A nurse is caring for Mrs. Thompson, who has been administered mannitol to reduce cerebral edema after a stroke. Which of the following assessments is the most critical for the nurse to perform to evaluate the effectiveness of the mannitol therapy?

C) Assess for changes in Glasgow Coma Scale (GCS) score

A nurse is caring for Mrs. Thompson, who has been diagnosed with post-stroke complications, including cerebral edema. Which of the following interventions should the nurse prioritize to effectively manage her condition?

A) Administering prescribed mannitol to decrease intracranial pressure and monitoring for diuresis.

B) Encouraging oral fluid intake to ensure hydration and support renal function.

C) Positioning the patient flat to promote cerebral perfusion and prevent further edema.

D) Initiating high-dose corticosteroids to reduce inflammation and edema.

Mrs. Thompson has shown a reduction in cerebral edema after administration of mannitol, but continues to experience persistent hypertension and hyperglycemia. Which of the following nursing interventions is most appropriate to prioritize at this time?

C) Monitor blood pressure closely and prepare to administer additional antihypertensive medication as prescribed.

A) Implement a fluid restriction to further reduce intracranial pressure.

B) Collaborate with the dietitian to adjust her diabetic meal plan to better control blood sugar levels.

C) Monitor blood pressure closely and prepare to administer additional antihypertensive medication as prescribed.

D) Arrange for a speech-language pathologist consultation to assess swallowing difficulties.

Mrs. Thompson, who has been receiving mannitol for cerebral edema, shows improvement in her neurological status. However, her blood pressure remains elevated, and she has developed dysphagia. Which of the following actions should the nurse prioritize to address her current condition?

C) Refer Mrs. Thompson to a speech-language pathologist for a swallowing assessment.

A) Increase the dose of mannitol to further reduce intracranial pressure.

B) Collaborate with the healthcare provider to adjust antihypertensive medication.

C) Refer Mrs. Thompson to a speech-language pathologist for a swallowing assessment.

D) Monitor glucose levels more frequently to manage hyperglycemia.

Mrs. Thompson has a new infarct in the posterior circulation and is on warfarin therapy. Her INR is 1.8. What is the most appropriate nursing action to ensure her anticoagulation is therapeutic and prevent further cerebrovascular events?

D) Notify the healthcare provider to consider increasing the warfarin dosage.

A) Continue current warfarin dosage and recheck INR in one week.

B) Administer vitamin K to reverse the effects of warfarin.

C) Educate the patient on increasing dietary intake of vitamin K-rich foods.

D) Notify the healthcare provider to consider increasing the warfarin dosage.

Mrs. Thompson's recent MRI scan revealed a new infarct in the posterior circulation, and her INR was found to be subtherapeutic at 1.8. Considering her current situation, which intervention should the nurse prioritize to address her increased risk of further embolic events?

B) Initiate immediate heparin therapy while adjusting warfarin dosage.

A) Increase the dosage of mannitol to reduce intracranial pressure.

B) Initiate immediate heparin therapy while adjusting warfarin dosage.

C) Administer a higher dose of statins to lower LDL cholesterol rapidly.

D) Encourage fluid restriction to manage potential nephrotoxicity.

Mrs. Thompson, an elderly patient, has developed increased confusion and dysphagia. The healthcare team suspects a urinary tract infection (UTI) and is concerned about aspiration risk. Which of the following nursing interventions is most appropriate to address her current symptoms and prevent further complications?

B) Place Mrs. Thompson in an upright position during meals to reduce the risk of aspiration.

A) Encourage Mrs. Thompson to drink more fluids to flush out the urinary tract infection.

B) Place Mrs. Thompson in an upright position during meals to reduce the risk of aspiration.

C) Administer a sedative to help manage her agitation and confusion.

D) Begin a nasogastric tube feeding regimen to ensure adequate nutrition.

A nurse is caring for Mrs. Thompson, who has developed increased confusion, agitation, and dysphagia with a recent diagnosis of a urinary tract infection (UTI). Considering her current condition, what is the nurse's priority action to prevent further complications?

C) Implement aspiration precautions during meals to prevent aspiration pneumonia.

A) Administer the prescribed antibiotics to treat the UTI.

B) Monitor her INR closely to ensure her warfarin is within therapeutic range.

C) Implement aspiration precautions during meals to prevent aspiration pneumonia.

D) Adjust her position regularly to prevent pressure ulcers.

A nurse is caring for Mrs. Thompson, who is recovering from a urinary tract infection and has moderate oropharyngeal dysphagia. She has developed mild dehydration, as evidenced by elevated BUN and creatinine levels. What is the most appropriate nursing intervention to address Mrs. Thompson's hydration needs while minimizing the risk of aspiration?

C) Offer thickened liquids regularly and monitor intake closely.

A) Encourage frequent sips of water between meals.

B) Increase her intravenous fluid rate to maintain hydration.

C) Offer thickened liquids regularly and monitor intake closely.

D) Administer diuretics to manage potential fluid overload.

Mrs. Thompson has demonstrated moderate oropharyngeal dysphagia and mild dehydration following her stroke. Which nursing intervention is the most effective in preventing further complications related to her dysphagia and ensuring adequate hydration?

B) Offer small amounts of thickened liquids frequently throughout the day.

A) Encourage Mrs. Thompson to drink fluids quickly to increase her intake.

B) Offer small amounts of thickened liquids frequently throughout the day.

C) Limit fluid intake to mealtimes to prevent aspiration.

D) Administer diuretics to manage her elevated BUN and creatinine levels.

post stroke care - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic cascade - After a stroke, the sudden lack of blood flow leads to a depletion of oxygen and glucose, causing energy failure, cell death, and the release of cytotoxic neurotransmitters like glutamate, which further damage brain tissue.

• Secondary mechanism: Blood-brain barrier disruption - Stroke can compromise the integrity of this barrier, leading to increased permeability. This permits neurotoxic substances and inflammatory cells to enter the brain, worsening edema and neuronal injury.

• Key complication: Cerebral edema - The accumulation of fluid in the brain tissue increases intracranial pressure, potentially leading to further neuronal damage and impairing recovery. Monitoring and managing edema are crucial to prevent secondary brain injury and improve patient outcomes.

Patient Profile

Demographics:

67-year-old female, retired school teacher

History:

• Key past medical history: Ischemic stroke 3 months ago, hypertension, type 2 diabetes

• Current medications: Aspirin 81 mg daily, Lisinopril 10 mg daily, Metformin 500 mg twice daily, Simvastatin 20 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Weakness on the right side and difficulty speaking

• Key symptoms: Slurred speech, right-sided hemiparesis, occasional headaches, mild confusion

• Vital signs: Blood pressure 160/95 mmHg, heart rate 95 bpm, respiratory rate 20 breaths per minute, temperature 99.1°F (37.3°C)

Section 1

The patient, Mrs. Thompson, was admitted for further evaluation and management following her post-stroke symptoms and newly reported headaches and confusion. Upon initial assessment, her right-sided hemiparesis and slurred speech were noted to have slightly worsened compared to previous evaluations, suggesting potential complications with her recovery process. A neurological examination revealed increased muscle tone on the right side, with a reflex score of 3+ indicating heightened reflex activity. Her Glasgow Coma Scale (GCS) score was 13, reflecting mild confusion and a decreased ability to follow commands.

Laboratory results showed elevated blood glucose levels at 180 mg/dL, which may be contributing to her confusion and could impede her overall recovery. Additionally, a repeat CT scan of the brain was performed, revealing signs of progressive cerebral edema. This was evidenced by a midline shift of 3 mm, suggestive of increased intracranial pressure. Her blood pressure remains elevated at 160/95 mmHg, despite being on antihypertensive therapy, indicating the need for more aggressive blood pressure management to prevent further neurological compromise.

Given these findings, the healthcare team determined that immediate interventions are necessary to address the cerebral edema and manage her blood pressure and glucose levels more effectively. The team initiated an osmotic diuretic, such as mannitol, to reduce intracranial pressure, and adjusted her antihypertensive regimen to include a beta-blocker to achieve better blood pressure control. Close monitoring of her neurological status and vital signs will be critical in the subsequent hours, as these interventions aim to stabilize her condition and prevent further complications.

Section 2

As Mrs. Thompson's care progressed, her response to the initiated interventions was closely monitored. Within the first few hours of administering mannitol, her neurological status showed subtle improvement. Her GCS score improved to 14, indicating a slight enhancement in her ability to follow commands and a decrease in confusion. This improvement suggested a positive response to the osmotic diuretic, as the reduction in intracranial pressure appeared to alleviate some of her neurological symptoms. However, her blood pressure remained a concern, as it fluctuated between 150/90 mmHg and 165/98 mmHg despite the adjustment in her antihypertensive regimen. This persistent hypertension necessitated further evaluation of her medication adherence and potential secondary causes of refractory hypertension.

New diagnostic results from follow-up blood tests revealed a persistent hyperglycemia issue, with glucose levels still elevated at 175 mg/dL, despite efforts to manage her levels with insulin therapy. This indicated a potential need to reevaluate her insulin regimen and investigate underlying factors contributing to her glucose instability. Additionally, repeat CT imaging showed a slight decrease in cerebral edema, evidenced by a reduction in the midline shift to 2 mm. While this was encouraging, the healthcare team remained vigilant for any signs of deterioration.

Despite these interventions, Mrs. Thompson developed new complications, including increased difficulty with swallowing, raising concerns about the risk of aspiration pneumonia. This dysphagia required the immediate involvement of a speech-language pathologist to assess her swallowing function and recommend appropriate dietary modifications. Given these developments, the healthcare team expanded their focus to include comprehensive management strategies to address her multifactorial needs, ensuring that her recovery trajectory remained on a positive path while minimizing the risk of further complications.

Section 3

As Mrs. Thompson's condition continued to evolve, new diagnostic results provided further insight into her complex clinical picture. A recent MRI scan revealed an unexpected development: a small, new infarct in the posterior circulation. This finding was concerning, as it suggested the possibility of ongoing embolic events or inadequate anticoagulation. Her current anticoagulation therapy was re-evaluated, and it was determined that her INR levels were subtherapeutic at 1.8, necessitating an adjustment in her warfarin dosage to achieve therapeutic anticoagulation. Additionally, her lipid panel showed elevated LDL cholesterol at 160 mg/dL, prompting the initiation of statin therapy to address her hyperlipidemia and reduce the risk of further cerebrovascular events.

In parallel, Mrs. Thompson's renal function tests showed a slight decline, with her creatinine rising to 1.4 mg/dL from a baseline of 1.0 mg/dL. This change raised concerns about potential nephrotoxicity, possibly related to the ongoing use of mannitol and other medications. The healthcare team considered the need to adjust her medication regimen to protect her renal function while continuing to manage her intracranial pressure and hypertensive status effectively. A nephrology consult was requested to provide additional insights into optimizing her care plan.

Despite these challenges, Mrs. Thompson's overall clinical stability remained tenuous, necessitating close monitoring and dynamic adjustments to her treatment plan. The multidisciplinary team, including neurology, cardiology, nephrology, and speech therapy, collaborated to ensure that all aspects of her care were addressed comprehensively. Each new finding and intervention was carefully weighed, considering the potential benefits and risks, as the team worked diligently to navigate her complex medical needs and guide her towards a sustainable recovery.

Section 4

New Complications:

As the days progressed, Mrs. Thompson began exhibiting signs of increased confusion and agitation, a notable deviation from her previously oriented mental status. Her vital signs included a blood pressure of 160/95 mmHg, heart rate of 88 beats per minute, respiratory rate of 20 breaths per minute, and oxygen saturation holding steady at 96% on room air. However, a low-grade fever of 100.4°F was noted, prompting the healthcare team to investigate further. A urinalysis was ordered and revealed the presence of white blood cells and nitrates, indicating a possible urinary tract infection (UTI). The decision was made to initiate a course of antibiotics to address the infection, as untreated UTIs can exacerbate confusion, particularly in the elderly and those with neurological impairments.

Simultaneously, Mrs. Thompson's speech therapist reported a sudden increase in dysphagia symptoms, including coughing during meals and observable pocketing of food. This raised concerns about the risk of aspiration, necessitating immediate intervention to prevent aspiration pneumonia. A modified barium swallow study was scheduled to assess her swallowing function more thoroughly. In the interim, her diet was adjusted to pureed consistency, and she was placed on aspiration precautions, including upright positioning during and after meals.

As these new complications emerged, the multidisciplinary team reassessed her care plan. The nephrology consult provided insights into optimizing her medication regimen to protect renal function, suggesting a reduction in the dosage of medications potentially contributing to nephrotoxicity. Additionally, her warfarin was closely monitored and adjusted to achieve a target INR of 2.0-3.0. The team remained vigilant, recognizing that each complication not only required targeted interventions but also had the potential to interact with her existing conditions, thereby creating a delicate balance in her ongoing recovery process.

Section 5

As Mrs. Thompson’s care continued, the healthcare team closely monitored her response to the interventions for her urinary tract infection and increased dysphagia symptoms. Over the next 48 hours, there was a noticeable improvement in her overall demeanor; her agitation decreased, and her orientation to time and place showed signs of stabilization. Her vital signs remained relatively stable, with her blood pressure slightly improved at 150/90 mmHg, heart rate at 84 beats per minute, and respiratory rate steady at 18 breaths per minute. Her fever resolved, returning to a normal 98.6°F, indicating a positive initial response to the antibiotic treatment.

However, the results from the modified barium swallow study revealed moderate oropharyngeal dysphagia with delayed initiation of the swallow reflex and reduced laryngeal elevation, confirming the risk of aspiration. Consequently, the speech therapist recommended continued use of a pureed diet with thickened liquids and reinforced the importance of maintaining aspiration precautions. Regular swallow therapy sessions were initiated to strengthen her swallowing muscles and improve coordination. The nursing staff remained vigilant during her meals, ensuring that Mrs. Thompson was not only in the correct position but also encouraging slow, deliberate eating to minimize the risk of aspiration.

Despite these interventions, the team noted that Mrs. Thompson had developed a new complication: mild dehydration. Her latest laboratory results showed elevated blood urea nitrogen (BUN) levels at 28 mg/dL and serum creatinine at 1.5 mg/dL, suggesting that her fluid intake had decreased, likely due to discomfort from swallowing difficulties. To address this, the healthcare team increased her fluid intake through careful monitoring of oral intake and considered the administration of intravenous fluids to ensure adequate hydration. This new challenge underscored the importance of continuous reassessment and adaptation of Mrs. Thompson’s care plan to address the interconnectedness of her post-stroke complications, setting the stage for further evaluation and intervention.