A nurse is caring for a patient with malignant middle cerebral artery (MCA) syndrome who is receiving intravenous mannitol to manage cerebral edema. Which of the following nursing interventions is most important to monitor the effectiveness of the treatment?

A) Monitor the patient's urine output closely.

B) Assess the patient's pupillary response.

C) Measure the patient’s blood glucose levels regularly.

D) Evaluate the patient's respiratory rate.

A nurse is caring for a patient diagnosed with malignant middle cerebral artery syndrome. The patient exhibits increasing confusion, decreased responsiveness, and right-sided hemiplegia. Which nursing intervention should be prioritized to effectively manage the patient's cerebral edema?

A) Administer intravenous mannitol as prescribed

B) Encourage oral fluid intake to maintain hydration

C) Position the patient flat to improve cerebral perfusion

D) Apply restraints to prevent injury from confusion

A patient with elevated intracranial pressure is being monitored for cerebral edema. Despite interventions, the patient shows no improvement in neurological status, and serum sodium is elevated. Which of the following is the most appropriate nursing action to prioritize in this situation?

B) Notify the healthcare provider about the potential need for a decompressive craniectomy.

A) Increase the rate of hypertonic saline infusion to further reduce cerebral edema.

B) Notify the healthcare provider about the potential need for a decompressive craniectomy.

C) Reduce fluid intake immediately to address the hypernatremia.

D) Administer a diuretic to decrease intracranial pressure.

A patient with elevated intracranial pressure is being monitored, and the healthcare team has observed signs consistent with a Cushing's response. Given the patient's current status and interventions, which nursing action is most appropriate to prioritize at this time?

C) Elevate the head of the bed to 30 degrees to promote venous drainage and reduce intracranial pressure.

A) Administer an additional dose of hypertonic saline to further reduce cerebral edema.

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

C) Elevate the head of the bed to 30 degrees to promote venous drainage and reduce intracranial pressure.

D) Increase the oxygen flow rate to 4 liters per minute to improve oxygen saturation levels.

A patient with suspected increased intracranial pressure (ICP) due to cerebral edema is being considered for decompressive craniectomy. Which nursing intervention is most appropriate to minimize further increases in ICP while awaiting surgery?

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

B) Administer 500 mL of normal saline bolus.

C) Encourage deep breathing exercises.

D) Place the patient in Trendelenburg position.

A patient with elevated intracranial pressure and a midline shift is scheduled for a decompressive craniectomy. Which nursing intervention is most important to prioritize before the surgical procedure?

C) Monitoring serum sodium levels closely to prevent complications from hypertonic saline therapy.

A) Administering an oral antihypertensive to lower blood pressure.

B) Increasing oxygen flow rate to 4 liters per minute to enhance oxygenation.

C) Monitoring serum sodium levels closely to prevent complications from hypertonic saline therapy.

D) Educating the family about the surgical procedure and obtaining informed consent.

A patient who recently underwent a decompressive craniectomy is exhibiting a decreased level of consciousness with a Glasgow Coma Scale score of 8, unequal pupils, and labile blood pressure. Which of the following is the priority nursing action at this time?

D) Notify the neurosurgical team about the changes in the patient's neurological status

A) Administer prescribed antihypertensive medication to stabilize blood pressure

B) Prepare the patient for immediate surgical intervention by the neurosurgical team

C) Adjust the ventilator settings to manage the irregular respiratory pattern

D) Notify the neurosurgical team about the changes in the patient's neurological status

A patient with a decreased Glasgow Coma Scale (GCS) score, unequal pupils, and irregular respiratory pattern is being monitored following a decision for decompressive craniectomy. Which nursing intervention is most critical to perform immediately?

D) Notify the neurosurgical team of the patient's worsening neurological status.

A) Administer an antihypertensive medication to control blood pressure fluctuations.

B) Prepare the patient for intubation to secure the airway and ensure adequate oxygenation.

C) Adjust the patient's fluid management plan to address elevated serum creatinine levels.

D) Notify the neurosurgical team of the patient's worsening neurological status.

A patient with increased intracranial pressure and respiratory acidosis is being managed with hypertonic saline and is under consideration for intubation. Which nursing intervention is a priority to prevent further complications in this scenario?

B) Monitor serum electrolytes closely to prevent imbalances.

A) Position the patient supine to promote cerebral perfusion.

B) Monitor serum electrolytes closely to prevent imbalances.

C) Increase fluid intake to support renal function.

D) Provide frequent oral care to prevent ventilator-associated pneumonia (VAP).

A patient with increased intracranial pressure and respiratory acidosis is being considered for mechanical ventilation. Which of the following nursing interventions is most crucial in this scenario to prevent further complications?

C) Monitor arterial blood gases frequently to assess ventilation effectiveness.

A) Administer hypertonic saline to manage cerebral edema.

B) Position the patient supine to ensure comfort and ease of monitoring.

C) Monitor arterial blood gases frequently to assess ventilation effectiveness.

D) Restrict fluid intake to prevent fluid overload and renal injury.

Cva - Nursing Case Study

Pathophysiology

• Primary mechanism: Cerebral ischemia occurs when blood flow to a part of the brain is obstructed, often due to an embolism or thrombosis, leading to decreased oxygen and nutrient delivery, which causes neuronal cell death and loss of brain function.

• Secondary mechanism: Hemorrhagic stroke results from the rupture of a cerebral blood vessel, causing bleeding into or around brain tissue, which increases intracranial pressure and further reduces blood flow, exacerbating neuronal injury.

• Key complication: Both ischemic and hemorrhagic strokes can lead to secondary brain injury through inflammation and edema, contributing to further neuronal damage and significant neurological deficits.

Patient Profile

Demographics:

67-year-old male, retired accountant

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• 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, mild headache

• Vital signs: Blood pressure 180/100 mmHg, heart rate 96 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 94% on room air

Section 1

As the medical team continues to monitor the patient, they observe a change in his neurological status approximately 12 hours post-admission. The patient, who initially presented with right-sided weakness and slurred speech, now exhibits increasing confusion and disorientation. A repeat neurological examination reveals a decrease in responsiveness, with a Glasgow Coma Scale (GCS) score dropping from 14 to 10. The right-sided weakness has progressed to complete hemiplegia, and there is now evidence of neglect of the right side. These changes prompt an urgent re-evaluation of the patient's condition to determine the underlying cause.

A CT scan of the brain is performed to assess for potential complications. The imaging reveals a significant increase in cerebral edema around the initial ischemic area, suggesting a progression to a malignant middle cerebral artery (MCA) syndrome. This condition is characterized by the rapid and severe swelling of brain tissue, which can lead to increased intracranial pressure and a midline shift. The edema is likely exacerbating the patient's neurological deficits and contributing to his declining consciousness.

In response to these findings, the healthcare team initiates aggressive measures to manage the cerebral edema. This includes elevating the head of the bed to 30 degrees to promote venous drainage, administering intravenous mannitol to reduce intracranial pressure, and considering hypertonic saline therapy. The patient's blood glucose levels are closely monitored and controlled to prevent further ischemic injury. As the team prepares for the possibility of surgical intervention, such as decompressive craniectomy, they continue to assess the patient's response to these interventions, aiming to stabilize his condition and prevent further deterioration.

Section 2

As the medical team closely monitors the patient's response to the interventions aimed at reducing cerebral edema, they observe some changes in his clinical status. The patient's vital signs indicate a slight increase in blood pressure, with readings now averaging 160/100 mmHg, possibly reflecting a Cushing's response due to elevated intracranial pressure. Heart rate remains steady at 84 beats per minute, and respiratory rate is slightly elevated at 22 breaths per minute. Oxygen saturation is maintained at 96% on 2 liters of nasal cannula oxygen. Despite the interventions, the patient's GCS score remains at 10, showing no immediate improvement in consciousness level.

Laboratory results reveal a serum sodium level of 150 mmol/L, indicating mild hypernatremia due to the administration of hypertonic saline. The healthcare team carefully balances the need to reduce cerebral edema with the risk of exacerbating electrolyte imbalances. Blood glucose is controlled within target range, at 130 mg/dL, minimizing additional risk to cerebral tissues. Neurological assessment continues to show significant right-sided neglect and persistent hemiplegia, with no improvement in motor function.

Given the lack of significant improvement in the patient's neurological status, the team deliberates the next steps, including the potential need for surgical intervention. A neurosurgical consultation is requested to evaluate the feasibility and timing of a decompressive craniectomy, considering the risks and benefits for the patient. The team continues to assess the patient frequently, prepared to escalate care as necessary, while maintaining communication with the family to keep them informed and involved in decision-making. This careful monitoring and reassessment are crucial as the patient's condition remains precarious, requiring vigilant clinical reasoning to navigate the complexities of his care.

Section 3

As the medical team continues to monitor the patient, they notice a change in his clinical status that prompts immediate attention. The patient's blood pressure has climbed further, now averaging 175/105 mmHg, suggesting a possible worsening of intracranial pressure. His respiratory rate has increased to 24 breaths per minute, and he is exhibiting irregular breathing patterns, raising concerns about potential brainstem involvement. His oxygen saturation remains stable at 95% on 2 liters of nasal cannula oxygen, but the elevated blood pressure and altered respiratory patterns prompt the team to reassess his neurological status.

A repeat CT scan of the head is ordered to evaluate any progression of cerebral edema or hemorrhagic transformation. The imaging reveals increased midline shift and potential herniation risk, highlighting the urgency of addressing the intracranial pressure. In light of these findings, the neurosurgical team prioritizes the case for a decompressive craniectomy, weighing the potential benefits of relieving pressure against the risks of surgical complications. Meanwhile, the critical care team adjusts the patient's hypertonic saline protocol, carefully titrating the infusion to manage serum sodium levels, which have now risen to 152 mmol/L, while aiming to mitigate further neurological compromise.

The patient's family is updated on the new developments and the proposed surgical intervention. The healthcare team emphasizes the importance of prompt action to prevent further neurological deterioration. The decision-making process involves a detailed discussion with the family about the potential outcomes and the rationale behind the aggressive management plan. As the team prepares for possible surgical intervention, they remain vigilant in their monitoring, ready to address any additional complications that may arise as the patient's condition continues to evolve.

Section 4

As the healthcare team closely monitors the patient following the decision for a decompressive craniectomy, there is a notable change in his neurological status. The patient's level of consciousness has decreased, as evidenced by a drop in his Glasgow Coma Scale (GCS) score to 8, indicating a progression towards severe impairment. In addition to the decreased responsiveness, his pupils are now unequal with the left pupil dilated and sluggish to light, suggesting worsening lateralization and possible herniation. These findings necessitate urgent communication with the neurosurgical team to expedite the surgical intervention.

Simultaneously, the patient's blood pressure has become more labile, with fluctuations between 165/95 mmHg and 180/110 mmHg, despite ongoing management. His heart rate has increased to 112 beats per minute, and his respiratory pattern remains irregular, characterized by periods of apnea interspersed with rapid, shallow breaths. The critical care team adjusts his ventilatory support to maintain adequate oxygenation and ventilation, while also considering the potential need for intubation if respiratory compromise progresses.

Laboratory results reveal a serum creatinine level of 1.8 mg/dL, elevated from previous measures, indicating potential acute kidney injury possibly linked to the hypertonic saline administration. This necessitates a careful reevaluation of his fluid and electrolyte management plan to balance the need for controlling intracranial pressure with the risk of further renal compromise. The interdisciplinary team discusses these developments, ensuring a coordinated approach as they prepare for the impending surgical procedure, emphasizing the need for swift yet comprehensive management to optimize patient outcomes.

Section 5

As the healthcare team continues to manage the patient's condition, new diagnostic results provide further insight into his deteriorating status. A repeat CT scan of the brain reveals significant midline shift and worsening cerebral edema, corroborating the clinical findings of increased intracranial pressure and potential herniation. These imaging results emphasize the urgency of the decompressive craniectomy as a necessary intervention to alleviate pressure and prevent further neurological decline.

In addition to the imaging findings, arterial blood gas analysis shows a respiratory acidosis with a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 65 mmHg, indicating inadequate ventilation and oxygenation. The metabolic component remains relatively compensated with a bicarbonate level of 26 mEq/L, suggesting the primary issue is respiratory in nature. This reinforces the critical care team's consideration for intubation and mechanical ventilation to stabilize the patient's respiratory status and ensure adequate gas exchange.

The new complications related to renal function are further highlighted by the presence of an elevated blood urea nitrogen (BUN) of 32 mg/dL, confirming acute kidney injury. The interdisciplinary team revisits the patient's fluid management strategy, cautiously balancing hypertonic saline administration to manage intracranial pressure with the need to prevent further renal insult. They decide to initiate renal protective measures, including careful monitoring of fluid status and electrolyte levels, while preparing for potential renal replacement therapy if the kidney function worsens. As these developments unfold, the team remains vigilant, ready to adapt the plan of care as the patient's condition evolves, always prioritizing a holistic approach to optimize his chances of recovery.