What is the primary reason for monitoring Mr. Thompson's neurological status closely after his initial assessment?

A) To ensure early detection of any changes that could indicate increased intracranial pressure

B) To confirm that his current medications are effective

C) To prevent the development of slurred speech

D) To evaluate if his blood glucose levels are stable

What is the primary reason for monitoring Mr. Thompson's neurological status frequently following his initial assessment?

B) To detect any changes that may indicate increased intracranial pressure

A) To ensure his vital signs remain stable

B) To detect any changes that may indicate increased intracranial pressure

C) To assess for improvement in his blood glucose levels

D) To evaluate the effectiveness of physical therapy interventions

Which of the following interventions is most appropriate for managing Mr. Thompson's occasional dizziness when transitioning from lying to sitting positions?

B) Encouraging him to change positions slowly

A) Administering a prescribed diuretic

B) Encouraging him to change positions slowly

C) Instructing him to avoid sitting up entirely

D) Increasing his fluid intake to reduce dizziness

What is a key nursing intervention to prevent potential complications when Mr. Thompson experiences dizziness upon changing positions?

B) Advise Mr. Thompson to change positions slowly

A) Encourage Mr. Thompson to remain lying down throughout the day

B) Advise Mr. Thompson to change positions slowly

C) Increase Mr. Thompson's salt intake to raise blood pressure

D) Restrict Mr. Thompson's fluid intake to reduce dizziness

What is the primary reason for educating Mr. Thompson to sit on the edge of the bed before standing?

B) To prevent orthostatic hypotension

A) To increase his muscle strength

B) To prevent orthostatic hypotension

C) To improve his balance and coordination

D) To reduce the risk of falls due to dizziness

What is the primary nursing intervention to prevent orthostatic hypotension in Mr. Thompson?

B) Advise Mr. Thompson to sit on the edge of the bed for a few minutes before standing.

A) Encourage Mr. Thompson to stand up quickly from a sitting position.

B) Advise Mr. Thompson to sit on the edge of the bed for a few minutes before standing.

C) Restrict Mr. Thompson's fluid intake to prevent dizziness.

D) Instruct Mr. Thompson to avoid all physical activity to prevent headaches.

What is the primary reason for elevating Mr. Thompson's legs in the management of his edema?

B) To enhance lymphatic drainage

A) To improve blood circulation to the heart

B) To enhance lymphatic drainage

C) To prevent the development of pressure ulcers

D) To increase muscle strength in the legs

What is the primary reason for recommending iron-rich foods and iron supplementation in Mr. Thompson's care plan?

B) To increase his hemoglobin levels

A) To improve his respiratory rate

B) To increase his hemoglobin levels

C) To enhance his physical endurance

post CVA client care - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemia occurs when blood flow to the brain is reduced or blocked, leading to a lack of oxygen and nutrients, which causes brain cell death and damage.

• Secondary mechanism: Inflammation follows ischemic injury, resulting in swelling and release of harmful chemicals, which can further damage brain tissue and exacerbate neurological deficits.

• Key complication: Edema or swelling of the brain tissue can increase intracranial pressure, potentially leading to further neuronal injury and impaired recovery.

Patient Profile

Demographics:

65 years old, male, retired school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Mild right-sided weakness

• Key symptoms: Slight difficulty with speech, right arm and leg weakness

• Vital signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F

Section 1

As the nursing team continues to monitor Mr. Thompson, the initial assessment findings provide valuable insights into his current condition. During a focused neurological examination, the nurse observes that Mr. Thompson exhibits slight facial drooping on the right side, consistent with his mild right-sided weakness. Despite these minor motor deficits, he remains alert and oriented to person, place, and time. His speech, although slightly slurred, is coherent, and he is able to follow simple commands without difficulty. The nurse notes that his grip strength is weaker in the right hand compared to the left, and his right leg shows mild resistance against passive movements.

Vital signs are stable, with blood pressure reading at 130/80 mmHg, heart rate 78 bpm, and respiratory rate 16 breaths per minute. His oxygen saturation is 96% on room air, indicating adequate respiratory function. A blood glucose check reveals a level of 140 mg/dL, slightly elevated but not alarming given his diabetes history. These findings suggest that Mr. Thompson is in a stable condition, with minor deficits primarily affecting motor skills.

The nursing team discusses the care plan, emphasizing the importance of ongoing monitoring for any changes in neurological status and potential complications such as increased intracranial pressure. They prioritize interventions to prevent further stroke progression, including ensuring medication adherence and educating Mr. Thompson about the importance of blood pressure and glucose control. The team also plans to implement a physical therapy regimen to improve his strength and mobility, aiming to enhance his independence and quality of life as he progresses in his recovery journey.

Section 2

As Mr. Thompson progresses through his early recovery phase, the nursing team closely monitors his response to interventions designed to improve his motor function and prevent further complications. After several sessions with the physical therapist, Mr. Thompson shows encouraging signs of improvement. He demonstrates increased strength in his right hand, now able to exert moderate grip pressure, and his right leg exhibits improved resistance against passive movements. His facial drooping is less pronounced, and his speech clarity has marginally improved, allowing for more fluid communication. These positive developments indicate that the physical therapy regimen is effectively enhancing his neuromuscular function.

The nursing team also continues to focus on Mr. Thompson's cardiovascular and metabolic health, recognizing the importance of maintaining stable blood pressure and glucose levels. A recent follow-up blood pressure reading is 128/78 mmHg, and his blood glucose level has decreased to 130 mg/dL, reflecting better control. These improvements are attributed to effective medication management and Mr. Thompson's adherence to dietary recommendations. The team reinforces the importance of these lifestyle modifications, emphasizing their role in preventing future cerebrovascular events.

Despite these positive indicators, Mr. Thompson occasionally reports mild headaches and slight dizziness when transitioning from lying to sitting positions. The nursing team takes these symptoms seriously, ensuring regular monitoring of his neurological status to rule out any potential complications such as postural hypotension or increased intracranial pressure. They educate Mr. Thompson on the importance of changing positions slowly and ensuring adequate hydration. The team remains vigilant, ready to adjust his care plan as needed based on any new assessment findings, striving to support his journey towards full recovery and independence.

Section 3

As Mr. Thompson continues his early recovery, the nursing team is pleased to observe further progress in his motor and cognitive functions. In a recent assessment, Mr. Thompson was able to walk a short distance with the help of a walker, demonstrating a more stable gait and increased confidence. His speech has also improved slightly, allowing him to participate more actively in conversations with both staff and family members. These advancements are promising signs that the rehabilitation efforts are yielding positive results.

However, the nursing team notes a new development; Mr. Thompson's mild headaches and dizziness have become slightly more frequent. To address these symptoms, the team conducts a thorough neurological assessment and reviews his medication regimen. They discover that his blood pressure, while mostly stable, occasionally drops to 115/70 mmHg during positional changes, suggesting a mild case of orthostatic hypotension. The team educates Mr. Thompson on strategies to manage these symptoms, such as sitting on the edge of the bed for a few minutes before standing and ensuring he remains well-hydrated throughout the day.

To further evaluate Mr. Thompson's condition, recent laboratory results are reviewed. His lipid profile shows a slight elevation, with LDL cholesterol at 140 mg/dL, prompting the team to revisit his dietary plan and discuss potential adjustments with the dietitian. These findings highlight the importance of ongoing assessment and individualized care planning to address emerging health concerns. The nursing team collaborates with Mr. Thompson and his family to reinforce the significance of adhering to lifestyle modifications and monitoring his symptoms closely. As they continue to support his recovery, they remain attentive to any changes in his condition, prepared to adapt his care plan to ensure his progress towards a full recovery.

Section 4

As Mr. Thompson continues his recovery journey, the nursing team remains vigilant in monitoring his condition. During a routine assessment, the team observes that Mr. Thompson has developed mild edema in his lower extremities, particularly noticeable around the ankles. To investigate further, they assess his fluid intake and output, noting that while his intake has been adequate, his output has decreased slightly over the past 24 hours. His vital signs remain stable, with a blood pressure reading of 120/75 mmHg and a heart rate of 78 beats per minute, but the team decides to conduct additional laboratory tests to explore the cause of the edema.

The laboratory results reveal a slight decrease in serum albumin levels, measuring at 3.4 g/dL, which could contribute to the fluid retention observed. Recognizing the importance of addressing this new complication, the nursing team collaborates with the dietitian to adjust Mr. Thompson's nutritional plan, ensuring adequate protein intake to support albumin levels. They also educate Mr. Thompson and his family on the importance of elevating his legs when sitting and maintaining a balanced diet to manage and prevent further edema.

In response to these interventions, Mr. Thompson's condition shows signs of improvement over the following days. The edema begins to subside, and his mobility remains unaffected, allowing him to continue participating actively in his rehabilitation exercises. The nursing team remains committed to monitoring his progress closely, ready to adapt his care plan as needed to support his ongoing recovery and address any new challenges that may arise. With careful attention and collaborative care, they are optimistic about his continued improvement and eventual return to full health.

Section 5

As Mr. Thompson continues his recovery, the nursing team notices a new area of concern: he has developed mild dyspnea during physical activity, such as walking short distances or performing his rehabilitation exercises. His respiratory rate is slightly elevated at 22 breaths per minute, but his oxygen saturation remains within normal limits at 95% on room air. To better understand this development, the team conducts a thorough respiratory assessment and reviews recent lab results, which reveal a hemoglobin level of 11.5 g/dL, slightly below the normal range, indicating mild anemia that could be contributing to his shortness of breath.

In light of these findings, the nursing team collaborates with the physician and dietitian to adjust Mr. Thompson's care plan. They recommend iron-rich foods and consider iron supplementation to address the anemia. Additionally, they educate Mr. Thompson and his family on energy conservation techniques to manage his dyspnea, such as pacing activities and incorporating rest periods. The physiotherapist is also consulted to tailor his rehabilitation exercises, ensuring they are less taxing on his respiratory system while still promoting physical recovery.

As these interventions are implemented, Mr. Thompson begins to experience less dyspnea during activities, and his energy levels show signs of improvement. The nursing team continues to monitor his hemoglobin levels and respiratory status closely, ready to adjust his care plan as needed. By addressing this minor complication promptly and effectively, they support Mr. Thompson's ongoing recovery, keeping him on track towards his goal of regaining full health. With collaborative care and patient education, the team remains optimistic about his progress and prepared for any further challenges that may arise in his recovery journey.