressive craniectomy. Which nursing intervention is most critical to prioritize before the surgery?

D) Monitoring and managing the patient's blood pressure to maintain cerebral perfusion.

A) Administering prescribed broad-spectrum antibiotics to prevent infection.

B) Initiating seizure precautions due to the risk of increased intracranial pressure.

C) Correcting the patient's hyponatremia by rapidly infusing hypertonic saline.

D) Monitoring and managing the patient's blood pressure to maintain cerebral perfusion.

A patient undergoing preparation for decompressive craniectomy shows a sudden decrease in Glasgow Coma Scale score and increased pupillary asymmetry. Which immediate action should the nurse prioritize to address the patient's deteriorating neurological status?

C) Initiate administration of hypertonic saline to reduce intracranial pressure

A) Administer prescribed antihypertensive medication to lower blood pressure

B) Prepare the patient for immediate transfer to the operating room

C) Initiate administration of hypertonic saline to reduce intracranial pressure

D) Increase the frequency of neurological assessments to monitor changes

A patient undergoing preparation for decompressive craniectomy presents with a Glasgow Coma Scale (GCS) score drop from 9 to 7 and a fixed, dilated pupil on the left side. Which nursing intervention should be prioritized to address the immediate concern of increased intracranial pressure?

A) Elevate the head of the bed to 30 degrees to facilitate venous drainage.

B) Administer a bolus of normal saline to ensure adequate hydration.

C) Apply a cooling blanket to reduce body temperature.

D) Provide supplemental oxygen to maintain oxygen saturation above 95%.

A patient with increased intracranial pressure (ICP) is showing minimal improvement despite the administration of mannitol and hypertonic saline. The patient also has significant hyponatremia with a serum sodium level of 126 mmol/L. What is the nurse's priority action in managing the patient's electrolyte imbalance to prevent further complications?

D) Consult with the healthcare provider to adjust the hypertonic saline infusion rate and assess for potential causes of hyponatremia.

A) Increase the rate of hypertonic saline infusion to rapidly correct the hyponatremia.

B) Monitor the patient's neurological status closely and report any changes immediately.

C) Administer isotonic saline to provide fluid replacement without exacerbating the electrolyte imbalance.

D) Consult with the healthcare provider to adjust the hypertonic saline infusion rate and assess for potential causes of hyponatremia.

A patient with increased intracranial pressure and significant hyponatremia is being managed with hypertonic saline and a sedative infusion. What is the priority nursing intervention to ensure effective management of the patient's condition?

A) Monitor serum sodium levels every 4 hours and adjust the hypertonic saline rate accordingly.

B) Assess for signs of pulmonary edema and adjust fluid restriction as needed.

C) Continuously monitor intracranial pressure and prepare for decompressive craniectomy.

D) Evaluate the patient's neurological status every hour and report any changes immediately.

Acut strok - Nursing Case Study

Pathophysiology

• Primary mechanism: Acute stroke primarily involves the sudden interruption of blood flow to a part of the brain, typically due to an ischemic event, such as a thrombus or embolus, leading to decreased oxygen and nutrient supply and resulting in neuronal injury and cell death.

• Secondary mechanism: The ischemic cascade is triggered, causing the release of excitatory neurotransmitters like glutamate, which leads to calcium influx, oxidative stress, and further neuronal damage and apoptosis.

• Key complication: If not promptly addressed, these processes can lead to irreversible brain damage, loss of neurological function, and potential complications such as cerebral edema and hemorrhagic transformation.

Patient Profile

Demographics:

67-year-old male, retired school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes Mellitus, Hyperlipidemia

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of right-sided weakness and slurred speech

• Key symptoms: Right arm and leg weakness, difficulty speaking, facial droop on the right side, headache, dizziness

• Vital signs: Blood pressure 180/100 mmHg, heart rate 102 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F (37°C), oxygen saturation 93% on room air

Section 1

As the patient is brought into the emergency department, the initial assessment reveals a worsening of his neurological symptoms. His right-sided weakness has progressed to complete hemiplegia, and he is now unable to speak coherently, only able to produce garbled sounds. The facial droop on the right side appears more pronounced, and his gaze is deviated to the left. His vital signs show a persistent elevation of blood pressure at 185/105 mmHg, heart rate has risen to 110 bpm, and oxygen saturation has slightly decreased to 91% despite being placed on supplemental oxygen. The clinical team suspects that the ischemic event is progressing, leading to increased intracranial pressure.

A CT scan without contrast is performed urgently to assess for any immediate complications such as hemorrhagic transformation or significant cerebral edema. The imaging reveals a large area of infarction in the left middle cerebral artery territory, with subtle signs of developing cerebral edema but no evidence of hemorrhage. This finding is concerning for the potential of worsening brain swelling, which could lead to further decline in neurological status. Additionally, laboratory results show elevated blood glucose levels at 250 mg/dL, which necessitates careful management to prevent further exacerbation of the ischemic injury.

Given these findings, the healthcare team initiates measures to manage the cerebral edema and control the patient's blood pressure and blood glucose levels. Mannitol is considered to reduce intracranial pressure, and an insulin infusion is started to bring the glucose levels within target range. The patient is closely monitored for any signs of neurological deterioration or new complications, such as respiratory compromise due to the potential for brainstem involvement. The next steps involve ongoing evaluation and potential escalation of care, including consultation with neurology and consideration of more advanced interventions should the patient's condition continue to decline. This situation emphasizes the need for vigilant monitoring and timely intervention to mitigate the risks of further complications in acute stroke management.

Section 2

As the healthcare team continues with the management of the patient's acute stroke, they closely monitor his response to the interventions initiated. Despite the administration of mannitol, the patient's neurological status shows signs of further decline. The nursing staff reports that the patient is becoming less responsive, with a decrease in his Glasgow Coma Scale (GCS) score from 10 to 7, indicating a significant change in his level of consciousness. Additionally, his blood pressure remains elevated despite antihypertensive therapy, now recorded at 190/110 mmHg, prompting concerns about uncontrolled hypertension exacerbating cerebral edema.

The team performs a repeat neurological examination, which reveals increased pupil asymmetry, with the right pupil now sluggishly reactive and larger in size compared to the left. This finding raises suspicion for worsening intracranial pressure and possible herniation syndrome. Concurrently, the patient's respiratory status is deteriorating; his oxygen saturation drops to 88% on high-flow oxygen, and he exhibits irregular breathing patterns, suggestive of potential brainstem involvement. The clinical team decides to intubate the patient to secure the airway and provide adequate ventilation, aiming to prevent hypoxia, which could further aggravate neurological injury.

In response to these developments, the neurology team is consulted urgently, and a decision is made to escalate care. The possibility of surgical intervention, such as decompressive craniectomy, is discussed to alleviate pressure and prevent further neurological compromise. The patient's family is briefed about the critical situation, emphasizing the need for prompt action to address the life-threatening complications. This critical juncture in the patient's management underscores the importance of rapid clinical reasoning and decision-making to optimize outcomes in the context of severe ischemic stroke with evolving complications.

Section 3

As the medical team proceeds with the management of the patient's acute stroke, new diagnostic results from a CT scan reveal significant cerebral edema with a midline shift, confirming the suspicion of increased intracranial pressure and potential herniation. The scan also highlights an extensive area of ischemia in the left hemisphere, correlating with the patient's deteriorating neurological status. In response to these findings, the neurology team recommends an urgent decompressive craniectomy to relieve intracranial pressure and prevent further herniation, hoping to preserve remaining neurological function.

Meanwhile, laboratory results return, showing an elevated white blood cell count of 15,000/mm³, suggesting a possible infectious process or systemic inflammatory response secondary to the stroke. This prompts the team to initiate a sepsis workup, including blood cultures, while broad-spectrum antibiotics are started preemptively. The patient's electrolytes reveal hyponatremia, with a sodium level of 128 mmol/L, likely contributing to his altered mental status. The team initiates a cautious correction of the sodium imbalance to avoid rapid shifts that could further complicate the patient's condition.

Despite these aggressive interventions, the patient's vital signs remain concerning. His blood pressure persists at high levels, 185/105 mmHg, despite the administration of additional antihypertensive medications. Heart rate is noted at 110 beats per minute, indicating a possible stress response or pain. The nursing staff administers analgesics and sedatives to manage discomfort and reduce metabolic demands. Continuous monitoring of the patient's neurological and physiological status is emphasized, as the team prepares for the impending surgical procedure, while remaining vigilant for any signs of new or worsening complications. This stage of care requires precise coordination and clinical reasoning to manage the complex interplay of stroke complications and ensure stabilization before surgery.

Section 4

As the surgical team prepares for the decompressive craniectomy, the patient's status undergoes a sudden change, prompting immediate reassessment. The nurse notes a decrease in the patient's Glasgow Coma Scale (GCS) score, dropping from 9 to 7, indicating a decline in consciousness. The patient displays increased pupillary asymmetry, with the left pupil now fixed and dilated, suggestive of worsening intracranial pressure. These changes necessitate rapid intervention to stabilize the patient before surgery can proceed.

In response to the deteriorating neurological status, the team intensifies their efforts to control intracranial pressure. Mannitol is administered to reduce cerebral edema, and hypertonic saline is cautiously infused to address hyponatremia and further aid in decreasing intracranial pressure. Despite these measures, the patient's blood pressure remains elevated at 190/110 mmHg, complicating efforts to stabilize cerebral perfusion. The cardiovascular team is consulted to optimize the patient's antihypertensive regimen, balancing the need to lower blood pressure without compromising cerebral perfusion.

As the situation evolves, the team remains vigilant for signs of new complications. Continuous electrocardiogram monitoring reveals frequent premature ventricular contractions, raising concerns about potential electrolyte imbalances or myocardial stress. The laboratory team is instructed to expedite results of repeat electrolyte panels and cardiac enzymes to rule out any underlying cardiac ischemia. The interdisciplinary team convenes to reassess priorities, focusing on fine-tuning management strategies to stabilize the patient and mitigate risks ahead of the urgent surgical intervention. This collaborative approach underscores the critical importance of dynamic clinical reasoning in navigating the complexities of acute stroke management and its associated complications.

Section 5

As the team awaits the new diagnostic results, they focus on the immediate response to interventions already in place. Despite the administration of mannitol and hypertonic saline, the patient's intracranial pressure shows only minimal improvement. The neurology team decides to initiate a continuous infusion of a sedative to reduce metabolic demand and cerebral oxygen consumption, cautiously monitoring for any further decline in neurological status. Meanwhile, the cardiovascular team adjusts the antihypertensive regimen, introducing a carefully titrated dose of intravenous labetalol to manage the patient's blood pressure, which now reads 180/100 mmHg. This intervention aims to maintain cerebral perfusion pressure within an optimal range, balancing the need to reduce systemic blood pressure while ensuring adequate cerebral blood flow.

Shortly thereafter, the laboratory results return, revealing significant hyponatremia with a serum sodium level of 126 mmol/L, indicating that the patient's electrolyte disturbance persists despite initial interventions. This finding necessitates an adjustment in the hypertonic saline infusion rate and prompts a review of the patient's fluid balance and renal function. Concurrently, the cardiac enzyme panel shows no acute ischemic changes, alleviating immediate concerns of myocardial infarction, yet the continued presence of premature ventricular contractions suggests ongoing myocardial stress, potentially linked to the electrolyte imbalance.

The patient's status remains critical, with the fixed and dilated left pupil continuing to signal increased intracranial pressure. The team prioritizes rapid stabilization, coordinating with the surgical team to expedite the decompressive craniectomy. This decision underscores the need for timely surgical intervention to alleviate cerebral pressure and prevent further neurological deterioration. As they prepare for surgery, the team remains acutely aware of the delicate balance required in managing this complex interplay of factors, emphasizing the critical role of collaborative clinical reasoning in guiding the patient's care trajectory.