A patient with an ischemic stroke presents with signs of cerebral edema. The healthcare team initiates treatment with IV mannitol. Which nursing intervention is most critical to prevent complications associated with this treatment?

A) Monitor the patient for signs of dehydration and electrolyte imbalances.

B) Encourage the patient to ambulate frequently to prevent deep vein thrombosis.

C) Advise the patient to limit fluid intake to reduce the risk of fluid overload.

D) Place the patient in a supine position to promote cerebral perfusion.

A patient who recently experienced an ischemic stroke presents with early signs of cerebral edema and elevated blood pressure. What is the priority nursing intervention to prevent further complications?

D) Administer prescribed IV mannitol promptly.

A) Monitor blood glucose levels every 4 hours.

B) Elevate the head of the bed to 30 degrees.

C) Encourage the patient to drink plenty of fluids.

D) Administer prescribed IV mannitol promptly.

A patient with suspected worsening cerebral edema shows signs of Cushing's triad and fluctuating levels of consciousness. What is the nurse's priority intervention to decrease the risk of further neurological deterioration?

A) Administer IV mannitol as prescribed

B) Increase the head of the bed to 30 degrees

C) Initiate a fluid restriction regimen

D) Provide supplemental oxygen to maintain SpO2 above 95%

A patient with a history of stroke is exhibiting signs of increased intracranial pressure, including changes in consciousness and vital signs indicative of Cushing's triad. What is the most appropriate initial nursing intervention to help manage the patient's increased intracranial pressure?

A) Elevate the head of the bed to 30 degrees to promote venous drainage.

B) Administer a rapid IV bolus of normal saline to maintain cerebral perfusion pressure.

C) Position the patient in a Trendelenburg position to enhance cerebral blood flow.

D) Apply ice packs to the patient's head to reduce cerebral metabolism.

A patient with increased intracranial pressure (ICP) is receiving mannitol therapy. The nurse notes a decrease in serum sodium levels. Which action should the nurse take first?

B) Notify the healthcare provider of potential hyponatremia.

A) Increase the frequency of neurological assessments.

B) Notify the healthcare provider of potential hyponatremia.

C) Restrict the patient's fluid intake to manage fluid balance.

D) Administer a hypertonic saline solution to correct sodium levels.

A patient with increased intracranial pressure is receiving mannitol therapy. The nurse notes a decrease in serum sodium levels. What should be the nurse's priority action?

B) Notify the healthcare provider about potential hyponatremia.

A) Increase the frequency of neurological assessments.

B) Notify the healthcare provider about potential hyponatremia.

C) Administer a hypotonic saline solution to correct sodium levels.

D) Continue monitoring serum osmolality without immediate intervention.

A patient with a recent stroke and ongoing treatment with mannitol exhibits a sudden decrease in level of consciousness and worsening hyponatremia. Given these clinical findings, which nursing intervention is most critical to implement immediately?

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

A) Administer hypertonic saline to correct hyponatremia

B) Prepare for immediate intubation and mechanical ventilation

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

D) Initiate a fluid restriction to manage hyponatremia

A patient with a recent stroke is experiencing a sudden decrease in consciousness and is now only responsive to painful stimuli. His Glasgow Coma Scale score has dropped significantly, and he shows signs of worsening hyponatremia. What is the most appropriate nursing intervention to prioritize in this situation?

B) Prepare the patient for an immediate CT scan to assess intracranial pressure.

A) Administer a hypertonic saline solution to address hyponatremia.

B) Prepare the patient for an immediate CT scan to assess intracranial pressure.

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

D) Initiate seizure precautions due to the risk of hyponatremia-related seizures.

A patient with an acute stroke is exhibiting signs of increased intracranial pressure and respiratory compromise. Based on the clinical scenario, which nursing intervention should be prioritized to address the patient's current respiratory status?

B) Administer supplemental oxygen to improve oxygen saturation

A) Initiate intravenous fluid therapy to maintain blood pressure

B) Administer supplemental oxygen to improve oxygen saturation

C) Prepare the patient for immediate intubation to secure the airway

D) Provide chest physiotherapy to clear pulmonary secretions

A patient with escalating intracranial pressure following a stroke is scheduled for an urgent decompressive craniectomy. The patient now shows signs of increased respiratory effort, wheezing, and decreased oxygen saturation. What is the nurse's priority intervention to address the patient's current respiratory status?

D) Initiate high-flow oxygen therapy to improve oxygen saturation levels.

A) Increase the patient's head of bed to 30 degrees to improve ventilation.

B) Prepare the patient for immediate intubation to secure the airway.

C) Administer prophylactic antibiotics to prevent aspiration pneumonia.

D) Initiate high-flow oxygen therapy to improve oxygen saturation levels.

CVA - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced cerebral blood flow due to arterial occlusion leads to ischemic stroke, depriving brain tissue of oxygen and nutrients, causing neuronal injury and death.

• Secondary mechanism: Hemorrhagic stroke occurs when a blood vessel ruptures, resulting in bleeding within or around the brain, increasing intracranial pressure and causing further neural damage.

• Key complication: Both types of stroke can lead to brain edema, which exacerbates injury by compressing brain structures and potentially leading to herniation if untreated.

Patient Profile

Demographics:

65-year-old male, retired construction worker

History:

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

• Current medications: Lisinopril 20 mg daily, Metformin 500 mg twice daily, Atorvastatin 40 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of right-sided weakness and slurred speech

• Key symptoms: Right arm and leg weakness, difficulty speaking, facial droop on the right side, headache, dizziness

• Vital signs: Blood pressure 160/95 mmHg, heart rate 92 bpm, respiratory rate 22 breaths per minute, temperature 99.1°F, oxygen saturation 94% on room air

Section 1

As the nursing team conducts an initial assessment, the patient's condition reveals further details that underscore the complexity of his presentation. An NIH Stroke Scale is administered, and the patient scores a 14, indicating a moderate stroke. Neurological examination confirms the presence of expressive aphasia, right-sided hemiparesis, and partial neglect. Pupils are equal and reactive to light, but the patient reports a worsening headache and new onset of nausea. Blood glucose is checked, showing a level of 180 mg/dL, indicating mild hyperglycemia, which is a common stress response but can complicate recovery if not monitored.

The medical team orders an immediate CT scan of the head to distinguish between an ischemic and hemorrhagic stroke. The CT reveals no evidence of hemorrhage, confirming an ischemic event. However, the scan does indicate the early signs of cerebral edema in the left hemisphere, highlighting the risk of increased intracranial pressure. Lab results show elevated cholesterol levels and an A1C of 7.5%, suggesting suboptimal diabetes management, contributing to vascular complications. The patient's blood pressure remains elevated at 162/96 mmHg despite medication, raising concerns about uncontrolled hypertension exacerbating cerebral edema.

In response to these findings, the patient is started on IV mannitol to address the cerebral edema and prevent further neuronal damage. Blood pressure control is prioritized with adjustments to his antihypertensive regimen, and insulin therapy is considered to better manage his blood glucose levels. The healthcare team monitors for changes in neurological status, emphasizing the need for vigilant observation for signs of increasing intracranial pressure, such as worsening consciousness or new focal neurological deficits. The unfolding scenario underscores the interconnectedness of his chronic conditions with the acute stroke event, necessitating a comprehensive and multi-disciplinary approach to optimize the patient's recovery trajectory.

Section 2

As the healthcare team continues to monitor the patient, they observe a change in his status that necessitates immediate attention. Over the course of several hours, the patient's level of consciousness begins to fluctuate. Initially alert and oriented to person only, he now exhibits increasing confusion and struggles to follow simple commands. This change raises the suspicion of worsening cerebral edema, prompting the team to reassess his neurological status and vital signs with increased frequency.

The patient's vital signs reveal a concerning trend; his blood pressure remains elevated at 168/100 mmHg despite adjustments to his antihypertensive regimen. His heart rate has increased to 110 beats per minute, and respiratory rate has risen to 22 breaths per minute. A repeat NIH Stroke Scale assessment shows a slight increase to 16, indicating a progression in stroke severity. Additionally, the patient begins to exhibit signs of Cushing's triad, with bradycardia and irregular respirations, further suggesting increased intracranial pressure.

In response to these developments, the clinical team decides to intensify interventions aimed at reducing intracranial pressure and stabilizing the patient's condition. The dosage of IV mannitol is carefully titrated, and an osmotic diuretic is considered to further manage cerebral edema. The team also implements a more aggressive insulin regimen to control blood glucose levels, recognizing the potential for hyperglycemia to exacerbate neurological injury. Continuous cardiac monitoring is initiated to detect arrhythmias, and preparations are made for potential escalation of care, including consultation with a neurosurgeon. This evolving scenario highlights the critical importance of dynamic clinical reasoning and interdisciplinary collaboration in managing the complexities of stroke care.

Section 3

As the clinical team implements the intensified interventions, they closely monitor the patient's response to treatment. Over the next few hours, there is a modest improvement in his neurological status. The patient's level of consciousness stabilizes slightly, and he becomes intermittently oriented to person and place. His blood pressure decreases to 150/90 mmHg, suggesting a positive response to the adjusted antihypertensive regimen. However, the patient's heart rate remains elevated at 108 beats per minute, and his respiratory rate continues at 20 breaths per minute. Despite these efforts, the patient still exhibits irregular respirations, prompting ongoing concern about persistent increased intracranial pressure.

Laboratory results reveal elevated serum osmolality levels, indicating the effectiveness of mannitol therapy in drawing fluid from the cerebral tissues. However, there is a noted decrease in serum sodium levels, raising the possibility of developing hyponatremia as a side effect of the osmotic diuretics. The patient's blood glucose levels have been successfully controlled, stabilizing within the target range of 140-180 mg/dL, reducing the risk of further neurological damage from hyperglycemia. Despite this progress, a follow-up CT scan of the brain shows a slight increase in midline shift, indicating ongoing cerebral edema.

The team recognizes the need for vigilant monitoring and potential further adjustments to the treatment plan. A multidisciplinary discussion is held to consider the feasibility of surgical intervention, such as decompressive craniectomy, to alleviate intracranial pressure if conservative measures fail to produce significant improvement. Nursing staff continue to perform frequent neurological assessments and vital signs checks, while also educating the patient's family on the current situation and the critical nature of the next steps. This comprehensive approach underscores the necessity of continuous clinical reasoning and adaptation in the management of complex stroke cases.

Section 4

As the clinical team continues to monitor the patient, a notable change in status occurs. Approximately 12 hours post-admission, the patient exhibits a sudden decrease in his level of consciousness. He becomes difficult to arouse and is only responsive to painful stimuli. This development prompts an immediate reassessment of his neurological status. Upon examination, the patient's Glasgow Coma Scale score drops from 12 to 8, indicating a significant decline. His pupils are now unequal, with a sluggish response to light on the right side, suggesting worsening cerebral edema or possible herniation.

Concurrently, new laboratory results show a further decrease in serum sodium levels, now measuring 127 mEq/L, confirming worsening hyponatremia. This electrolyte imbalance raises concerns about the potential for cerebral salt wasting syndrome or inappropriate antidiuretic hormone secretion as a complication of the stroke and mannitol therapy. Additionally, repeat serum osmolality is slightly elevated at 310 mOsm/kg, reflecting ongoing osmotic activity but also posing a risk for renal impairment. The patient's blood pressure remains stable at 148/92 mmHg, but his heart rate has increased to 115 beats per minute, indicating possible compensatory mechanisms or stress response.

In light of these developments, the healthcare team engages in a critical decision-making process regarding the next steps in management. Given the patient's deteriorating neurological status and the ineffectiveness of current conservative measures, the discussion shifts toward the urgency of surgical intervention. The neurosurgical team is consulted to evaluate the potential benefits of a decompressive craniectomy to relieve intracranial pressure. Meanwhile, nursing staff intensify their monitoring efforts, ensuring that any further changes in the patient's condition are promptly communicated and addressed. This situation highlights the importance of dynamic clinical reasoning and the need for adaptive interventions in managing complex cerebrovascular accidents.

Section 5

As the clinical team deliberates the next steps, the neurosurgical consultation confirms the need for an urgent decompressive craniectomy to address the escalating intracranial pressure. The procedure is anticipated to mitigate the risk of herniation and potentially improve the patient’s neurological outcomes. While preparations for surgery are underway, the nursing team maintains vigilant monitoring. The patient’s vital signs reveal further instability: his heart rate continues to climb, now at 122 beats per minute, and his respiratory rate has increased to 24 breaths per minute, suggesting an evolving stress response or impending respiratory compromise. His blood pressure, however, remains relatively stable at 150/90 mmHg.

In the midst of these developments, a new complication emerges. The patient begins to exhibit signs of increased respiratory effort, with audible wheezing and decreased oxygen saturation, now at 88% on room air. This prompts a rapid assessment for potential pulmonary embolism or aspiration pneumonia, both of which are significant risks in the context of an acute stroke. A chest X-ray is ordered and reveals bilateral infiltrates, raising the suspicion of aspiration. The decision is made to initiate supplemental oxygen therapy and consider prophylactic antibiotics while awaiting further diagnostic confirmation.

These changes in the patient’s status necessitate a reevaluation of the overall management strategy. The team discusses the potential need for intubation to secure the airway and prevent further respiratory compromise, especially in light of the planned surgical intervention. This scenario underscores the dynamic interplay between neurological and systemic complications in cerebrovascular accidents, highlighting the necessity for ongoing reassessment and intervention to optimize patient outcomes. As the surgical team prepares, the interdisciplinary collaboration remains crucial in navigating the complexities of the patient's condition and ensuring a coordinated response to the evolving clinical picture.