A nurse is caring for Mr. Thompson, who is experiencing increased confusion, disorientation, and aphasia following an ischemic stroke. His blood pressure has increased, and oxygen saturation is 91% on room air. Which nursing intervention is the priority to address the suspected cerebral edema and prevent further complications?

A) Administer supplemental oxygen and elevate the head of the bed to 30 degrees.

B) Administer a prescribed antipyretic to reduce fever and decrease metabolic demand.

C) Encourage fluid intake to ensure adequate hydration and perfusion.

D) Perform passive range of motion exercises to prevent muscle contractures.

Mr. Thompson's worsening neurological status and decreased oxygen saturation suggest a potential complication following his ischemic stroke. Which nursing intervention is most critical to implement immediately to address his current symptoms and prevent further deterioration?

B) Elevate the head of the bed to 30 degrees and monitor neurological status frequently.

A) Increase the rate of intravenous fluids to improve circulation.

B) Elevate the head of the bed to 30 degrees and monitor neurological status frequently.

C) Administer a sedative to decrease agitation and confusion.

D) Encourage oral fluids to maintain hydration and electrolyte balance.

A nurse is caring for Mr. Thompson, who is being treated for cerebral edema with mannitol and corticosteroids. His blood pressure remains elevated at 182/110 mmHg. Which nursing intervention should be prioritized to ensure optimal patient outcomes?

B) Administer antihypertensive medication as prescribed to manage elevated blood pressure.

A) Monitor Mr. Thompson's blood glucose levels closely due to corticosteroid therapy.

B) Administer antihypertensive medication as prescribed to manage elevated blood pressure.

C) Increase oxygen supplementation to improve oxygen saturation levels further.

D) Encourage Mr. Thompson to perform deep breathing exercises to reduce intracranial pressure.

A nurse is caring for Mr. Thompson, who is receiving mannitol to reduce cerebral edema. The nurse notes that Mr. Thompson's blood pressure is 182/110 mmHg and his neurological status remains compromised. Which of the following actions should the nurse prioritize next?

A) Administer prescribed antihypertensive medication

B) Elevate the head of the bed to 30 degrees

C) Perform a reassessment of the Glasgow Coma Scale

D) Prepare to administer corticosteroids as ordered

Mr. Thompson's condition has deteriorated with a decrease in his Glasgow Coma Scale (GCS) score and evidence of worsening cerebral edema. What is the most appropriate nursing intervention to prioritize at this time?

C) Elevate the head of the bed to 30 degrees to facilitate venous drainage from the brain.

A) Increase environmental stimuli to maintain patient alertness.

B) Position the patient in a Trendelenburg position to improve cerebral perfusion.

C) Elevate the head of the bed to 30 degrees to facilitate venous drainage from the brain.

D) Administer a sedative to reduce restlessness and agitation.

A nurse is caring for Mr. Thompson, who recently showed a decrease in his Glasgow Coma Scale score and increased cerebral edema. Which nursing intervention is most critical to prioritize at this time?

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

A) Administering prescribed corticosteroids to reduce cerebral edema.

B) Initiating seizure precautions to prevent potential complications.

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

D) Providing continuous cardiac monitoring to detect arrhythmias.

A nurse is caring for Mr. Thompson, who is experiencing fluctuating blood pressure and signs of cerebral edema. Which nursing intervention is most critical to prevent further neurological deterioration?

B) Elevating the head of the bed to 30 degrees

A) Administering prescribed antihypertensive medication immediately

B) Elevating the head of the bed to 30 degrees

C) Applying continuous cardiac monitoring to detect arrhythmias

D) Preparing for potential administration of hypertonic saline

A nurse is caring for Mr. Thompson, who is experiencing labile blood pressure and cerebral edema. Which nursing intervention is most appropriate to help decrease intracranial pressure in Mr. Thompson?

A) Elevate the head of the bed to 30 degrees and maintain neutral neck alignment.

B) Administer a rapid infusion of intravenous fluids to stabilize blood pressure.

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

D) Encourage deep breathing exercises to reduce respiratory alkalosis.

A nurse is caring for Mr. Thompson, who has developed signs of a possible infection and acute kidney injury. Which intervention should the nurse prioritize to address the risk of acute kidney injury while awaiting further orders from the healthcare provider?

B) Monitor urine output closely

C) Administer diuretics as prescribed

D) Adjust the dose of antibiotics

Mr. Thompson's recent clinical changes include a fever, increased white blood cell count, decreased urine output, and electrolyte imbalances. As the nurse, what is the priority intervention to address these changes and prevent further complications?

C) Initiate broad-spectrum antibiotics to address the suspected infection.

A) Increase the dosage of mannitol to address cerebral edema.

B) Administer hypertonic saline to manage hypernatremia.

C) Initiate broad-spectrum antibiotics to address the suspected infection.

D) Restrict fluid intake to prevent fluid overload and protect renal function.

Stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke results from an obstruction of blood flow in cerebral arteries, often due to atherosclerosis or embolism, leading to decreased oxygen and nutrient supply to brain tissue, causing cell death and loss of neurological function.

• Secondary mechanism: Hemorrhagic stroke occurs when a blood vessel in the brain ruptures, leading to bleeding into or around brain tissue. This increases intracranial pressure and causes direct damage to brain cells, further impairing neurological function.

• Key complication: Both types of stroke can lead to cerebral edema, which exacerbates brain injury by increasing intracranial pressure, reducing cerebral perfusion, and potentially causing herniation, which is life-threatening.

Patient Profile

Demographics:

65-year-old male, retired high school teacher

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

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

• Key symptoms: Slurred speech, difficulty walking, facial droop on the right side, mild headache

• Vital signs: Blood pressure 180/110 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute, temperature 37.2°C, oxygen saturation 94% on room air

Section 1

Change in Patient Status:

As the patient, Mr. Thompson, is being monitored in the acute care setting, there is an observed change in his neurological status. Approximately 12 hours post-admission, Mr. Thompson begins to exhibit increased confusion and disorientation, indicating a potential worsening of his condition. His right-sided weakness persists, but there is now a notable increase in the severity of his speech difficulties, with episodes of aphasia becoming more pronounced. Repeat vital signs show a slight increase in blood pressure to 185/115 mmHg, while heart rate and respiratory rate remain stable. However, oxygen saturation drops to 91% on room air, prompting the medical team to initiate supplemental oxygen.

Given these changes, the healthcare team suspects the development of cerebral edema, a common complication following an ischemic stroke. This suspicion is supported by Mr. Thompson's escalating symptoms of confusion and deteriorating speech, which suggest increased intracranial pressure. A CT scan is urgently ordered to assess for signs of brain swelling and potential herniation. The nursing team is tasked with closely monitoring Mr. Thompson's neurological status, ensuring that his airway remains patent and maintaining his head in a midline position to optimize cerebral perfusion. The case presents an opportunity for clinical reasoning as the team evaluates the effectiveness of the current treatment regimen and considers potential adjustments, such as the administration of osmotic diuretics or corticosteroids, to manage the suspected edema and prevent further complications.

Section 2

As the CT scan results are reviewed, they reveal moderate cerebral edema with signs of midline shift, but no evidence of intracerebral hemorrhage. The medical team swiftly decides to initiate treatment with mannitol, an osmotic diuretic, to reduce the swelling and prevent further increase in intracranial pressure. The nursing team administers the prescribed dose and closely monitors Mr. Thompson's response to the intervention. Within an hour, there is a slight improvement in his oxygen saturation, now reading at 93% with supplemental oxygen, indicating a potentially positive response to the treatment.

Despite this improvement, Mr. Thompson's neurological status remains a concern. His confusion persists, and he continues to struggle with expressive aphasia, making effective communication a challenge. The nursing team conducts a thorough neurological assessment, noting that Mr. Thompson is responsive to verbal stimuli but exhibits delayed processing and difficulty following commands. His blood pressure remains elevated at 182/110 mmHg, necessitating ongoing antihypertensive management to prevent further vascular complications.

These findings prompt the healthcare team to consider additional interventions. The decision is made to start corticosteroids to further address the cerebral edema and provide neuroprotection. The team also discusses the necessity of continuous neurological monitoring, including frequent Glasgow Coma Scale assessments, to detect any subtle changes in Mr. Thompson's status. The plan is to reassess the effectiveness of the current interventions after six hours, at which point further imaging studies may be warranted to evaluate the progression of the edema and guide future treatment decisions. This stage of Mr. Thompson's care underscores the importance of dynamic clinical reasoning and adaptability in managing complex stroke complications.

Section 3

Several hours into the management plan, Mr. Thompson's condition exhibits a notable change. The nursing team observes a sudden increase in his restlessness and agitation, which prompts an immediate neurological reassessment. His Glasgow Coma Scale (GCS) score, previously stable at 13, has now decreased to 10, indicating a decline in his level of consciousness. This change raises concerns about worsening cerebral edema or evolving complications, necessitating prompt intervention. His pupils are sluggishly reactive, and he exhibits increased weakness in his right extremities, suggesting potential progression of his neurological deficits.

In response to these alarming signs, the healthcare team decides to expedite repeat imaging studies to assess any changes in the cerebral edema or signs of other complications such as ischemic progression or impending herniation. A repeat CT scan is quickly arranged, revealing increased midline shift and worsening edema, but still no evidence of hemorrhage. This reinforces the gravity of Mr. Thompson's condition and the need for aggressive management to stabilize intracranial dynamics.

As the situation unfolds, the nursing team collaborates closely with the medical staff to refine the treatment approach. The corticosteroid dosage is adjusted to enhance its therapeutic effect, and careful consideration is given to optimizing Mr. Thompson's fluid balance and blood pressure control. The interdisciplinary team remains vigilant, recognizing that Mr. Thompson's journey is at a critical juncture. This phase of care demands continuous monitoring and quick clinical reasoning to navigate the complexities of his evolving neurological status and prevent further deterioration.

Section 4

As the team intensifies their monitoring efforts, they notice that Mr. Thompson's blood pressure has become increasingly labile, with readings fluctuating between hypertensive surges of 180/100 mmHg and periods of relative hypotension at 100/60 mmHg. This instability in blood pressure suggests a potential autonomic dysregulation, likely exacerbating the cerebral edema and contributing to further neurological decline. His heart rate remains tachycardic at 110 beats per minute, while his respiratory rate has increased to 24 breaths per minute, indicating possible respiratory compensation. Arterial blood gas analysis reveals a mild respiratory alkalosis with a pH of 7.48 and a partial pressure of carbon dioxide (PaCO2) of 32 mmHg, reflecting his increased respiratory effort.

In response to these findings, the medical team evaluates the need for more aggressive management of Mr. Thompson's cerebral edema and blood pressure fluctuations. The nursing team ensures he is positioned with the head of the bed elevated to facilitate venous drainage and decrease intracranial pressure. They are mindful of maintaining a neutral neck alignment to optimize cerebral perfusion. Mannitol is considered to help reduce cerebral edema, and antihypertensive medications are reviewed to stabilize his blood pressure without compromising cerebral perfusion pressure. Continuous electrocardiographic monitoring is initiated to detect any cardiac arrhythmias that could exacerbate his condition.

Despite these interventions, Mr. Thompson's neurological status remains tenuous. He intermittently exhibits Cheyne-Stokes respiration, and his right-sided weakness progresses to a complete hemiplegia. The interdisciplinary team discusses the potential need for more invasive interventions, such as hypertonic saline therapy or even surgical options like decompressive craniectomy, to manage the severe edema effectively. As the team deliberates these critical decisions, they remain acutely aware of the precarious balance required to navigate Mr. Thompson's complex and rapidly evolving clinical picture.

Section 5

As the interdisciplinary team continues to navigate Mr. Thompson's complex condition, they are met with a new set of complications. Overnight, Mr. Thompson develops a fever of 38.9°C (102°F), and his white blood cell count has increased to 15,000/mm³, suggesting a possible infection. His sputum cultures are pending, but his respiratory secretions have become thicker and more purulent, raising concerns about the development of pneumonia, a frequent complication in patients with impaired consciousness and reduced mobility. The team initiates empirical broad-spectrum antibiotics while awaiting culture results, recognizing the need to address this potential infection promptly to prevent further deterioration.

The nursing staff notes that Mr. Thompson's urine output has decreased to less than 0.5 mL/kg/hr over the last six hours, raising concerns about acute kidney injury, possibly secondary to the mannitol therapy or the fluctuating blood pressure. Serum creatinine levels have risen from 1.0 mg/dL to 2.1 mg/dL, and electrolyte imbalances are evident, with a sodium level of 150 mEq/L, indicating hypernatremia. The team adjusts his fluid management plan, considering the delicate balance needed to manage his cerebral edema while protecting renal function.

These developments prompt the team to reassess their treatment strategies. The neurologist suggests a more aggressive approach to managing cerebral edema, considering the addition of hypertonic saline therapy to the current regimen. Simultaneously, the nephrology consultant evaluates the need for renal support, potentially involving the initiation of continuous renal replacement therapy if there is no improvement. The team remains vigilant, understanding that each intervention carries its risks and potential benefits, and they must tailor their approach to Mr. Thompson's evolving clinical needs.