A patient who has experienced an ischemic stroke is noted to have worsening headache and increased confusion. What is the priority nursing intervention?

D) Notify the healthcare provider of the change in condition

A) Administer prescribed antihypertensive medication immediately

B) Prepare the patient for a repeat CT scan

C) Elevate the head of the bed to 30 degrees

D) Notify the healthcare provider of the change in condition

A patient with a confirmed ischemic stroke presents with worsening headache and increased confusion. As a nurse, which of the following actions is the most appropriate to take first?

B) Request an immediate CT scan to assess for hemorrhagic transformation.

A) Administer a fast-acting antihypertensive medication to lower blood pressure.

B) Request an immediate CT scan to assess for hemorrhagic transformation.

C) Increase the frequency of neurological assessments to every 15 minutes.

D) Administer a prescribed dose of insulin to address elevated blood glucose levels.

A patient with acute ischemic stroke is experiencing increased intracranial pressure (ICP) despite initial stabilization efforts. The medical team has administered mannitol to reduce cerebral edema. What is the most important nursing action to perform after administering mannitol?

A) Monitor for signs of dehydration and electrolyte imbalances.

B) Elevate the head of the bed to 45 degrees to promote venous drainage.

C) Administer additional antihypertensives to further lower blood pressure.

D) Encourage the patient to increase fluid intake to prevent dehydration.

A patient with ischemic stroke is exhibiting signs of increased intracranial pressure and has received an osmotic diuretic to manage cerebral edema. Which of the following assessments is most critical for the nurse to perform to evaluate the effectiveness of this treatment?

C) Evaluate the patient's level of consciousness

A) Monitor the patient's blood pressure for stability

B) Assess the patient's urine output for increase

C) Evaluate the patient's level of consciousness

D) Check the patient's blood glucose levels

A patient with a history of stroke and dysphagia presents with a fever and mild infiltrates in the lower lobes on a chest X-ray. Which nursing intervention should be prioritized to prevent further respiratory complications?

A) Elevate the head of the bed to 30-45 degrees

B) Administer antipyretics to reduce fever

C) Encourage oral fluids to maintain hydration

D) Perform chest physiotherapy every 4 hours

A patient who recently experienced a stroke is now showing signs of a potential infection with a fever of 38.5°C (101.3°F) and mild infiltrates on a chest X-ray. Which nursing intervention is most appropriate to prioritize in this situation?

C) Begin broad-spectrum antibiotic therapy as prescribed.

A) Administer antipyretics to reduce the fever.

B) Encourage frequent coughing and deep breathing exercises.

C) Begin broad-spectrum antibiotic therapy as prescribed.

D) Increase fluid intake to promote hydration.

A patient with suspected aspiration pneumonia is experiencing acute respiratory distress and has been transitioned to a high-flow nasal cannula. Arterial blood gas analysis reveals a pH of 7.30, pCO2 of 55 mmHg, and pO2 of 60 mmHg. Which nursing intervention is most appropriate to address the patient's current respiratory status?

A) Encourage the patient to take deep breaths and cough every hour.

C) Increase the rate of intravenous fluid administration to improve circulation.

D) Administer a bronchodilator to reduce airway inflammation.

A patient with aspiration pneumonia is exhibiting signs of respiratory distress and has arterial blood gas results indicating acute respiratory acidosis. Which nursing intervention should be prioritized to address the patient's current respiratory status effectively?

A) Increase the flow rate on the nasal cannula to 6 liters per minute.

C) Administer a bronchodilator to improve airway patency.

D) Encourage the patient to take deep breaths and cough regularly.

A patient with a history of stroke and recent respiratory distress is now showing subtle neurological changes, including fluctuating level of consciousness and new right upper extremity weakness. While awaiting a CT scan, what is the most appropriate nursing intervention to prioritize in this situation?

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

A) Administer IV fluids to ensure adequate hydration

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

C) Monitor for signs of increased intracranial pressure and notify the physician

D) Perform frequent neurological checks every 2 hours to assess changes

A patient on non-invasive positive pressure ventilation (NIPPV) shows improvement in respiratory parameters but begins to exhibit new neurological symptoms, including fluctuating consciousness and right upper extremity weakness. What is the nurse's priority intervention while awaiting the CT results?

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

A) Increase the flow rate of the NIPPV to enhance oxygenation.

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

C) Administer a sedative to manage the patient's fluctuating consciousness.

D) Prepare the patient for possible intubation by assessing airway equipment.

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs due to an obstruction in the blood vessels supplying the brain, often from a thrombus or embolus, leading to reduced oxygen and nutrient delivery to brain tissue, causing cell death.

• Secondary mechanism: Hemorrhagic stroke results from the rupture of a blood vessel within the brain, leading to bleeding, increased intracranial pressure, and subsequent damage to brain tissue due to compression and toxic effects of blood.

• Key complication: Both types of stroke can result in neurological deficits such as paralysis, speech difficulties, and cognitive impairments depending on the affected brain region, impacting patient mobility and function.

Patient Profile

Demographics:

67-year-old female, retired school teacher

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 weakness on the right side of the body

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

• Vital signs: Blood pressure 180/100 mmHg, heart rate 92 bpm, respiratory rate 20 breaths per minute, temperature 98.4°F, oxygen saturation 93% on room air

Section 1

As the medical team begins the initial assessment, the priority is to stabilize the patient's condition and ascertain the extent of the stroke. The patient's neurological status is closely monitored using the National Institutes of Health Stroke Scale (NIHSS). Her score indicates moderate severity, with pronounced right-sided weakness, aphasia, and facial droop. The team swiftly orders a CT scan of the head to differentiate between an ischemic and hemorrhagic stroke, which reveals evidence of an ischemic stroke with no signs of hemorrhage.

Laboratory results return and provide additional information. Her blood glucose is elevated at 180 mg/dL, and her HbA1c is 8.2%, indicating suboptimal control of her Type 2 Diabetes, which may have contributed to her stroke risk. Lipid panel results show LDL levels of 140 mg/dL, suggesting that her hyperlipidemia is not adequately controlled despite medication. Given her hypertension, with continued elevated blood pressure readings of 185/105 mmHg, there is concern about the risk of further vascular events.

The patient's condition remains stable initially, but there is a notable change in her status when she begins to experience worsening headache and increased confusion, raising concerns about potential complications such as cerebral edema or hemorrhagic transformation. The medical team decides to perform additional imaging to rule out these possibilities and adjusts her treatment plan to address her hypertensive crisis and manage her elevated blood sugar levels. This evolving scenario underscores the need for vigilant monitoring and dynamic clinical reasoning to prevent further deterioration.

Section 2

As the medical team continues to monitor the patient, her condition takes a concerning turn. Despite initial stabilization efforts, the patient begins to exhibit signs of increased intracranial pressure, including a worsening headache and escalating confusion. Vital signs indicate a significant rise in blood pressure, now at 190/110 mmHg, despite ongoing antihypertensive therapy. The patient's heart rate has also increased to 110 beats per minute, and her respiratory pattern shows irregularities, with periods of shallow breathing interspersed with deeper breaths. Neurologically, the patient demonstrates a further decline in her NIHSS score, with more pronounced aphasia and right-sided weakness.

Given these changes, the team orders an urgent MRI to assess for potential cerebral edema or hemorrhagic transformation. The MRI results reveal early signs of cerebral edema around the ischemic region, but fortunately, there is no evidence of hemorrhagic transformation. The medical team recognizes the necessity to address this complication promptly to prevent further neurological damage. An osmotic diuretic, such as mannitol, is administered to reduce the cerebral edema, and the patient's antihypertensive regimen is intensified with the addition of an intravenous medication to achieve better blood pressure control. Simultaneously, an insulin drip is initiated to manage her hyperglycemia more effectively, aiming to mitigate further vascular complications.

The healthcare team's interventions begin to show positive effects within a few hours. The patient's headache starts to diminish, and her level of confusion gradually improves, indicating a reduction in intracranial pressure. Her blood pressure begins to stabilize, with readings lowering to 165/95 mmHg, and her blood glucose levels are steadily decreasing. Despite these encouraging signs, the team remains vigilant, aware that the patient's journey is far from over. They continue to closely monitor her neurological status and vital signs, ready to adjust the treatment plan as necessary to navigate any new challenges that may arise.

Section 3

As the team continues to monitor the patient, a new complication arises that requires immediate attention. Despite the initial success with reducing intracranial pressure and stabilizing blood pressure, the patient develops a fever, with her temperature rising to 38.5°C (101.3°F). The possibility of an infection is a concern, prompting the healthcare team to conduct a thorough assessment and order a series of diagnostic tests, including a complete blood count (CBC), blood cultures, and a chest X-ray, to identify any underlying cause of the fever.

The results reveal a slight elevation in white blood cell count, suggesting a potential infection, although the blood cultures are not immediately conclusive. The chest X-ray indicates mild infiltrates in the lower lobes, raising suspicion of aspiration pneumonia, a common complication in stroke patients with dysphagia. In response, the medical team initiates broad-spectrum antibiotic therapy while awaiting more definitive culture results and enhances respiratory support by increasing oxygen supplementation to maintain adequate oxygenation.

The patient's overall condition reflects a delicate balance, as her neurological status remains stable following the initial interventions for cerebral edema. The fever, however, underscores the need for ongoing vigilance and adaptability in her care plan. The team emphasizes the importance of continued monitoring of her respiratory function, oxygen saturation, and neurological signs, while also considering the potential need for further interventions to address any new developments. The management of this new complication becomes a critical component of the patient's evolving journey, highlighting the interconnected nature of her medical challenges.

Section 4

As the healthcare team continues their vigilant monitoring of the patient, a new complication arises. Despite the initiation of broad-spectrum antibiotics and enhanced respiratory support, the patient begins to exhibit signs of respiratory distress. Her respiratory rate increases to 28 breaths per minute, and oxygen saturation levels drop to 88% on 4 liters of supplemental oxygen via nasal cannula. Auscultation of the lungs reveals coarse crackles and diminished breath sounds bilaterally, particularly in the lower lobes, corroborating the earlier suspicion of aspiration pneumonia.

In response to these changes, the clinical team decides to escalate respiratory support by transitioning the patient to a high-flow nasal cannula, delivering heated and humidified oxygen to achieve target saturation levels above 92%. Additionally, they perform arterial blood gas (ABG) analysis, which reveals a pH of 7.30, pCO2 of 55 mmHg, and pO2 of 60 mmHg, indicating acute respiratory acidosis secondary to hypoventilation and impaired gas exchange. These findings necessitate a reassessment of her respiratory management and consideration of non-invasive positive pressure ventilation (NIPPV) to improve ventilation and oxygenation.

The patient's evolving condition prompts the healthcare team to re-evaluate her overall management plan. With the new challenge of respiratory compromise, the interdisciplinary team reinforces the importance of regular repositioning, chest physiotherapy, and continued monitoring of neurological and respiratory status. They remain vigilant for any signs of further deterioration, understanding the delicate balance required to maintain her stability amidst the complexities of her condition. The journey becomes one of careful coordination and adaptability, as they work to mitigate the risk of additional complications and support the patient's recovery trajectory.

Section 5

The healthcare team observes the patient closely following the transition to high-flow nasal cannula and the introduction of non-invasive positive pressure ventilation (NIPPV). Over the next 24 hours, there is a notable response to these interventions. Her respiratory rate gradually decreases to 22 breaths per minute, and oxygen saturation improves to 93% while on NIPPV. The repeat arterial blood gas analysis shows a pH of 7.35, pCO2 of 50 mmHg, and pO2 of 68 mmHg, indicating a partial improvement in her respiratory acidosis and oxygenation status. This positive trend offers a cautious optimism regarding her respiratory recovery, although the team remains vigilant for any signs of instability.

Despite these improvements, the patient begins to exhibit subtle neurological changes that warrant further investigation. Her level of consciousness fluctuates, and she becomes increasingly lethargic, raising concerns about potential cerebral complications. A focused neurological assessment reveals a new weakness in her right upper extremity, which was previously recovering well post-stroke. These findings prompt the healthcare team to order an urgent CT scan of the brain to rule out the possibility of a secondary stroke or evolving intracranial process that might explain the new neurological deficits.

As the team awaits the CT results, they prioritize maintaining optimal cerebral perfusion and oxygenation, understanding the critical nature of timely intervention in the face of potential neurological deterioration. The introduction of these new complications underscores the intricate interplay between the patient's respiratory and neurological systems, emphasizing the need for a coordinated, multidisciplinary approach to her care. This situation sets the stage for further diagnostic exploration and potential adjustments in her therapeutic regimen, as the team strives to support her recovery while navigating the complexities of her condition.