A patient with a confirmed ischemic stroke in the left middle cerebral artery territory is showing signs of increased confusion, restlessness, and headache within 24 hours of admission. What is the most appropriate nursing intervention at this time?

B) Administer a prescribed osmotic diuretic to reduce potential cerebral edema.

A) Increase the rate of intravenous fluids to maintain cerebral perfusion.

B) Administer a prescribed osmotic diuretic to reduce potential cerebral edema.

C) Reposition the patient from supine to Trendelenburg to improve cerebral blood flow.

D) Initiate contact precautions to prevent the spread of potential infection.

A patient with acute stroke exhibits increased intracranial pressure, anisocoria, and elevated blood pressure despite antihypertensive therapy. The healthcare team initiates osmotherapy with mannitol and adjusts the antihypertensive regimen. Which nursing intervention is most critical to prioritize in this situation?

A) Monitor the patient's neurological status every hour.

B) Administer oral fluids to maintain hydration.

C) Position the patient supine to decrease cardiac workload.

D) Encourage active range of motion exercises to prevent contractures.

A patient with an acute ischemic stroke is showing signs of increased intracranial pressure (ICP) as evidenced by a midline shift and decreased consciousness. Despite antihypertensive therapy, the patient's blood pressure remains elevated. Which nursing intervention is most appropriate to prioritize at this time?

B) Elevate the head of the bed to 30 degrees to decrease ICP

A) Administer a bolus of intravenous fluids to improve cerebral perfusion

B) Elevate the head of the bed to 30 degrees to decrease ICP

C) Encourage the patient to perform deep breathing exercises to reduce anxiety

D) Apply ice packs to the patient's head to lower the body temperature and reduce swelling

A patient with elevated intracranial pressure (ICP) and persistent hypertension is being managed with mannitol and adjusted antihypertensive therapy. Despite a reduction in ICP, the blood pressure remains uncontrolled. Which nursing intervention is most appropriate to address the persistent hypertension in this patient?

B) Assess the patient for pain or discomfort and administer analgesics as needed

A) Administer additional doses of mannitol to further decrease ICP

B) Assess the patient for pain or discomfort and administer analgesics as needed

C) Increase the frequency of neurological assessments to monitor for changes

D) Recommend an increase in the current antihypertensive medication dosage

A patient with recent cerebral edema is being treated with mannitol and hypertonic saline. Despite these treatments, the patient's blood pressure remains elevated, and there is a concern for potential seizures. What is the most appropriate nursing intervention to prioritize at this time?

B) Assess the patient for signs of pain or discomfort

A) Administer a sedative to prevent seizures

B) Assess the patient for signs of pain or discomfort

C) Increase the dosage of antihypertensive medication

D) Prepare for surgical intervention

A patient is exhibiting new-onset confusion, restlessness, and motor agitation with a significant decrease in serum sodium levels, despite receiving hypertonic saline therapy. Which nursing action should be prioritized to address the potential underlying cause of these symptoms?

D) Increase the frequency of neurological assessments and monitor for signs of cerebral edema

A) Administer additional hypertonic saline to correct hyponatremia

B) Prepare for immediate administration of anticonvulsant medication

C) Review the patient's medication regimen for potential contributing factors

D) Increase the frequency of neurological assessments and monitor for signs of cerebral edema

A patient with worsening hypertensive crisis and a decrease in serum sodium is exhibiting new-onset confusion and restlessness. What is the most appropriate initial nursing action to address the patient's current condition?

C) Implement seizure precautions

A) Administer a bolus of hypertonic saline

B) Elevate the head of the bed to 30 degrees

C) Implement seizure precautions

D) Prepare the patient for immediate surgical decompression

A patient with intermittent focal seizure activity is receiving intravenous levetiracetam and hypertonic saline for hyponatremia. The patient also has a labile blood pressure and is on a nicardipine infusion. Which nursing intervention is most important to prioritize for this patient?

B) Perform hourly neurological assessments to monitor for signs of increased intracranial pressure.

A) Monitor the patient's serum potassium levels closely and provide supplementation as needed.

B) Perform hourly neurological assessments to monitor for signs of increased intracranial pressure.

C) Adjust the nicardipine infusion rate based on current blood pressure readings to maintain stability.

D) Assess fluid balance and adjust hypertonic saline infusion to prevent overcorrection of serum sodium levels.

A patient is being treated for subclinical seizures and hypertensive crisis. The current treatment plan includes intravenous levetiracetam, hypertonic saline for hyponatremia, potassium supplementation, and nicardipine infusion for blood pressure management. Given these interventions, which nursing action is critical to prioritize to prevent complications?

A) Monitor for signs of central pontine myelinolysis due to rapid sodium correction.

B) Assess for signs of bradycardia as a side effect of levetiracetam.

C) Observe for signs of hyperkalemia following potassium supplementation.

D) Evaluate for signs of hypotension after initiating nicardipine infusion.

Stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs when a blood clot obstructs a cerebral artery, leading to reduced blood flow and oxygen to brain tissue. This results in cell death and loss of neurological function in the affected area.

• Secondary mechanism: Hemorrhagic stroke involves the rupture of a blood vessel in the brain, causing bleeding and increased intracranial pressure. This disrupts normal brain function and can also damage brain tissue directly.

• Key complication: Both types can lead to edema, where swelling exacerbates tissue damage by further compressing and compromising blood supply to surrounding brain areas. Prompt management is crucial to minimize long-term neurological deficits.

Patient Profile

Demographics:

64-year-old male, retired construction worker

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, facial droop on the right side, difficulty swallowing, mild headache, confusion

• Vital signs: Blood pressure 180/105 mmHg, heart rate 98 bpm, respiratory rate 22 breaths/min, temperature 37.8°C, oxygen saturation 91% on room air

Section 1

As the medical team proceeded with the initial assessment, they prioritized stabilizing the patient's airway, breathing, and circulation due to his compromised oxygen saturation of 91% on room air. Supplemental oxygen was administered, and his oxygen saturation improved to 96%. A detailed neurological examination confirmed the presence of right-sided hemiparesis, pronounced facial droop, and dysarthria, suggesting significant involvement of the left hemisphere of the brain. Given the elevated blood pressure of 180/105 mmHg, which poses a risk for worsening cerebral edema, the team initiated an intravenous antihypertensive to gradually lower his blood pressure.

The patient was swiftly transported for a CT scan to differentiate between an ischemic and a hemorrhagic stroke. The CT scan revealed an ischemic stroke in the territory of the left middle cerebral artery without any evidence of hemorrhage. Lab results showed elevated blood glucose levels at 220 mg/dL, possibly exacerbating the ischemic process, and necessitating tight glucose control to prevent further complications. Serum electrolytes and renal function were within normal limits, but the elevated LDL cholesterol level underscored the need for further lipid management.

Despite the initial interventions, the patient's status began to change within the first 24 hours. He developed increased confusion, restlessness, and a more pronounced headache, raising concerns about possible cerebral edema or evolving stroke. The nursing team prepared to monitor his neurological status closely, employing frequent assessments using the NIH Stroke Scale, and were ready to collaborate with the medical team to escalate care if signs of deterioration continued. These developments highlighted the need for ongoing clinical reasoning to address potential complications such as increased intracranial pressure, and to adjust the care plan dynamically.

Section 2

As the nursing team diligently monitored the patient, they observed a concerning trend in his neurological status. His NIH Stroke Scale score increased from 8 to 12, indicating a worsening condition. He demonstrated a decrease in consciousness, now only responding to verbal stimuli with incomprehensible sounds. His right-sided hemiparesis became more pronounced, and he developed anisocoria, with the left pupil being larger and sluggish in response to light. This raised suspicion of increased intracranial pressure (ICP), potentially due to expanding cerebral edema, a known complication in the acute post-stroke phase.

In response to these changes, the medical team ordered an urgent repeat CT scan to assess for any new developments such as hemorrhagic transformation or significant edema. The scan revealed a slight midline shift, consistent with increased ICP due to significant cerebral swelling, but no hemorrhage was present. The patient's blood pressure remained elevated despite antihypertensive therapy, now reading 185/110 mmHg, further contributing to the risk of increased ICP. In light of these findings, the team initiated osmotherapy with mannitol to reduce cerebral edema and adjusted the antihypertensive regimen to more aggressively target blood pressure control, balancing the need to maintain adequate cerebral perfusion.

Meanwhile, the nursing team continued to provide vigilant monitoring, focusing on airway protection given the patient's altered level of consciousness and potential for aspiration. They prepared to implement additional supportive measures, such as elevating the head of the bed to 30 degrees to facilitate venous drainage and decrease ICP. The evolving situation required the team to continuously re-evaluate the care plan, emphasizing the importance of timely interventions and collaboration in managing the complexities of acute stroke care. The next steps would involve reassessing the patient's response to these interventions and determining if further escalation, such as surgical decompression, might be necessary.

Section 3

As the medical team continued to manage the patient's condition, they observed mixed responses to the interventions. Following the administration of mannitol, the patient's ICP showed a slight reduction, as evidenced by an improvement in pupillary response; the left pupil became more reactive to light. Additionally, the patient's level of consciousness showed marginal improvement; he began to follow simple commands intermittently. However, his blood pressure remained persistently elevated, now fluctuating between 178/105 mmHg and 190/115 mmHg, suggesting an inadequate response to the adjusted antihypertensive therapy. The nursing team noted that despite these modest improvements, the patient's right-sided hemiparesis had not improved, and his NIH Stroke Scale score remained elevated at 11.

In an effort to further understand the underlying issues, a repeat CT scan was performed to evaluate the effectiveness of the current treatment strategy. The scan indicated that while the midline shift had not progressed, the cerebral edema persisted. Laboratory results showed a slight electrolyte imbalance with mild hyponatremia, potentially a side effect of osmotherapy. The team decided to adjust the mannitol dosage and introduce hypertonic saline to correct the electrolyte disturbance and help manage cerebral edema more effectively. Additionally, they considered the possibility of hidden sources of blood pressure elevation, such as pain or discomfort, and planned to assess these factors more thoroughly.

Despite these ongoing challenges, the team remained vigilant, aware of the potential for new complications such as seizures, given the patient's current neurological status and fluctuating blood pressure. They prepared to implement seizure precautions and planned to monitor the patient's cardiac status closely, given the cardiovascular strain posed by sustained hypertension. The nursing team emphasized the importance of continuous re-evaluation and multidisciplinary collaboration to navigate the complexities of the patient's evolving condition. The next steps would involve closely monitoring the patient's response to the modified treatment plan and determining the necessity for more invasive interventions, such as surgical options, should the patient's condition fail to stabilize.

Section 4

In the subsequent hours, the medical team observed a significant change in the patient's status, which prompted immediate attention. The patient began exhibiting new-onset confusion and restlessness, deviating from his previously stable yet impaired level of consciousness. Vital signs indicated a worsening hypertensive crisis, with blood pressure readings now fluctuating between 195/110 mmHg and 205/120 mmHg. Heart rate remained elevated at 110 beats per minute, and respiratory rate increased to 24 breaths per minute. The team noted an increase in motor agitation, particularly in the right arm, suggesting possible neurological deterioration.

Given these developments, the team prioritized a thorough reassessment to identify potential causes for the change in status. A stat EEG was ordered to evaluate for seizure activity, given the recent neurological changes and fluctuating blood pressure. Concurrently, a repeat electrolyte panel revealed a further decrease in serum sodium levels, now at 130 mEq/L, raising concerns about the efficacy of the hypertonic saline therapy and the risk of further neurological compromise. The nursing team initiated seizure precautions, including padded side rails and close monitoring of neurological signs, while preparing for potential administration of anticonvulsant medication.

In light of these findings, the multidisciplinary team convened to discuss the next steps. They considered the potential need for more aggressive intervention, such as surgical decompression, if the patient's condition continued to deteriorate despite medical management. The focus remained on stabilizing the patient's blood pressure and correcting the electrolyte imbalance while maintaining vigilance for signs of further complications. This evolving situation underscored the importance of dynamic clinical reasoning and the need for timely adjustments to the treatment plan in response to the patient's rapidly changing condition.

Section 5

As the team continued to monitor the patient's condition, the new diagnostic results from the stat EEG showed intermittent focal seizure activity localized to the left cerebral hemisphere, which aligned with the patient's new onset motor agitation and confusion. This finding indicated that the patient was experiencing subclinical seizures, which might have contributed to his neurological decline. In response, the medical team promptly initiated anticonvulsant therapy with intravenous levetiracetam to stabilize neuronal activity and prevent further seizures, while maintaining seizure precautions.

Simultaneously, the patient's serum sodium level required critical attention due to concerns of hyponatremia potentially exacerbating cerebral edema. The repeat electrolyte panel also revealed a potassium level slightly decreased at 3.4 mEq/L, necessitating cautious potassium supplementation to prevent cardiac complications, especially in the context of the patient's hypertensive crisis. The team adjusted the hypertonic saline infusion rate to more aggressively address the sodium imbalance and closely monitored the patient's fluid balance to avert overcorrection, which could lead to central pontine myelinolysis.

Despite these targeted interventions, the patient's blood pressure remained labile, with readings continuing to oscillate between dangerous levels. This prompted the team to re-evaluate the antihypertensive regimen, opting to introduce a continuous infusion of nicardipine, a calcium channel blocker, to achieve better control over blood pressure and reduce the risk of further neurological injury. The nursing team maintained vigilant neurological assessments every hour, looking for any signs of improvement or further deterioration. The combination of anticonvulsants and refined hypertensive management was hoped to stabilize the patient's condition, but the team remained on high alert for any new complications that might necessitate surgical intervention, such as increased intracranial pressure or significant cerebral herniation.