A patient with a suspected stroke presents with worsening right-sided weakness, increasing confusion, and elevated blood pressure. Which initial nursing intervention is most critical in managing this patient's condition?

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

A) Administer antihypertensive medication to lower blood pressure immediately.

B) Initiate continuous cardiac monitoring to observe heart rate changes.

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

D) Prepare for intubation to secure airway patency.

A patient with a history of diabetes presents with acute right-sided weakness, confusion, and elevated blood pressure. After initiating supplemental oxygen and alerting the rapid response team, what is the nurse's priority intervention while awaiting the CT scan results?

B) Monitor and document neurological status using the Glasgow Coma Scale

A) Administer aspirin to prevent further clot formation

B) Monitor and document neurological status using the Glasgow Coma Scale

C) Prepare for immediate administration of thrombolytic therapy

D) Initiate aggressive blood pressure management with antihypertensives

A patient is receiving thrombolytic therapy (tPA) after an ischemic stroke in the middle cerebral artery territory. The patient's blood pressure remains elevated at 195/110 mmHg. Which nursing intervention is the most appropriate to address this situation while ensuring the safety and effectiveness of the therapy?

B) Initiate intravenous antihypertensive therapy to rapidly decrease blood pressure.

A) Administer a scheduled dose of oral antihypertensive medication and continue to monitor.

B) Initiate intravenous antihypertensive therapy to rapidly decrease blood pressure.

C) Reassess blood pressure in 30 minutes and consult with the healthcare provider if it remains elevated.

D) Hold the tPA therapy until the blood pressure is within a safe range.

A patient with an ischemic stroke in the middle cerebral artery territory is being prepared for tissue plasminogen activator (tPA) administration. The patient's blood pressure remains elevated at 195/110 mmHg despite initial medical management. What is the most appropriate nursing intervention to address the elevated blood pressure before administering tPA?

B) Initiate intravenous antihypertensive therapy to rapidly lower blood pressure to below 185/110 mmHg.

A) Administer oral antihypertensive medication and wait for blood pressure to decrease naturally.

B) Initiate intravenous antihypertensive therapy to rapidly lower blood pressure to below 185/110 mmHg.

C) Withhold tPA administration until blood pressure is within normal limits without intervention.

D) Begin fluid restriction to help decrease blood pressure through reduced blood volume.

A patient receiving tPA for an acute ischemic stroke has shown a deterioration in neurological status with a Glasgow Coma Scale score of 8 and anisocoria. Blood pressure is significantly elevated at 200/115 mmHg. After communicating with the neurologist, what is the most appropriate initial nursing intervention to prioritize the patient's care?

B) Prepare the patient for an immediate repeat CT scan.

A) Initiate a continuous infusion of nicardipine to manage hypertension.

B) Prepare the patient for an immediate repeat CT scan.

C) Administer additional insulin to control the blood glucose level.

D) Prepare for potential osmotic therapy to reduce intracranial pressure.

A patient with acute ischemic stroke receiving tPA infusion shows a sudden decrease in Glasgow Coma Scale score and anisocoria, with a critically high blood pressure despite treatment. What is the priority nursing action following this change in the patient's status?

B) Prepare the patient for an immediate CT scan to assess for hemorrhagic transformation.

A) Increase the rate of intravenous labetalol to achieve rapid blood pressure reduction.

B) Prepare the patient for an immediate CT scan to assess for hemorrhagic transformation.

C) Administer an increased dose of insulin to control elevated blood glucose levels.

D) Elevate the head of the bed to 30 degrees to reduce intracranial pressure.

A patient with an ischemic stroke has developed hemorrhagic transformation and increased intracranial pressure. Which nursing intervention is most critical in preventing further complications in this patient?

A) Administer mannitol as prescribed to decrease intracranial pressure

B) Increase the nicardipine infusion rate to lower blood pressure rapidly

C) Position the patient supine to enhance cerebral perfusion

D) Administer a rapid bolus of IV fluids to maintain blood pressure

A patient with acute ischemic stroke has developed a hemorrhagic transformation, leading to the discontinuation of tPA. Mannitol is being administered to manage increased intracranial pressure (ICP). What is the primary nursing priority when monitoring the effectiveness of mannitol therapy in this patient?

D) Measuring urine output hourly

A) Monitoring blood pressure every 2 hours

B) Checking serum electrolyte levels regularly

C) Assessing pupil size and reactivity frequently

D) Measuring urine output hourly

A patient with a history of intracerebral hemorrhage is exhibiting increased agitation, restlessness, elevated heart rate, and hypertension despite receiving nicardipine. Her sodium level is 128 mEq/L. Which of the following interventions should the nurse prioritize to address the immediate complications observed in this patient?

D) Consult with the interdisciplinary team to reassess and adjust the current treatment plan.

A) Increase the rate of the nicardipine infusion to rapidly lower blood pressure.

B) Initiate a hypertonic saline infusion to correct the hyponatremia.

C) Administer a sedative to manage the patient's agitation and restlessness.

D) Consult with the interdisciplinary team to reassess and adjust the current treatment plan.

A patient with a history of intracerebral hemorrhage is being treated for elevated blood pressure and hyponatremia. The nursing team notices increased agitation and restlessness, with vital signs showing a heart rate of 110 bpm and blood pressure of 190/100 mmHg. Laboratory results reveal a sodium level of 128 mEq/L. Which of the following actions should the nurse prioritize to address the patient's current condition?

B) Administer hypertonic saline to correct the hyponatremia slowly.

A) Increase the nicardipine infusion rate to rapidly lower blood pressure.

B) Administer hypertonic saline to correct the hyponatremia slowly.

C) Place the patient in a quiet, dark environment to reduce agitation.

D) Consult with the healthcare provider to adjust the osmotic therapy regimen.

acute stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Acute stroke often results from an interruption of blood flow due to either an ischemic event (usually caused by a blood clot obstructing a cerebral artery) or a hemorrhagic event (where a weakened blood vessel ruptures, leading to bleeding in the brain). Both mechanisms lead to a rapid reduction in oxygen and nutrient delivery to brain tissue, causing cell death and loss of neurological function.

• Secondary mechanism: In ischemic stroke, the obstruction causes an ischemic cascade, where lack of oxygen triggers a series of cellular events, including excitotoxicity and oxidative stress, further damaging brain cells and expanding the area of infarction.

• Key complication: Both types of strokes can lead to cerebral edema as the brain's response to injury, potentially increasing intracranial pressure and causing further neurological deficits or herniation if not promptly managed.

Patient Profile

Demographics:

67-year-old female, retired teacher

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of right-sided weakness and difficulty speaking

• Key symptoms: Slurred speech, facial droop on the right side, confusion, headache

• Vital signs: Blood pressure 190/110 mmHg, heart rate 102 bpm, respiratory rate 22 breaths per minute, temperature 37.6°C, oxygen saturation 94% on room air

Section 1

Change in Patient Status:

Shortly after the initial assessment, the patient's condition began to evolve. Her neurological status showed further deterioration, evidenced by a widening of the right-sided weakness and increasing difficulty in maintaining coherence during speech. Observations indicated a progression in her confusion, now accompanied by an intermittent loss of orientation to time and place. Repeat vital signs revealed a significant increase in blood pressure to 200/115 mmHg, with the heart rate slightly increased to 110 bpm. Oxygen saturation dropped to 92% on room air, prompting the initiation of supplemental oxygen therapy via nasal cannula at 2 liters per minute.

Given these changes, a rapid response team was alerted, and a decision was made to perform an urgent CT scan of the head to differentiate between ischemic and hemorrhagic stroke, guiding further interventions. Concurrently, the nursing team focused on maintaining airway patency, closely monitoring neurological status using the Glasgow Coma Scale, and preparing for potential thrombolytic therapy if ischemic stroke was confirmed. Blood glucose levels were also monitored, given her diabetes history, to prevent exacerbation of the stroke due to hyperglycemia. As the team awaited diagnostic results, they considered the need for potential escalation to intensive monitoring and care, anticipating possible complications such as increased intracranial pressure or the need for more aggressive blood pressure management.

Section 2

The urgent CT scan revealed an ischemic stroke in the middle cerebral artery territory, confirming the need for thrombolytic therapy. As the team prepared to administer tissue plasminogen activator (tPA), they continued to monitor the patient closely. Her neurological status remained precarious, with the Glasgow Coma Scale score dropping to 10, indicating a moderate level of impaired consciousness. The right-sided weakness progressed to complete hemiplegia, and her speech became severely dysarthric, further complicating communication efforts. Vital signs continued to be concerning, with blood pressure persistently elevated at 195/110 mmHg despite initial medical management, hinting at the possibility of autoregulatory dysfunction due to the evolving stroke.

In response to these findings, the medical team discussed the potential risks and benefits of administering tPA, considering the patient's worsening neurological status and elevated blood pressure. They also explored the need for more aggressive blood pressure control, potentially requiring intravenous antihypertensives to reduce the risk of hemorrhagic transformation while maintaining cerebral perfusion. The nursing staff played a critical role in this decision-making process, highlighting the importance of continuous monitoring for signs of increased intracranial pressure, such as changes in pupil reactivity or further decline in consciousness, which could necessitate immediate intervention.

As preparations for tPA administration continued, the team remained vigilant for new complications, particularly the risk of hemorrhage given the patient's hypertensive state and history of diabetes. The patient's blood glucose level was moderately elevated at 180 mg/dL, prompting adjustments in her insulin therapy to avoid exacerbating the ischemic damage. This complex interplay of factors demanded careful clinical reasoning and coordination among the healthcare team to optimize patient outcomes while minimizing potential adverse effects from the interventions.

Section 3

As the team proceeded with the administration of tPA, they noted some concerning changes in the patient's status. Approximately 30 minutes after starting the infusion, the patient's neurological condition deteriorated. Her Glasgow Coma Scale score dropped further to 8, indicating a severe level of impaired consciousness. Pupillary examination revealed anisocoria, with the right pupil becoming sluggish to light, raising immediate concerns for increased intracranial pressure or potential hemorrhagic transformation. Blood pressure remained critically high at 200/115 mmHg, despite the initiation of intravenous labetalol, highlighting the difficulty in achieving adequate control without compromising cerebral perfusion.

The nursing team promptly communicated these changes to the attending neurologist, triggering a rapid reassessment of the patient's condition. A repeat CT scan was ordered to rule out secondary complications such as hemorrhage. Concurrently, the medical team adjusted the antihypertensive regimen, opting for a more aggressive approach with continuous infusion of nicardipine to achieve a gradual reduction in blood pressure. The patient's blood glucose levels were re-evaluated, revealing a further increase to 210 mg/dL, necessitating additional insulin administration to mitigate any further ischemic injury.

These developments demanded swift clinical reasoning and close collaboration among the healthcare team to navigate the complex balance of managing the acute stroke, preventing hemorrhagic transformation, and addressing the emerging complications. The team remained poised to initiate further interventions, such as osmotic therapy or neurosurgical consultation, should the patient's condition continue to decline. The evolving scenario underscored the critical importance of comprehensive monitoring and dynamic decision-making in the acute stroke setting, setting the stage for the next steps in the patient's care trajectory.

Section 4

As the team continued to manage the patient's condition, the repeat CT scan results arrived, revealing a small area of hemorrhagic transformation within the previously ischemic region. This finding confirmed the suspicions raised by the initial neurological deterioration and anisocoria. The presence of hemorrhagic transformation posed a significant challenge, necessitating an immediate halt to the tPA infusion to prevent further bleeding. The neurologist, together with the nursing team, re-evaluated the treatment strategy, recognizing the need to strike a delicate balance between managing the hemorrhage and preserving cerebral perfusion.

In response to the new diagnostic findings, the patient's management plan was adjusted to include the administration of mannitol to reduce intracranial pressure. The decision to initiate osmotic therapy was based on the persistent signs of increased intracranial pressure and the aim to stabilize her neurological status. Meanwhile, the continuous nicardipine infusion was closely monitored and titrated to maintain a target blood pressure that would optimize cerebral perfusion without exacerbating the bleeding. The patient's blood glucose level was stabilized with a carefully calculated insulin regimen, preventing further metabolic stress on the brain.

The nursing team maintained vigilant monitoring of the patient’s neurological status and vital signs, looking for any signs of further deterioration or improvement. The patient’s Glasgow Coma Scale score remained at 8, but with the interventions in place, the team observed a slight improvement in her pupillary response, offering a glimmer of hope. As they awaited further stabilization or the potential need for neurosurgical intervention, the healthcare team remained engaged in frequent reassessments and multidisciplinary discussions, demonstrating the essential role of integrated clinical reasoning in navigating the complexities of acute stroke management with developing complications.

Section 5

As the vigilant monitoring continued, the nursing team noticed a subtle but critical change in the patient's status. Despite the initial stabilization, the patient began to exhibit increased agitation and restlessness, indicating potential worsening of her condition. Her heart rate increased to 110 beats per minute, and her blood pressure showed a concerning rise to 190/100 mmHg, despite the ongoing nicardipine infusion. These vital sign deviations suggested a possible new complication, prompting an immediate reassessment of her treatment plan. The team quickly recognized that the elevated blood pressure could further exacerbate the risk of hemorrhagic expansion and worsen cerebral edema, necessitating prompt intervention.

Simultaneously, the patient's laboratory results returned, revealing a sodium level of 128 mEq/L, indicative of hyponatremia. This electrolyte imbalance, potentially a result of osmotic therapy with mannitol, could contribute to the patient's neurological symptoms and complicate her management. With these new findings, the healthcare team faced a challenging decision-making process, requiring precise clinical reasoning to address the intricate balance of managing the patient's cerebral perfusion, blood pressure, and electrolyte status.

In response, the treatment strategy was adjusted to include cautious correction of the hyponatremia with hypertonic saline, aiming to gradually restore her sodium levels to a safer range. The nicardipine infusion was re-evaluated and titrated more aggressively to achieve better blood pressure control. The multidisciplinary team, including neurology, nephrology, and critical care, engaged in comprehensive discussions to ensure every aspect of the patient's care was meticulously coordinated. This collaborative approach emphasized the importance of integrating new clinical data and adapting the management plan to navigate the evolving complexities of the patient's condition.