A patient in the stroke unit has experienced a drop in oxygen saturation to 88% on room air, increased confusion, further deterioration in right-sided weakness, and more garbled speech. Given these developments, what is the priority nursing intervention?

B) Conduct a bedside swallowing assessment to evaluate the risk of aspiration.

A) Increase the oxygen flow rate to 4 liters per minute via nasal cannula.

B) Conduct a bedside swallowing assessment to evaluate the risk of aspiration.

C) Notify the healthcare provider about the potential need for thrombolytic therapy reevaluation.

D) Administer a bolus of intravenous fluids to address potential dehydration.

A patient has been admitted to the stroke unit with a confirmed ischemic stroke due to middle cerebral artery occlusion. The patient's oxygen saturation levels are dropping, and she exhibits increased confusion and right-sided weakness. Which of the following nursing interventions is the highest priority to address the patient's current condition?

A) Increase the supplemental oxygen to 4 liters per minute via nasal cannula

B) Consult with speech therapy for a swallowing assessment

C) Administer insulin to address elevated blood glucose levels

D) Prepare the patient for possible thrombolytic therapy upon reevaluation

A patient with early aspiration pneumonia secondary to impaired swallowing ability is being transitioned to a Venturi mask set at 35% FiO2. The nurse is also coordinating care with speech therapy for the patient's dysphagia. Which nursing intervention is most critical to prevent further respiratory complications in this patient?

B) Positioning the patient in a semi-Fowler's position during and after meals.

A) Increasing the FiO2 to 40% to improve oxygen saturation levels.

B) Positioning the patient in a semi-Fowler's position during and after meals.

C) Encouraging the patient to perform incentive spirometry exercises every hour.

D) Administering prescribed antibiotics immediately to treat aspiration pneumonia.

A patient with early aspiration pneumonia and dysphagia is receiving care. The healthcare team has initiated the use of a Venturi mask at 35% FiO2 and modified the patient's diet to pureed textures with honey-thickened liquids. As the nurse, which of the following interventions should be prioritized to further reduce the risk of aspiration pneumonia?

B) Position the patient in a semi-Fowler's position during and after meals.

A) Encourage the patient to perform deep breathing exercises every 2 hours.

B) Position the patient in a semi-Fowler's position during and after meals.

C) Administer prophylactic antibiotics to prevent bacterial pneumonia.

D) Schedule the patient for frequent oral suctioning to maintain airway clearance.

A patient with a recent history of stroke and mild cerebral edema is being treated with intravenous mannitol. Which nursing intervention is most important to perform to prevent complications from this treatment?

C) Check the patient's serum electrolyte levels regularly.

A) Monitor the patient's blood pressure every 4 hours.

B) Assess the patient's neurological status every hour.

C) Check the patient's serum electrolyte levels regularly.

D) Monitor the patient's urine output every 8 hours.

A 72-year-old female patient with a history of stroke is being managed for mild cerebral edema and aspiration pneumonia. Her current treatment includes intravenous mannitol and an adjusted antibiotic regimen, with ongoing monitoring of fluid and electrolyte balance. Given her persistent confusion and difficulty following commands, which nursing intervention is most critical to prioritize in her care plan?

D) Coordinating with speech therapy to optimize swallowing techniques and prevent aspiration.

A) Implementing seizure precautions to prevent potential complications from cerebral edema.

B) Encouraging early mobilization to promote respiratory function and prevent pneumonia progression.

C) Administering prescribed antihypertensive medications to maintain stable blood pressure.

D) Coordinating with speech therapy to optimize swallowing techniques and prevent aspiration.

A patient with worsening aspiration pneumonia is experiencing increased respiratory distress and a decline in neurological status. Which of the following nursing interventions is the priority to address her immediate clinical needs?

C) Elevate the head of the bed to 30-45 degrees and monitor oxygen saturation closely.

A) Administer the broader-spectrum antibiotic as prescribed.

C) Elevate the head of the bed to 30-45 degrees and monitor oxygen saturation closely.

D) Initiate chest physiotherapy and encourage the use of an incentive spirometer.

A patient with worsening aspiration pneumonia presents with increased consolidation in the right lung, low-grade fever, elevated white blood cell count, and decreased Glasgow Coma Scale score. What should be the priority nursing intervention to address the patient's current respiratory status?

D) Increase oxygen delivery to maintain adequate oxygen saturation levels

A) Administer the prescribed broader-spectrum antibiotic immediately

B) Increase the frequency of neurological assessments to monitor changes

C) Implement chest physiotherapy and encourage the use of an incentive spirometer

D) Increase oxygen delivery to maintain adequate oxygen saturation levels

A patient with acute kidney injury secondary to systemic infection and possible nephrotoxic antibiotics presents with decreased urine output and increased serum creatinine. The multidisciplinary team is considering initiating diuretic therapy. Which nursing intervention is most critical to perform prior to administering the diuretic?

B) Check the patient's serum potassium level.

A) Monitor the patient's blood pressure and assess for hypotension.

B) Check the patient's serum potassium level.

C) Assess the patient's lung sounds for crackles.

D) Evaluate the patient's pain level using a standardized pain scale.

A patient with acute kidney injury is being managed with cautious diuretic therapy due to fluid overload. Which of the following nursing interventions is most appropriate to monitor the effectiveness of the treatment?

B) Measure blood pressure hourly.

C) Record intake and output every shift.

D) Assess for jugular venous distention daily.

Stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic strokes occur due to an obstruction in a cerebral blood vessel, often from atherosclerosis or embolism, leading to reduced blood flow and oxygen deprivation in brain tissues.

• Secondary mechanism: Hemorrhagic strokes result from a ruptured blood vessel, often due to hypertension or aneurysms, causing bleeding into or around the brain and increased intracranial pressure.

• Key complication: Both types can lead to neuronal death and brain tissue damage, resulting in deficits like paralysis, speech difficulties, and cognitive impairments, which require prompt intervention to minimize long-term effects.

Patient Profile

Demographics:

66-year-old female, retired school teacher

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

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

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

• Vital signs: Blood pressure 185/100 mmHg, heart rate 104 bpm, respiratory rate 22 breaths/min, temperature 37.2°C, oxygen saturation 92% on room air

Section 1

New Complications:

Shortly after admission to the stroke unit, the patient's condition began to evolve, revealing new complications. Despite initial stabilization efforts, her oxygen saturation levels continued to drop, falling to 88% on room air, prompting the need for supplemental oxygen via nasal cannula at 2 liters per minute. A repeat neurological assessment showed increased confusion and further deterioration in her right-sided weakness, with the strength in her right arm now graded at 1/5. Additionally, her speech became more garbled, raising concerns about further cerebral events or evolving damage.

Laboratory results indicated a worsening metabolic profile, with a blood glucose level spiking to 290 mg/dL, despite her prescribed Metformin regimen. Her lipid panel returned with an elevated LDL cholesterol of 160 mg/dL, and triglycerides at 240 mg/dL, suggesting poor control of her hyperlipidemia, which could have contributed to her current state. A head CT scan without contrast revealed a hyperdense MCA sign, consistent with a middle cerebral artery occlusion, confirming the ischemic nature of her stroke, and raising the urgency for reevaluation of thrombolytic therapy eligibility.

These developments necessitate careful clinical reasoning to manage the interplay between her existing conditions and the new complications. The healthcare team must consider the need for more aggressive control of her hypertension and diabetes, alongside acute stroke management, to prevent further ischemic insult. Additionally, the team must monitor for potential complications such as aspiration due to her impaired swallowing, necessitating a speech therapy consultation for a swallowing assessment and possibly a modified diet to reduce the risk of aspiration pneumonia. As the patient's journey continues, these interconnected issues must be addressed to improve her prognosis and quality of life.

Section 2

As the clinical team continued to address the evolving complications, the patient's respiratory status became a focal point of concern. Her oxygen saturation levels remained suboptimal despite the administration of supplemental oxygen, prompting a more detailed assessment. A chest X-ray was ordered and revealed bilateral infiltrates suggestive of early aspiration pneumonia, likely a consequence of her impaired swallowing ability. This finding required immediate intervention to prevent further respiratory compromise. The healthcare team initiated a plan to transition her to a higher level of respiratory support with a Venturi mask set at 35% FiO2 to maintain adequate oxygenation.

Parallel to managing her respiratory issues, the team consulted with speech therapy to assess and address her dysphagia. The assessment confirmed a significant risk for aspiration, and a decision was made to modify her diet to pureed textures with honey-thickened liquids to minimize the risk. The nursing staff received instructions for meticulous oral care to reduce the risk of bacterial colonization, which could exacerbate her pneumonia.

Concurrently, the patient's neurological status was closely monitored. Her increasing confusion and speech difficulties raised concerns about potential cerebral edema or new ischemic events. A follow-up CT scan with contrast was scheduled to evaluate these possibilities further. The team also adjusted her antihypertensive regimen, incorporating a calcium channel blocker to achieve better blood pressure control, which is vital in limiting further cerebral damage. These multifaceted interventions underscored the complexity of managing a patient with an evolving stroke, highlighting the need for continuous clinical reasoning and integrated care efforts to improve her condition and prevent additional complications.

Section 3

As the clinical team continued to monitor the patient's condition, new diagnostic results provided critical insights into her evolving status. The follow-up CT scan with contrast revealed no new ischemic events, but it did show mild cerebral edema, which required careful management. Her blood pressure, now more stable at 140/85 mmHg following the adjustment of her antihypertensive regimen, remained a priority to prevent exacerbation of the cerebral swelling. Laboratory tests indicated an elevated white blood cell count at 14,000/µL, supporting the diagnosis of aspiration pneumonia, while her C-reactive protein levels were also elevated, confirming systemic inflammation.

In response to these findings, the healthcare team initiated a more aggressive approach to managing her cerebral edema. Intravenous mannitol was administered to reduce intracranial pressure, while close monitoring of her fluid and electrolyte balance was implemented to prevent complications such as hypovolemia and electrolyte imbalances. Additionally, her antibiotic regimen was adjusted based on culture results to ensure targeted treatment of the pneumonia, and her oxygen saturation levels showed slight improvement, now consistently above 92% with the Venturi mask in place.

Despite these interventions, the patient's neurological status remained tenuous, with persistent confusion and difficulty following commands. The speech therapy team worked diligently to implement swallowing strategies and exercises to improve her dysphagia, though progress was slow. This complex interplay of factors highlighted the importance of comprehensive, coordinated care, as the team prepared to reassess her overall treatment plan. They focused on optimizing neurological recovery while preventing further respiratory compromise, illustrating the delicate balance of managing multiple complications in a stroke patient. The team remained vigilant, ready to adapt their strategy as the patient's journey continued to unfold.

Section 4

As the clinical team continued to monitor the patient's progress, a new complication emerged that required immediate attention. The patient developed a low-grade fever of 100.4°F (38°C), and her respiratory rate increased to 24 breaths per minute. Auscultation of the lungs revealed crackles in the right lower lobe, suggesting worsening of the aspiration pneumonia despite the adjusted antibiotic regimen. Her oxygen saturation dropped to 89% on the Venturi mask, necessitating an increase in oxygen flow to maintain adequate levels. In response, the team decided to perform a repeat chest X-ray, which showed increased consolidation in the right lung, indicating the need for further intervention.

The patient's laboratory results also indicated a shift in her condition. Her white blood cell count had risen to 16,000/µL, and procalcitonin levels were elevated, reinforcing the suspicion of a bacterial infection. Consequently, the infectious disease specialist recommended a broader-spectrum antibiotic to cover potential resistant organisms while awaiting further culture and sensitivity results. Meanwhile, the patient's neurological status showed subtle changes; her Glasgow Coma Scale score decreased from 12 to 10, highlighting a decline in her level of consciousness and prompting a more detailed neurological assessment.

Faced with these developments, the healthcare team revisited the patient's management plan. They decided to increase the frequency of neurological assessments to every two hours and continued to optimize her antibiotic therapy. The respiratory therapy team introduced chest physiotherapy and encouraged the use of an incentive spirometer to improve pulmonary function. This evolving scenario underscored the need for dynamic clinical reasoning, as the team worked to address the patient's complex and intertwined medical issues, aiming to stabilize her condition and support her recovery trajectory.

Section 5

New Complications

As the healthcare team continued to vigilantly monitor the patient's condition, a new complication emerged that required further attention. Despite the intensified interventions for her respiratory status, the patient began to exhibit signs of acute kidney injury. Her urine output decreased significantly, dropping to less than 400 mL over the last 24 hours. Laboratory tests revealed an increase in serum creatinine from 1.0 mg/dL to 2.2 mg/dL, and blood urea nitrogen levels rose to 35 mg/dL. These findings suggested a compromise in renal function, likely secondary to the combination of systemic infection and possible nephrotoxic effects of the antibiotics being administered.

This development prompted the team to consult with a nephrologist to evaluate the patient's renal status and consider potential modifications to her treatment regimen. The patient's fluid status was reassessed, revealing mild peripheral edema and jugular venous distention, indicating potential fluid overload. The nephrologist recommended initiating a cautious diuretic therapy to address the fluid balance while monitoring electrolytes closely. Additionally, the team considered adjusting the antibiotic regimen to reduce nephrotoxic risk, pending further culture results to guide specific therapy.

The emergence of renal complications added another layer of complexity to the patient's care, necessitating careful coordination among the multidisciplinary team. This situation required the team to revisit and integrate clinical reasoning across specialties to ensure a holistic approach. By addressing her renal function while continuing to manage her respiratory and neurological status, the team aimed to stabilize the patient and prevent further deterioration, underscoring the interconnected nature of her medical issues.