A patient with a confirmed ischemic stroke and atrial fibrillation on Warfarin therapy presents with a respiratory rate of 26 breaths per minute, heart rate of 140 bpm, and oxygen saturation of 88% on room air. Given these clinical manifestations, which nursing intervention should take priority?

C) Apply supplemental oxygen to improve oxygen saturation

A) Administer a beta-blocker to control the heart rate

B) Initiate thrombolytic therapy to restore cerebral perfusion

C) Apply supplemental oxygen to improve oxygen saturation

D) Prepare for intubation due to increased respiratory effort

A patient with a confirmed ischemic stroke and a history of atrial fibrillation is on Warfarin therapy and presents with an INR of 2.5. The patient has developed right-sided weakness, facial droop, and slurred speech. Considering her current condition and the recent increase in respiratory rate and heart rate, what is the priority nursing intervention?

B) Administer supplemental oxygen to maintain adequate oxygen saturation.

A) Initiate thrombolytic therapy to restore cerebral perfusion.

B) Administer supplemental oxygen to maintain adequate oxygen saturation.

C) Prepare for potential intubation due to increased respiratory effort.

D) Conduct a swallowing assessment to prevent aspiration pneumonia.

A patient with aspiration pneumonia and oropharyngeal dysphagia is being monitored for increased intracranial pressure. With a decrease in the Glasgow Coma Scale score from 14 to 10, which of the following nursing interventions is most appropriate to perform first to address her current clinical status?

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

B) Administer prescribed broad-spectrum antibiotics to treat the aspiration pneumonia.

C) Prepare for the insertion of a nasogastric tube to provide nutrition and medications.

D) Increase the flow rate of supplemental oxygen to maintain saturation above 92%.

A patient with aspiration pneumonia is being monitored for increased intracranial pressure. Her Glasgow Coma Scale score has decreased from 14 to 10, and she is currently on broad-spectrum antibiotics and supplemental oxygen. Which nursing intervention is the priority at this time?

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

B) Increase the rate of supplemental oxygen to improve oxygen saturation.

C) Schedule a follow-up swallowing assessment to evaluate dysphagia.

D) Administer prescribed mannitol to manage cerebral edema.

A patient with cerebral edema and a midline shift is receiving mannitol intravenously. Her condition evolves with signs of sepsis, and her neurological status shows asymmetry in pupil size. What is the priority nursing action at this time?

C) Initiate continuous neurological monitoring and prepare for potential surgical intervention.

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

B) Administer a vasopressor to quickly stabilize blood pressure.

C) Initiate continuous neurological monitoring and prepare for potential surgical intervention.

D) Call the physician to request an increase in antibiotic dosage.

A patient with cerebral edema is receiving intravenous mannitol to reduce intracranial pressure. The nurse notes that the patient's blood pressure is now 90/60 mmHg, heart rate is 120 beats per minute, and there is asymmetry in pupil size. What is the nurse's priority action in this situation?

B) Reassess the patient's neurological status and notify the healthcare provider immediately.

A) Administer a vasopressor to stabilize blood pressure.

B) Reassess the patient's neurological status and notify the healthcare provider immediately.

C) Increase the rate of mannitol infusion to further reduce intracranial pressure.

D) Discontinue mannitol and initiate fluid restriction to manage potential electrolyte imbalances.

A patient with respiratory acidosis secondary to hypoventilation is being managed with non-invasive positive pressure ventilation (NIPPV). The patient's blood cultures have returned positive for Gram-negative bacilli, and the antimicrobial regimen has been adjusted. Which nursing intervention is most critical to prioritize to ensure effective patient outcomes?

A) Monitor the patient's vital signs and oxygen saturation frequently.

B) Administer prescribed bronchodilators to optimize airway patency.

C) Perform regular chest physiotherapy to promote mucus clearance.

D) Educate the patient about the importance of completing the antibiotic course.

A patient has been diagnosed with respiratory acidosis secondary to hypoventilation and is receiving non-invasive positive pressure ventilation (NIPPV). Her recent CBC shows a WBC count of 18,500/mm³, and blood cultures are positive for Gram-negative bacilli. Which of the following nursing interventions is most critical to prioritize in this situation?

A) Administering prescribed antibiotics promptly

B) Increasing the frequency of neurological assessments

C) Monitoring for signs of skin breakdown due to NIPPV

D) Encouraging deep breathing exercises to improve gas exchange

A patient with a neurological condition is exhibiting a decrease in respiratory drive and level of consciousness. The healthcare team is considering escalating to invasive mechanical ventilation. What is the most appropriate initial nursing intervention to address this patient's current respiratory status?

B) Prepare for immediate intubation based on decreased respiratory rate and oxygen saturation.

A) Increase the flow rate of supplemental oxygen to improve saturation levels.

B) Prepare for immediate intubation based on decreased respiratory rate and oxygen saturation.

C) Reposition the patient to a semi-Fowler's position to facilitate breathing.

D) Administer a sedative to help manage anxiety and improve respiratory effort.

A nurse is caring for a patient with a declining respiratory and neurological status. The patient is currently on NIPPV, has a respiratory rate of 8 breaths per minute, an oxygen saturation of 85%, and a decreased GCS score from 10 to 8. What is the most appropriate nursing action to take next?

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

A) Increase the oxygen flow rate on the NIPPV to improve saturation.

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

C) Administer a dose of naloxone to reverse potential respiratory depression.

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

80 year old, female, PMH of a-fib, hypertension, arthritis, and dementia, and is currently having a CVA - Nursing Case Study

Pathophysiology

• Primary mechanism: Cerebral ischemia occurs when a blood clot from atrial fibrillation embolizes to the brain, causing an obstruction in a cerebral artery. This results in decreased blood flow and oxygen delivery to brain tissues, leading to neuronal injury and potential infarction.

• Secondary mechanism: Hypertension contributes to arterial wall damage and atherosclerosis, which can further narrow blood vessels and exacerbate the risk of ischemic stroke. Chronic high blood pressure can also lead to small vessel disease, reducing cerebral perfusion.

• Key complication: The presence of dementia complicates recovery, as pre-existing cognitive decline can worsen due to the stroke, making rehabilitation more challenging and potentially leading to further deterioration of cognitive and functional status.

Patient Profile

Demographics:

80-year-old female, retired teacher

History:

• Key past medical history: Atrial fibrillation, hypertension, arthritis, dementia

• Current medications: Warfarin, Lisinopril, Acetaminophen, Donepezil

• Allergies: Penicillin

Current Presentation:

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

• Key symptoms: Slurred speech, confusion, inability to move right arm and leg, facial droop on the right side

• Vital signs: Blood pressure 190/110 mmHg, heart rate 130 bpm (irregular), respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 88% on room air

Section 1

As the nursing team proceeds with the initial assessment, it becomes apparent that the patient's condition necessitates immediate intervention. A focused neurological examination confirms the right-sided weakness and facial droop, slurred speech, and confusion, consistent with a left hemispheric cerebrovascular accident. Given the patient's atrial fibrillation and current anticoagulation therapy with Warfarin, the team swiftly evaluates her INR levels, which return at 2.5, indicating therapeutic anticoagulation but not necessarily protective against embolic events.

The patient's oxygen saturation remains concerning at 88% on room air, prompting the initiation of supplemental oxygen therapy. While her blood pressure is notably elevated at 190/110 mmHg, the decision is made to manage it cautiously to maintain adequate cerebral perfusion without exacerbating the risk of further ischemic injury. An immediate CT scan of the brain is ordered to rule out hemorrhagic stroke, given the high risks associated with her anticoagulation status. The scan confirms an ischemic stroke, and the team considers the possibility of thrombolytic therapy, balancing the risks of bleeding against the potential benefits of restoring cerebral perfusion.

In the ensuing hours, the patient's condition shows signs of progression. Her respiratory rate increases to 26 breaths per minute, and she becomes increasingly tachycardic, with a heart rate now at 140 bpm. These changes suggest potential complications such as increased intracranial pressure or the development of aspiration pneumonia due to impaired swallowing. The nursing team, in collaboration with the medical team, initiates a swallowing assessment and plans for a chest X-ray to evaluate the possibility of aspiration. This evolving situation highlights the intricate interplay of her medical conditions and the critical importance of timely, evidence-based interventions to mitigate further complications.

Section 2

As the nursing team continues to monitor the patient, the chest X-ray results return, revealing infiltrates in the right lower lobe, consistent with aspiration pneumonia. This finding correlates with her increased respiratory rate and declining oxygen saturation, now at 85% despite supplemental oxygen. A swallowing assessment confirms oropharyngeal dysphagia, necessitating the initiation of NPO status and the placement of a nasogastric tube for nutrition and medication administration. The medical team starts the patient on broad-spectrum antibiotics to combat the pneumonia and adjusts her oxygen therapy to maintain saturations above 92%.

Meanwhile, the patient's neurological status remains a primary concern. She exhibits increasing lethargy and a decrease in her Glasgow Coma Scale score from 14 to 10 over several hours, suggesting a possible increase in intracranial pressure secondary to cerebral edema. An urgent repeat CT scan is ordered to assess for any changes, and the team prepares for potential interventions to manage increased intracranial pressure, such as administering mannitol or hypertonic saline if indicated by the imaging results.

Throughout this critical period, the interdisciplinary team, including nursing, neurology, and pulmonary specialists, engages in frequent assessments and collaborative decision-making. The patient's complex presentation highlights the necessity for vigilant monitoring and dynamic adaptation of the care plan. Each intervention is carefully weighed against her underlying conditions, emphasizing the importance of prioritizing her immediate needs while minimizing further risks. As the team awaits the repeat CT scan results, they remain poised to adjust the treatment strategy based on the evolving clinical picture.

Section 3

As the medical team continues to manage the patient, the repeat CT scan results arrive, indicating significant cerebral edema with a midline shift. This finding confirms the suspicion of increased intracranial pressure, necessitating immediate intervention. The decision is made to administer mannitol intravenously to reduce the cerebral swelling, closely monitoring the patient’s fluid status and electrolyte balance to prevent complications such as renal dysfunction or electrolyte imbalances.

Simultaneously, the patient's condition evolves as her respiratory status becomes increasingly tenuous. Despite the introduction of broad-spectrum antibiotics, her fever spikes to 101.8°F, and her white blood cell count rises to 15,000/mm³, indicating a robust inflammatory response. Her heart rate accelerates to 120 beats per minute, and her blood pressure drops to 90/60 mmHg, suggesting the onset of sepsis secondary to her aspiration pneumonia. The team immediately escalates the care plan by increasing her fluid resuscitation to stabilize her hemodynamics and considers the addition of a vasopressor if hypotension persists despite initial fluid boluses.

As the patient battles these complications, her neurological status is carefully reassessed. The nursing team observes a subtle but concerning asymmetry in her pupil size, raising alarms for potential further neurological compromise. This finding prompts a rapid re-evaluation of her treatment plan, emphasizing the need for continuous neurological checks and readiness to initiate more aggressive measures if her condition deteriorates further. The interdisciplinary team remains on high alert, ready to pivot the care strategy based on real-time developments and prioritizing interventions that balance her complex medical needs.

Section 4

As the medical team continues to navigate the complexities of the patient's condition, a new set of diagnostic results arrives, shedding light on her evolving status. The most recent arterial blood gas analysis reveals a partial pressure of carbon dioxide (PaCO2) of 52 mmHg and a pH of 7.32, indicative of respiratory acidosis. This finding correlates with the patient's deteriorating respiratory status and suggests hypoventilation, likely secondary to neurological compromise. In response, the healthcare team decides to initiate non-invasive positive pressure ventilation (NIPPV) to support her respiratory function and prevent further decline.

Concurrently, a repeat complete blood count (CBC) shows a significant increase in her WBC count to 18,500/mm³, reinforcing the suspicion of an ongoing infectious process. Despite initial broad-spectrum antibiotic therapy, blood cultures return positive for Gram-negative bacilli, necessitating a revision of her antimicrobial regimen to target the specific pathogen more effectively. This adjustment is critical in addressing the underlying sepsis, alongside continued fluid resuscitation efforts to manage her hemodynamic instability.

The interdisciplinary team remains vigilant, recognizing that the patient's multifaceted condition requires a dynamic and adaptive approach. They closely monitor her response to the NIPPV and revised antibiotic therapy, assessing for signs of improved gas exchange and hemodynamic stability. The nursing staff diligently performs frequent neurological assessments, watching for any further changes in pupil size or level of consciousness that may indicate worsening cerebral edema or increased intracranial pressure. This proactive and coordinated strategy is crucial in navigating the patient's complex clinical landscape, aiming to stabilize her while being prepared for any new complications that may arise.

Section 5

As the healthcare team continues to monitor the patient's response to the interventions, a noticeable change in her clinical status occurs. The patient's respiratory rate decreases to 8 breaths per minute despite the initiation of NIPPV, and her oxygen saturation drops to 85%. These findings suggest a progressive decline in her respiratory drive, potentially exacerbated by her neurological condition. The team promptly reassesses her ventilatory support settings and considers escalating to invasive mechanical ventilation to ensure adequate oxygenation and carbon dioxide clearance.

Simultaneously, the nursing staff observes a decline in her neurological status. The patient becomes more lethargic, and her Glasgow Coma Scale (GCS) score drops from 10 to 8, indicating a significant decrease in her level of consciousness. Pupillary examination reveals sluggish reactivity, suggesting increasing intracranial pressure. This change necessitates immediate neuroimaging to assess for any progression of the cerebral edema or other intracranial abnormalities that could be contributing to her deteriorating condition. The team prepares for potential interventions, such as osmotherapy or surgical options, to manage the increased intracranial pressure.

The interdisciplinary team remains alert to these new complications, recognizing the delicate balance required in managing the patient's multiple health challenges. They continue to adjust their approach based on the latest clinical data, striving to stabilize her while preventing further deterioration. With the patient's condition evolving rapidly, clear communication and timely decision-making become paramount in navigating this critical phase of her care journey.