A patient hospitalized with a recent ischemic stroke exhibits worsening dysarthria, right-sided hemiparesis, and facial droop. Her blood pressure remains elevated at 170/105 mmHg, and her blood glucose level is noted at 220 mg/dL. Which nursing intervention is most critical to prioritize in her care plan to prevent further neurological compromise?

A) Administering prescribed antihypertensive medication and reassessing blood pressure.

B) Educating the patient and family on the importance of adhering to dietary restrictions.

C) Encouraging ambulation and physical therapy to improve mobility.

D) Initiating a diabetic meal plan and administering insulin as prescribed.

A patient with a history of cerebrovascular accident is exhibiting new neurological symptoms, including increased dysarthria, right-sided hemiparesis, and facial droop. A CT scan confirms a new ischemic stroke in the left hemisphere. Considering the current clinical findings, which nursing intervention is most appropriate to prioritize at this time?

C) Administer antihypertensive medication as prescribed.

A) Monitor the patient's neurological status every 4 hours.

B) Educate the patient and family about the signs of stroke.

C) Administer antihypertensive medication as prescribed.

D) Initiate a diet plan to control blood glucose levels.

A patient with a recent ischemic stroke has developed aspiration pneumonia. Which nursing intervention is most important to prioritize to prevent further respiratory complications?

C) Elevating the head of the bed to 30-45 degrees

A) Administering prescribed antibiotics on time

B) Encouraging the patient to perform deep breathing exercises

C) Elevating the head of the bed to 30-45 degrees

D) Monitoring oxygen saturation levels frequently

A patient with a recent ischemic stroke is experiencing a low-grade fever and decreased breath sounds in the right lower lung field, leading to a diagnosis of aspiration pneumonia. Which nursing intervention is the priority to address this complication and prevent further respiratory deterioration?

C) Elevate the head of the bed to 30-45 degrees to prevent further aspiration

A) Administer the prescribed broad-spectrum antibiotics as scheduled

B) Encourage the patient to perform incentive spirometry every 2 hours

C) Elevate the head of the bed to 30-45 degrees to prevent further aspiration

D) Monitor the patient's temperature and report any increase above 101°F

A patient with aspiration pneumonia is on the seventh day of hospitalization and exhibits a respiratory rate of 24 breaths per minute, oxygen saturation of 90% on room air, and persistent decreased breath sounds in the right lower lung field. Given these findings, which nursing intervention is most appropriate to prioritize?

B) Encourage the patient to use incentive spirometry every hour while awake to enhance lung expansion.

A) Increase the rate of supplemental oxygen delivery to improve oxygenation.

B) Encourage the patient to use incentive spirometry every hour while awake to enhance lung expansion.

C) Administer prescribed bronchodilators to reduce airway resistance.

D) Position the patient in a high Fowler's position to facilitate breathing and lung expansion.

A patient with aspiration pneumonia is on the seventh day of hospitalization. Her oxygen saturation has decreased to 90% on room air, with increased work of breathing. The interdisciplinary team is considering advancing her respiratory support. Which nursing intervention should be prioritized to improve her respiratory status while waiting for the team’s decision?

C) Position the patient in high Fowler's position.

A) Increase the supplemental oxygen flow rate via nasal cannula.

B) Encourage frequent use of incentive spirometry.

C) Position the patient in high Fowler's position.

D) Administer a bronchodilator as prescribed.

A patient hospitalized for pneumonia exhibits increased respiratory rate, decreased oxygen saturation despite supplemental oxygen, and somnolence. Which nursing intervention should be prioritized to address the patient's respiratory status?

B) Prepare the patient for non-invasive positive pressure ventilation.

A) Increase the oxygen flow rate to 5 liters per minute.

B) Prepare the patient for non-invasive positive pressure ventilation.

C) Encourage the patient to perform incentive spirometry every hour.

D) Administer a dose of prescribed bronchodilator via nebulizer.

A patient hospitalized with pneumonia exhibits increased respiratory distress, hypoxemia, and signs of fatigue. A chest X-ray shows consolidation and a pleural effusion. Arterial blood gas analysis indicates alkalosis with a low PaO2 and decreased PaCO2. What is the most appropriate initial nursing intervention to address the patient's respiratory status?

A) Increase the oxygen flow rate to 5 liters per minute via nasal cannula.

B) Prepare the patient for thoracentesis to relieve the pleural effusion.

D) Encourage the patient to participate in deep breathing exercises despite fatigue.

Given the patient's sudden onset of sharp, right-sided chest pain, decreased blood pressure, and increased heart rate, which nursing intervention should be prioritized while awaiting confirmatory diagnostic test results?

C) Position the patient in high Fowler's and administer oxygen

A) Administer prescribed analgesics to manage chest pain

B) Prepare the patient for thoracentesis as scheduled

C) Position the patient in high Fowler's and administer oxygen

D) Initiate an IV bolus of normal saline to address hypotension

A patient with a multidrug-resistant strain of Pseudomonas aeruginosa is being treated with ceftazidime and tobramycin. Following the initiation of this treatment, she experiences sudden sharp right-sided chest pain, hypotension, and tachycardia. Which nursing intervention should be prioritized to address the patient's acute change in condition?

B) Notify the healthcare provider and prepare the patient for a chest X-ray and CT pulmonary angiogram.

A) Administer supplemental oxygen and prepare for immediate thoracentesis.

B) Notify the healthcare provider and prepare the patient for a chest X-ray and CT pulmonary angiogram.

C) Increase the rate of intravenous fluids to manage hypotension.

D) Position the patient in a semi-Fowler's position and reassess vital signs every 15 minutes.

HPN S/P CVA - Nursing Case Study

Pathophysiology

• Primary mechanism: Hypertension (HPN) leads to chronic damage of blood vessel walls, causing them to become stiff and narrow, which increases the risk of plaque formation and atherosclerosis. This process reduces cerebral blood flow and can lead to ischemic events in the brain.

• Secondary mechanism: Elevated blood pressure can cause microaneurysms in small cerebral vessels, which may rupture and result in hemorrhagic stroke (CVA). The sudden increase in intracranial pressure from bleeding can damage surrounding brain tissue.

• Key complication: After a cerebrovascular accident (CVA), patients may experience impaired neurological function, depending on the stroke's location and severity. This can affect motor skills, speech, and cognitive abilities, necessitating comprehensive rehabilitation and vigilant blood pressure management to prevent recurrence.

Patient Profile

Demographics:

67-year-old female, retired school teacher

History:

• Key past medical history: Hypertension (HPN), Status Post Cerebrovascular Accident (S/P CVA), Type 2 Diabetes Mellitus

• Current medications: Lisinopril, Metformin, Aspirin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing difficulty with speech and mobility

• Key symptoms: Mild hemiparesis on the right side, slurred speech, intermittent headaches, mild confusion

• Vital signs: Blood pressure 160/100 mmHg, Heart rate 88 bpm, Respiratory rate 18 breaths per minute, Temperature 37.4°C, Oxygen saturation 94% on room air

Section 1

New Complications:

On the third day of hospitalization, the patient exhibits a sudden change in her clinical status. The nursing team notes an acute worsening of her speech, progressing from mild slurring to more pronounced dysarthria. Additionally, her right-sided hemiparesis has intensified, with the patient now unable to raise her right arm. These changes coincide with a new onset of facial droop on the right side. The patient's blood pressure has remained elevated despite medication, now reading 170/105 mmHg. Her heart rate is stable at 90 bpm, but her oxygen saturation has decreased slightly to 92% on room air. Concerns rise about potential extension of her previous cerebrovascular accident or a new ischemic event.

In response to these new symptoms, the healthcare team orders a stat CT scan of the head to assess for any acute intracranial changes. The CT scan reveals a small, new ischemic stroke in the left hemisphere, consistent with the patient's recent symptomatology. Lab results show an elevated blood glucose level of 220 mg/dL, indicating possible suboptimal diabetes management. Additionally, there is evidence of mild renal impairment, with a creatinine level of 1.6 mg/dL, suggesting possible nephropathy, which could be contributing to her hypertension. The interdisciplinary team, including neurology and endocrinology, is consulted to optimize her management plan and prevent further neurological compromise. The team considers adjusting her antihypertensive regimen and closely monitoring her blood glucose levels to mitigate risk factors for further cerebrovascular incidents. The patient and her family are informed of the findings and the revised plan of care, emphasizing the importance of strict blood pressure and glucose control to stabilize her condition.

Section 2

Following the identification of a new ischemic stroke, the healthcare team implements a revised management plan to stabilize the patient's condition. Initial interventions include adjusting her antihypertensive medications to better control her elevated blood pressure, with the introduction of a calcium channel blocker added to her current regimen. The patient's blood glucose management is also intensified, with the endocrinology team prescribing a short-acting insulin to address her hyperglycemia swiftly while developing a long-term strategy to optimize her diabetes management. Continuous monitoring of her vital signs and neurological status is initiated, with frequent assessments to detect any further deterioration.

Over the next 24 hours, the team observes some positive responses to the interventions. The patient's blood pressure shows a gradual downward trend, with readings stabilizing around 150/95 mmHg, although still above the target range. Her blood glucose levels have decreased to 160 mg/dL, demonstrating improvement but necessitating ongoing adjustment and monitoring. Neurologically, there is a slight improvement in her speech, with the dysarthria becoming less pronounced, though her right-sided hemiparesis remains severe. The interdisciplinary team remains vigilant for signs of further ischemic events or complications, given her existing comorbidities and recent stroke.

Despite these improvements, new complications emerge on the fifth day. The patient develops a low-grade fever of 100.8°F, and upon auscultation, decreased breath sounds are noted in the right lower lung field, raising suspicion for a possible aspiration pneumonia, a common concern in post-stroke patients with dysphagia. A chest X-ray confirms the presence of infiltrates in the right lower lobe. The team initiates broad-spectrum antibiotics and implements aspiration precautions, including elevation of the head of the bed and a modified diet following a swallowing assessment by the speech therapy team. These developments necessitate ongoing clinical reasoning and prompt adjustments to the care plan to prevent further decline and promote recovery.

Section 3

On the seventh day of hospitalization, the patient's condition presents a mixed picture, prompting the healthcare team to re-evaluate the care plan. While the broad-spectrum antibiotics appear to have reduced her fever, with her temperature now fluctuating between 99.2°F and 100°F, the patient's respiratory status remains a concern. Repeat auscultation reveals persistent decreased breath sounds in the right lower lung field, and she exhibits increased work of breathing with a respiratory rate of 24 breaths per minute. Her oxygen saturation has dropped to 90% on room air, necessitating supplemental oxygen via nasal cannula to maintain saturations above 94%. These findings suggest that the initial aspiration pneumonia may be more complicated or that additional pulmonary issues are developing.

Laboratory results provide further insight into her evolving condition. The white blood cell count remains elevated at 14,000/mm³, indicating ongoing infection or inflammation. Blood cultures have returned negative so far, although a sputum culture is pending. Arterial blood gas analysis reveals a mild respiratory alkalosis, with a pH of 7.47, PaCO2 of 33 mmHg, and PaO2 of 70 mmHg, reflecting her increased respiratory effort and possible impaired gas exchange. These results prompt the team to consider additional imaging studies to evaluate for potential complications such as a developing pleural effusion or worsening consolidation.

Faced with these findings, the interdisciplinary team, including pulmonology, considers advancing her respiratory support if necessary and reassesses her antibiotic regimen to ensure optimal coverage. The nursing staff implements rigorous pulmonary hygiene measures, including chest physiotherapy and incentive spirometry, to enhance lung expansion and secretion clearance. They also continue close monitoring of her neurological status, as any further decline could exacerbate her respiratory challenges. This stage of the patient's journey demands careful balancing of interventions to address both her respiratory and neurological needs while preparing for potential escalation of care should her condition not improve.

Section 4

On the eighth day of hospitalization, the patient exhibits a notable change in her status, prompting further evaluation by the healthcare team. Her respiratory rate has increased to 28 breaths per minute, and despite being on 3 liters of oxygen via nasal cannula, her oxygen saturation has decreased to 88%, indicating worsening hypoxemia. She appears more fatigued, with shallow breathing patterns and intermittent use of accessory muscles. Her blood pressure remains stable at 130/80 mmHg, but her heart rate has increased to 110 beats per minute, likely a compensatory response to her respiratory distress. Neurologically, the patient is more somnolent, only responding to verbal stimuli and showing decreased interest in participating in pulmonary hygiene exercises.

Recognizing the need for immediate intervention, the team orders a chest X-ray, which reveals an increased area of consolidation in the right lower lobe, consistent with a progression of her pneumonia. Additionally, a new pleural effusion is noted on the right side, which could be contributing to her respiratory compromise. The pending sputum culture results become critical as the team assesses the need to adjust her antibiotic therapy to target specific pathogens more effectively. Meanwhile, the arterial blood gas analysis shows a worsening picture: the pH remains elevated at 7.49, with a further drop in PaO2 to 60 mmHg and a decreased PaCO2 of 30 mmHg, highlighting her increased respiratory effort and impaired gas exchange.

In response to these developments, the interdisciplinary team considers escalating respiratory support to non-invasive positive pressure ventilation to improve oxygenation and reduce her work of breathing. The potential need for thoracentesis to address the pleural effusion is discussed. The nursing staff intensifies efforts in frequent repositioning and continues comprehensive pulmonary hygiene, while closely monitoring her neurological status for any further decline. The patient's evolving condition underscores the complexity of her care, necessitating coordinated efforts to stabilize her respiratory function and prevent further complications.

Section 5

As the healthcare team implements non-invasive positive pressure ventilation (NIPPV) to support the patient's respiratory function, they notice a slight improvement in her oxygen saturation, which increases to 92%. Despite this intervention, her respiratory rate remains elevated at 26 breaths per minute, and she continues to exhibit signs of increased work of breathing, including the persistent use of accessory muscles. The nursing staff notes that while she is marginally more alert, responding to verbal stimuli more consistently, her overall energy levels remain low, and she is still reluctant to engage in pulmonary exercises. This suggests that while the NIPPV is helping, her respiratory compromise is not fully resolved.

The pending sputum culture results return, identifying the presence of a multidrug-resistant strain of Pseudomonas aeruginosa. This finding prompts the infectious disease consultant to recommend a change in her antibiotic regimen, switching to a combination of ceftazidime and tobramycin to more effectively target the pathogen. In conjunction with the antimicrobial therapy adjustment, the team decides to proceed with a thoracentesis to address the pleural effusion, aiming to alleviate the pressure on her right lung and further improve her breathing mechanics. The procedure is scheduled promptly, with the expectation that it will assist in reducing her respiratory distress and contribute to better overall outcomes.

As preparations for the thoracentesis are underway, the patient experiences a new complication: a sudden onset of sharp, right-sided chest pain accompanied by a decrease in her blood pressure to 100/60 mmHg and an increase in her heart rate to 120 beats per minute. This acute change raises concerns about a potential pneumothorax or pulmonary embolism, both of which could be complications related to her current respiratory status and recent interventions. The healthcare team quickly mobilizes to perform an urgent repeat chest X-ray and a CT pulmonary angiogram to rule out these possibilities, demonstrating the dynamic and challenging nature of managing her complex clinical picture.