A 68-year-old male patient with a recent ischemic stroke now presents with signs of hemorrhagic transformation and increased intracranial pressure. Which nursing intervention is the most critical at this time to prevent further neurological deterioration?

A) Administer intravenous mannitol to reduce cerebral edema.

B) Initiate aggressive anticoagulation therapy to prevent further clot formation.

C) Encourage the patient to perform active range of motion exercises to prevent muscle atrophy.

D) Administer high-dose corticosteroids to reduce inflammation in the brain.

A patient with suspected increased intracranial pressure is exhibiting Cheyne-Stokes respiration, a decreased Glasgow Coma Scale score of 8, and unequal pupils. Which of the following nursing interventions is most appropriate to prioritize in this situation?

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

A) Administer a sedative to reduce agitation and prevent further injury.

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

C) Increase the rate of intravenous fluids to ensure adequate cerebral perfusion.

D) Place the patient in a supine position to maintain cervical spine alignment.

A patient with severe cerebral edema is exhibiting Cheyne-Stokes respiration, unequal pupils, and a decreased Glasgow Coma Scale (GCS) score. Which nursing intervention is most critical in this scenario to prevent further neurological deterioration?

A) Administering increased doses of mannitol as prescribed to reduce intracranial pressure.

B) Placing the patient in a high Fowler's position to improve respiratory function.

C) Initiating a fluid restriction protocol to prevent further cerebral edema.

D) Preparing the patient for an immediate CT scan to assess the need for surgical intervention.

A patient with increased intracranial pressure is scheduled for a decompressive craniectomy. The nurse notes that the patient's oxygen saturation is fluctuating between 85% and 90% despite high-flow oxygen therapy. Which nursing intervention is most appropriate to optimize the patient's respiratory status prior to surgery?

A) Administer a dose of mannitol to decrease cerebral edema.

C) Increase the flow rate of supplemental oxygen.

D) Position the patient supine to enhance perfusion.

A patient with increased intracranial pressure (ICP) and uncal herniation is awaiting decompressive craniectomy. The healthcare team is administering mannitol to manage cerebral edema. Which nursing intervention is most critical to monitor the effectiveness of mannitol therapy in this patient?

A) Monitoring urine output every hour

B) Assessing pupil size and reactivity

C) Checking blood glucose levels frequently

D) Evaluating the patient's pain level regularly

A patient in the pre-operative phase exhibits signs of increased respiratory distress and an arterial blood gas analysis reveals a mixed respiratory and metabolic acidosis. What is the most appropriate initial nursing action to address the patient's condition?

D) Reassess and optimize the settings of the non-invasive ventilation to improve ventilation and oxygenation.

A) Increase the fraction of inspired oxygen (FiO2) on the non-invasive ventilation.

B) Administer intravenous bicarbonate to correct the acidosis.

C) Prepare the patient for immediate intubation and mechanical ventilation.

D) Reassess and optimize the settings of the non-invasive ventilation to improve ventilation and oxygenation.

A patient in the operating room is experiencing increased respiratory distress with a respiratory rate of 28 breaths per minute and oxygen saturation dropping to 82%. An arterial blood gas reveals pH 7.28, PaCO2 55 mmHg, and PaO2 60 mmHg. What is the most appropriate immediate nursing intervention to address this condition?

C) Optimize settings on non-invasive positive pressure ventilation

A) Increase the flow rate of supplemental oxygen

B) Initiate invasive mechanical ventilation

C) Optimize settings on non-invasive positive pressure ventilation

D) Administer a bronchodilator to improve airway patency

A patient with a recent stroke presents with signs of increased intracranial pressure (ICP), including a drop in Glasgow Coma Scale (GCS) score and unequal pupils. After administration of mannitol, which nursing intervention is most critical to evaluate the effectiveness of the treatment?

B) Assess the patient's level of consciousness and GCS score regularly.

A) Monitor blood pressure and heart rate every 15 minutes.

B) Assess the patient's level of consciousness and GCS score regularly.

C) Check the patient's urine output every hour.

D) Evaluate the patient's pupillary response to light.

A patient with known stroke has developed signs of increased intracranial pressure (ICP) and cerebral edema. After administering mannitol and elevating the head of the bed, which of the following clinical signs would indicate an improvement in the patient's condition?

A) Decrease in pupillary size and brisk reaction to light

B) Increase in blood pressure to 180/110 mmHg

C) Development of Cheyne-Stokes respirations

D) Further decrease in Glasgow Coma Scale score to 7

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs when a blood clot obstructs a cerebral artery, leading to reduced blood flow and oxygen deprivation in brain tissue, which results in cell death and loss of neurological function.

• Secondary mechanism: Hemorrhagic stroke results from the rupture of a cerebral blood vessel, causing blood to leak into or around the brain, increasing intracranial pressure and causing direct damage to brain cells.

• Key complication: Both types can lead to increased intracranial pressure and cerebral edema, further impairing blood flow and potentially causing widespread brain damage.

Patient Profile

Demographics:

68-year-old male, retired electrician

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden weakness on the right side of the body and slurred speech

• Key symptoms: Right-sided facial droop, difficulty speaking, confusion, headache, dizziness

• Vital signs: Blood pressure 190/105 mmHg, heart rate 98 bpm, respiratory rate 22 breaths per minute, temperature 37.2°C, oxygen saturation 92% on room air

Section 1

As the healthcare team continues to monitor the 68-year-old male patient, a new complication emerges. Approximately 24 hours after his initial presentation, the patient begins exhibiting signs of deteriorating neurological function. His level of consciousness decreases, and he becomes increasingly lethargic. The right-sided weakness progresses to complete paralysis, and his speech becomes more garbled and incoherent. Repeat vital signs reveal a blood pressure of 200/110 mmHg, heart rate of 105 bpm, respiratory rate of 24 breaths per minute, and oxygen saturation dropping to 88% on supplemental oxygen. The development of these symptoms raises concerns about the potential evolution of the ischemic stroke into a hemorrhagic transformation or the exacerbation of cerebral edema.

A follow-up CT scan of the brain is performed to assess for new developments. The imaging reveals a significant increase in cerebral edema and a small area of hemorrhagic conversion at the site of the initial ischemic insult. These findings indicate that the blood-brain barrier has been compromised, leading to bleeding into the brain tissue, which further elevates intracranial pressure. Laboratory results show an elevated blood glucose level of 250 mg/dL, which might be contributing to the poor control of cerebral swelling and adds complexity to the patient's condition.

This change in the patient's status requires an immediate adjustment in the treatment plan. The healthcare team must now consider the risk of further hemorrhagic transformation when managing the patient's blood pressure and anticoagulation needs. The focus shifts to reducing intracranial pressure and preventing further neurological decline. This involves initiating intravenous mannitol and hypertonic saline to manage cerebral edema, while closely monitoring the patient's neurological status and vital signs. Antihypertensive therapy may need to be cautiously adjusted to lower the blood pressure without compromising cerebral perfusion. These clinical decisions necessitate careful coordination and frequent re-evaluation to stabilize the patient's condition and prevent additional complications.

Section 2

Despite the aggressive management of cerebral edema, the patient's condition continues to evolve. Over the next several hours, the healthcare team observes a change in the patient's respiratory pattern, characterized by periods of irregular breathing and occasional apneic episodes. This pattern, known as Cheyne-Stokes respiration, suggests an alteration in the brainstem function, possibly due to increasing intracranial pressure. The patient's oxygen saturation intermittently drops to 85%, even with increased supplemental oxygen, necessitating further intervention to maintain adequate oxygenation and prevent hypoxic injury.

A repeat neurological assessment reveals a further decrease in the patient's Glasgow Coma Scale (GCS) score, now at 8, indicating a significant decline in consciousness. His pupils are unequal, with the left pupil sluggishly reactive to light compared to the right, suggesting possible brain herniation. The right-sided paralysis remains unchanged, and his speech is almost unintelligible, further reflecting the deterioration in neurological function.

In response to these alarming signs, the healthcare team considers the need for more invasive monitoring and potential surgical intervention. A neurosurgical consultation is urgently requested to evaluate the feasibility of decompressive craniectomy to relieve intracranial pressure. Concurrently, the team adjusts the patient's medication regimen, increasing the frequency of mannitol administration and cautiously titrating antihypertensive agents to achieve a target systolic blood pressure of less than 180 mmHg. These measures aim to stabilize the patient's condition while preparing for possible surgical intervention, underscoring the critical nature of timely and coordinated care in the management of severe stroke complications.

Section 3

As the healthcare team awaits the neurosurgical evaluation, they closely monitor the patient's vital signs and neurological status for any further changes. The patient's blood pressure has stabilized, with systolic readings consistently between 160-170 mmHg following adjustments to the antihypertensive regimen. However, the oxygen saturation remains a concern, fluctuating between 85% and 90% despite high-flow oxygen therapy. In response, the team decides to initiate non-invasive positive pressure ventilation to improve oxygenation and reduce the work of breathing.

A new series of diagnostic imaging, including a repeat CT scan of the brain, reveals an increase in midline shift and evidence of uncal herniation. These findings correlate with the clinical signs of unequal pupils and declining GCS, highlighting the urgent need for decompressive measures. Blood tests show worsening metabolic acidosis with a pH of 7.30 and a bicarbonate level of 18 mEq/L, likely due to hypoxia and impaired perfusion.

In light of these developments, the neurosurgical team prioritizes the patient for decompressive craniectomy. The decision is made to proceed with the surgery as soon as possible, given the clear indicators of elevated intracranial pressure and impending brain herniation. While preparing for the operating room, the patient's care plan includes continued aggressive management of cerebral edema with frequent mannitol dosing and close monitoring of neurological status. The healthcare team remains vigilant, understanding that the timely intervention is critical in preventing further neurological deterioration and optimizing the patient's long-term recovery potential.

Section 4

As the patient is prepared for the operating room, the healthcare team notes a sudden change in the patient's status. The patient exhibits signs of increased respiratory distress, characterized by labored breathing and a respiratory rate climbing to 28 breaths per minute. Despite the initiation of non-invasive positive pressure ventilation, oxygen saturation drops further to 82%. The team recognizes that these changes could indicate worsening pulmonary function or a progression of neurological compromise affecting respiratory centers.

In response to this acute deterioration, an arterial blood gas analysis is performed, revealing a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg. These results confirm the presence of a mixed respiratory and metabolic acidosis, likely due to a combination of hypoventilation and ongoing tissue hypoxia. Vital signs are monitored closely, with blood pressure now fluctuating between 150-165/95 mmHg and heart rate at 110 beats per minute, suggesting compensatory mechanisms are still active but under strain.

The healthcare team swiftly re-evaluates the current management strategy. In addition to preparing for surgical intervention, they reinforce the non-invasive ventilation strategy, optimizing settings to improve ventilation and oxygenation. Continuous monitoring ensures any further decline is promptly addressed, and the team remains on high alert for potential complications such as aspiration or further cardiovascular instability. These developments emphasize the delicate balance required in managing severe stroke cases and highlight the need for rapid, coordinated responses to dynamic clinical changes.

Section 5

As the healthcare team continues to manage the patient’s respiratory distress, they note a sudden increase in the patient's blood pressure to 175/100 mmHg and a heart rate that spikes to 120 beats per minute. This hypertensive episode, coupled with tachycardia, raises concerns about potential increased intracranial pressure (ICP), a common complication in stroke patients that could exacerbate neurological damage. Neurological assessments reveal a decrease in the patient's level of consciousness, with the Glasgow Coma Scale (GCS) score dropping from 12 to 9, indicating a significant deterioration. The pupils are now unequal, with a sluggish response to light, suggesting possible herniation or further cerebral edema.

In response to these alarming changes, the healthcare team prioritizes rapid imaging studies, including an urgent CT scan of the head, which confirms the presence of significant cerebral edema. This finding necessitates immediate intervention to prevent further neurological compromise. Mannitol, an osmotic diuretic, is administered to reduce ICP, and the patient is positioned with the head elevated at 30 degrees to optimize venous drainage from the brain. Additionally, the team considers the initiation of hypertonic saline therapy to further manage the swelling.

The patient’s response to these interventions is closely monitored, with frequent reassessments to evaluate the effectiveness of the treatment strategy. Over the next hour, the patient shows slight improvement in oxygen saturation, which rises to 88%, and a stabilization of heart rate at 110 beats per minute, suggesting a partial response to the interventions. However, the team remains vigilant for potential new complications, such as herniation or further cardiovascular instability, as they prepare for the possibility of transferring the patient to the intensive care unit for more aggressive monitoring and management. This phase of care underscores the critical importance of timely intervention and teamwork in managing complex stroke cases with evolving complications.