A patient with a large left middle cerebral artery infarct is being monitored for signs of increased intracranial pressure (ICP). Which of the following findings should the nurse immediately report to the healthcare provider as indicative of worsening ICP?

A) Decrease in Glasgow Coma Scale score from 8 to 6

B) Blood pressure increase to 200/110 mmHg

C) Heart rate increase to 120 bpm

D) Oxygen saturation drop to 90% on room air

A patient with a large left middle cerebral artery (MCA) infarct is being closely monitored for signs of increased intracranial pressure (ICP). Which of the following assessment findings would most likely indicate a worsening condition?

B) Heart rate 58 bpm, irregular breathing pattern, widened pulse pressure

A) Blood pressure 170/90 mmHg, heart rate 120 bpm, respiratory rate 20 breaths per minute

B) Heart rate 58 bpm, irregular breathing pattern, widened pulse pressure

C) Increased lethargy, reactive pupils, blood pressure 160/80 mmHg

D) Blood pressure 180/95 mmHg, heart rate 100 bpm, respiratory rate 24 breaths per minute

A patient with cerebral edema is receiving mannitol therapy. The nurse notes a sluggishly reactive right pupil and elevated serum sodium levels. Which nursing intervention is most appropriate at this time?

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

A) Increase the rate of mannitol infusion to enhance diuresis.

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

C) Administer additional hypertonic saline to address elevated sodium levels.

D) Reduce fluid intake to prevent further electrolyte imbalances.

A patient with cerebral edema is being treated with mannitol and shows slight improvement in consciousness but has an elevated serum sodium level. What is the most appropriate nursing action to address the elevated serum sodium level?

C) Continue monitoring serum electrolytes and notify the healthcare provider

A) Increase the infusion rate of mannitol to enhance diuresis

B) Administer a hypotonic IV solution as prescribed

C) Continue monitoring serum electrolytes and notify the healthcare provider

D) Restrict oral fluid intake to prevent further sodium elevation

A patient with increased intracranial pressure and hypernatremia is being considered for a change in treatment from mannitol to hypertonic saline. Which clinical assessment finding should the nurse prioritize when monitoring for potential complications related to hypertonic saline therapy?

D) Decreased serum sodium levels

A patient with worsening intracranial pressure has developed hypernatremia with serum sodium levels at 152 mEq/L. The clinical team is reconsidering the use of mannitol and is evaluating the initiation of hypertonic saline. What should be the nurse's priority intervention to address the patient's current condition?

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

A) Administer a bolus of intravenous normal saline to dilute sodium levels.

B) Increase the patient's oxygen flow rate to improve saturation levels.

C) Prepare to administer hypertonic saline as ordered to manage cerebral edema.

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

A patient with cerebral edema is receiving hypertonic saline therapy. The nursing staff observes an improvement in neurological status, but the serum sodium level is elevated at 150 mEq/L. What is the priority nursing intervention at this time?

B) Monitor the patient’s neurological status closely and report any significant changes to the healthcare provider.

A) Increase the rate of hypertonic saline infusion to enhance cerebral edema reduction.

B) Monitor the patient’s neurological status closely and report any significant changes to the healthcare provider.

C) Administer a hypotonic saline solution to lower the serum sodium level rapidly.

D) Restrict fluid intake to prevent further elevation of serum sodium levels.

A patient with cerebral edema is receiving hypertonic saline therapy. Which of the following interventions is the most important for the nurse to prioritize to prevent complications related to elevated serum sodium levels?

D) Collaborate with the healthcare team to adjust the sodium level gradually

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

B) Monitor the patient's neurological status every 2 hours

C) Restrict the patient's fluid intake to manage hypernatremia

D) Collaborate with the healthcare team to adjust the sodium level gradually

A patient receiving hypertonic saline therapy exhibits a sudden increase in systolic blood pressure and a decline in Glasgow Coma Scale score. The CT scan shows increased midline shift and worsening cerebral edema. What is the most appropriate nursing action to prioritize at this time?

B) Prepare the patient for a potential decompressive craniectomy as advised by the neurosurgical team.

A) Increase the rate of hypertonic saline infusion to reduce intracranial pressure.

B) Prepare the patient for a potential decompressive craniectomy as advised by the neurosurgical team.

C) Administer a fast-acting antihypertensive medication to lower the blood pressure immediately.

D) Consult with the nephrology team to adjust the electrolyte balance and monitor for osmotic demyelination.

A patient receiving hypertonic saline therapy for cerebral edema exhibits a sudden increase in systolic blood pressure and a decline in Glasgow Coma Scale score. CT scan shows worsening cerebral edema and increased midline shift. What is the most appropriate nursing action to prioritize in this situation?

B) Prepare the patient for potential surgical intervention while monitoring neurological status closely

A) Increase the rate of hypertonic saline infusion to manage cerebral edema

B) Prepare the patient for potential surgical intervention while monitoring neurological status closely

C) Administer antihypertensive medication to manage elevated blood pressure

D) Initiate fluid restriction to address hypernatremia

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs due to a blockage in cerebral blood vessels, often from a thrombus or embolus, leading to reduced blood flow and oxygen deprivation in brain tissue, causing cell death and loss of neurological function.

• Secondary mechanism: Hemorrhagic stroke arises when a blood vessel in the brain ruptures, leading to bleeding and increased intracranial pressure, which compresses brain tissue and disrupts normal brain function.

• Key complication: Both types can lead to cerebral edema and increased intracranial pressure, potentially causing further neuronal injury, brain herniation, and significant impairment of vital functions if not promptly managed.

Patient Profile

Demographics:

65-year-old female, retired school teacher

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, difficulty walking, right-sided facial droop, headache

• Vital signs: Blood pressure 180/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, oxygen saturation 93% on room air, temperature 98.6°F

Section 1

Change in Patient Status:

Shortly after admission to the hospital, the patient demonstrates a change in her neurological status. Her previously slurred speech becomes incomprehensible, and she is increasingly lethargic, responding only to painful stimuli. The right-sided weakness progresses to complete paralysis, and she is unable to lift her right arm or leg. Her Glasgow Coma Scale (GCS) score drops from 13 to 8, indicating a significant decline in consciousness. Vital signs reveal a further increase in blood pressure to 190/100 mmHg, heart rate at 110 bpm, respiratory rate at 24 breaths per minute, and oxygen saturation remains at 93% on room air.

In response to these developments, the healthcare team performs an urgent CT scan of the brain, which reveals a large left middle cerebral artery (MCA) infarct with evidence of significant cerebral edema. The midline shift of brain structures suggests increased intracranial pressure, raising concerns about potential brain herniation. This finding necessitates immediate intervention to prevent further neurological deterioration. The team considers options such as osmotic therapy with mannitol and potential surgical intervention for decompression.

The nursing team must closely monitor the patient's neurological status, vital signs, and response to treatments. This involves frequent reassessments for signs of worsening intracranial pressure, such as Cushing's triad (bradycardia, irregular respirations, and widened pulse pressure) and pupil changes. The situation requires collaboration with neurology and neurosurgery specialists to determine the most appropriate course of action, balancing the risks and benefits of aggressive interventions against the patient's overall prognosis and pre-existing conditions.

Section 2

Response to Interventions:

Following the initiation of osmotic therapy with mannitol to reduce cerebral edema, the healthcare team closely monitors the patient's response. Initially, there is a slight improvement in the patient's level of consciousness; she opens her eyes spontaneously and can mumble a few words, though her speech remains largely unintelligible. Her Glasgow Coma Scale (GCS) score improves marginally to 9. Blood pressure shows a minor decrease to 180/95 mmHg, heart rate stabilizes at 105 bpm, and respiratory rate decreases to 20 breaths per minute. Oxygen saturation improves slightly to 95% on 2 liters of nasal cannula oxygen, indicating a positive but cautious response to the intervention.

Despite these encouraging signs, the nursing team remains vigilant for any signs of increased intracranial pressure. Neurological assessments are conducted every 30 minutes, with particular attention to pupil size and reactivity. The right pupil is noted to be sluggishly reactive, a finding that suggests persistent pressure on the brainstem. Blood tests reveal elevated serum sodium levels, a side effect of mannitol that necessitates careful monitoring to prevent electrolyte imbalances. The decision is made to consult with the neurosurgery team to discuss the feasibility and timing of a decompressive craniectomy, given the ongoing risk of cerebral herniation.

The clinical team must weigh the potential benefits of surgical intervention against the risks, considering the patient's pre-existing conditions and overall prognosis. Discussions with the family are initiated to align treatment goals with the patient's previously expressed wishes and quality of life considerations. The situation remains critical, requiring the team to remain adaptive and responsive to any further changes in the patient's condition, while maintaining open communication with all stakeholders involved in her care.

Section 3

New Complications

As the clinical team continues to monitor the patient, a new complication emerges. During a routine neurological assessment, the nursing staff observes that the patient's left pupil is now becoming sluggishly reactive as well, indicating potential worsening of intracranial pressure. Accompanying this, the patient exhibits increased confusion and agitation, which are concerning signs of altered mental status. The Glasgow Coma Scale (GCS) score declines slightly back to 8, suggesting a setback in neurological status. Vital signs reveal that while the heart rate remains stable at 106 bpm, blood pressure has increased again to 190/100 mmHg, and oxygen saturation has decreased to 92% despite maintaining 2 liters of nasal cannula oxygen.

Additionally, a new set of laboratory results shows a further increase in serum sodium levels, now at 152 mEq/L, indicating hypernatremia. This electrolyte imbalance raises concerns about the continued use of mannitol and its contribution to the patient's fluid and electrolyte status. The elevated sodium levels necessitate immediate intervention to prevent complications like seizures or further neurological deterioration. Furthermore, a recent CT scan of the head reveals an increase in midline shift, suggesting worsening cerebral edema and increasing risk for herniation.

These developments prompt the clinical team to reassess their approach, considering the initiation of hypertonic saline therapy as an alternative to mannitol for managing cerebral edema. The neurosurgery team is consulted urgently to evaluate the patient's eligibility and timing for decompressive craniectomy, given the rapid progression of symptoms. This situation underscores the critical need for precise clinical reasoning to balance aggressive intervention with the patient's overall stability, ensuring that all potential complications are anticipated and managed promptly. The team remains in close communication with the patient's family to update them on the evolving situation and to reaffirm treatment goals.

Section 4

As the clinical team initiates hypertonic saline therapy in place of mannitol, they closely monitor the patient's response to this intervention. Over the next few hours, the patient's neurological status shows subtle improvement. The left pupil, previously sluggish, becomes more reactive to light, and the patient's GCS score improves slightly to 10, indicating a modest recovery in consciousness. However, while these changes are encouraging, the nursing staff remains vigilant, as cerebral edema and elevated intracranial pressure are still significant concerns. Vital signs reveal that the blood pressure has decreased slightly to 180/95 mmHg, and the heart rate remains stable at 104 bpm. Oxygen saturation improves to 94% with continued supplemental oxygen, suggesting better respiratory function.

Despite the positive trends, new laboratory results pose fresh challenges. The serum sodium level remains elevated at 150 mEq/L, requiring careful management to prevent osmotic demyelination syndrome. The patient's serum osmolality is also elevated, reflective of the hypertonic saline therapy, necessitating a delicate balance to address both cerebral edema and electrolyte imbalances effectively. The neurosurgery team, after reviewing the updated CT scan and clinical findings, opts to prepare for a potential decompressive craniectomy should the patient's condition worsen, emphasizing the urgency of a multidisciplinary approach to prevent further deterioration.

In light of these developments, the clinical team reassesses their treatment strategy, prioritizing frequent neurological assessments and continuous monitoring of vital signs and lab values. They engage in detailed discussions with the patient's family, explaining the rationale behind current interventions and potential surgical options. This transparent communication ensures alignment with the patient's care goals and prepares all parties for any further steps that may be required in this complex clinical scenario. The team's ability to integrate clinical reasoning with dynamic patient data underscores the critical nature of adaptive decision-making in the management of evolving complications in stroke care.

Section 5

As the clinical team continues to monitor the patient's response to hypertonic saline therapy, new complications emerge that demand immediate attention. Approximately six hours into the therapy, the patient exhibits a sudden increase in systolic blood pressure to 200 mmHg, despite previous stabilization efforts. This hypertensive surge raises concerns about the potential for further intracranial hemorrhage or exacerbation of cerebral edema. Concurrently, the nursing staff notices a change in the patient's level of consciousness; the patient, who had shown slight improvement, now appears more lethargic and unresponsive to verbal stimuli, prompting an urgent reassessment of their Glasgow Coma Scale score, which has declined to 8.

In response to these alarming developments, the clinical team orders an urgent repeat CT scan to evaluate any changes in intracranial dynamics that may explain the altered neurological status. The scan reveals increased midline shift and worsening of cerebral edema, necessitating immediate consideration of surgical interventions. Meanwhile, the lab results highlight a further rise in serum sodium to 155 mEq/L and serum osmolality at 320 mOsm/kg, indicating that the hypertonic saline therapy is contributing to a critical electrolyte imbalance. The team swiftly adjusts the treatment protocol, considering a cautious reduction of hypertonic saline infusion and a transition to alternative osmotic therapies to mitigate the risk of osmotic demyelination.

This turn of events emphasizes the importance of a multidisciplinary approach, as the team consults with nephrology and neurosurgery specialists to recalibrate the management plan. The conversation with the patient's family becomes more urgent, focusing on the potential need for a decompressive craniectomy. Clinical reasoning is paramount as the team weighs the risks and benefits of surgical intervention against the backdrop of rapidly evolving complications, making informed, collaborative decisions that aim to stabilize the patient's condition and improve their prognosis.