A 68-year-old female patient with a confirmed ischemic stroke affecting the left middle cerebral artery territory is experiencing increased confusion, disorientation, and complete right-sided hemiplegia despite clot-dissolving therapy. Her blood pressure is 175/108 mmHg, and her oxygen saturation has dropped to 92% on room air. Which of the following nursing interventions is most appropriate to address the current clinical picture and prevent further complications?

A) Administer supplemental oxygen to improve her oxygen saturation levels.

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

C) Position the patient supine to enhance cerebral blood flow.

D) Initiate seizure precautions to protect the patient from potential injury.

A 68-year-old female patient with a confirmed ischemic stroke affecting the left middle cerebral artery territory is experiencing increased confusion, disorientation, and complete right-sided hemiplegia. Her blood pressure is elevated, and oxygen saturation has decreased. What is the priority nursing intervention to address her current condition?

A) Administer supplemental oxygen to improve oxygen saturation.

B) Initiate intravenous fluids to maintain adequate hydration.

C) Prepare the patient for possible neurosurgical intervention.

D) Educate the family on the signs of increased intracranial pressure.

A patient with a recent ischemic stroke is being treated for increased intracranial pressure (ICP) with intravenous mannitol. The nurse elevates the head of the bed to 30 degrees. What is the primary rationale for this nursing intervention?

B) To promote venous drainage from the brain

A) To decrease cerebral metabolic demand

B) To promote venous drainage from the brain

C) To enhance the absorption of mannitol

D) To prevent the risk of aspiration pneumonia

A patient with a recent stroke is receiving osmotherapy with intravenous mannitol to manage cerebral edema. Despite a stabilized blood pressure, the patient remains lethargic and has decreased pupillary response. Which nursing intervention is most critical to prioritize in this scenario?

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

A) Administer a higher dose of mannitol to rapidly reduce intracranial pressure.

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

C) Prepare the patient for immediate surgical intervention to relieve pressure.

D) Initiate seizure precautions in anticipation of potential seizures.

A nurse is caring for a patient with cerebral edema and aspiration pneumonia. Despite interventions, the patient's neurological status and oxygenation remain compromised. Which nursing intervention is most appropriate to prioritize at this time?

A) Increase the frequency of neurological assessments to monitor for any changes.

B) Initiate continuous enteral feeding to improve nutritional status.

C) Prepare for intubation and mechanical ventilation to secure the airway.

D) Administer a higher dose of diuretics to aggressively manage cerebral edema.

A nurse is caring for a patient with cerebral edema and aspiration pneumonia. The patient is on non-invasive positive pressure ventilation, and her Glasgow Coma Scale (GCS) score remains at 8. Which nursing intervention is most critical at this time to ensure adequate oxygenation while minimizing the risk of increased intracranial pressure?

B) Maintain the head of the bed at 30 degrees and avoid excessive hyperventilation.

A) Frequently monitor the patient's oxygen saturation and adjust the ventilator settings as needed.

B) Maintain the head of the bed at 30 degrees and avoid excessive hyperventilation.

C) Perform frequent suctioning to prevent aspiration of secretions.

D) Administer sedatives to reduce the patient's respiratory effort and intracranial pressure.

A patient with worsening cerebral edema is experiencing a decline in her neurological status as evidenced by a drop in her GCS score and unequal pupillary response. Her respiratory status is compromised with hypoxemia and respiratory acidosis. Which of the following is the most appropriate initial nursing intervention to optimize her respiratory function while minimizing the risk of increased intracranial pressure?

B) Position the patient with the head of the bed elevated at 30 degrees

A) Increase the FiO2 on the non-invasive ventilation to improve oxygen saturation

B) Position the patient with the head of the bed elevated at 30 degrees

C) Prepare the patient for immediate intubation and mechanical ventilation

D) Administer a sedative to reduce metabolic demand and lower carbon dioxide levels

A patient with increased intracranial pressure and deteriorating neurological status is being evaluated for respiratory support. Her arterial blood gas shows respiratory acidosis with hypoxemia. What is the most appropriate initial nursing intervention to optimize her respiratory status while considering her neurological condition?

B) Prepare for endotracheal intubation and mechanical ventilation

A) Increase the settings on the non-invasive positive pressure ventilation

B) Prepare for endotracheal intubation and mechanical ventilation

C) Position the patient in high Fowler's position to enhance ventilation

D) Administer supplemental oxygen via nasal cannula

A patient with severe intracranial pressure is being prepared for an emergency decompressive craniectomy following intubation and mechanical ventilation. Which nursing intervention is most critical to perform immediately before the surgical procedure?

D) Verifying informed consent is signed and present in the chart

A) Administering prophylactic antibiotics as ordered

B) Ensuring the patient's head is positioned midline

C) Checking and documenting the patency of IV lines

D) Verifying informed consent is signed and present in the chart

A nurse is caring for a patient who has just undergone an emergency decompressive craniectomy following a severe stroke. The patient is intubated and on mechanical ventilation. Which nursing intervention is the highest priority to prevent further neurological deterioration in this patient?

B) Elevating the head of the bed to 30 degrees.

A) Frequent neurological assessments every 15 minutes.

B) Elevating the head of the bed to 30 degrees.

C) Administering prescribed mannitol and monitoring serum osmolality.

D) Ensuring strict aseptic technique to prevent infection.

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs when a blood clot obstructs an artery supplying the brain, leading to reduced blood flow and oxygen deprivation, causing neuronal cell death and loss of function in affected brain regions.

• Secondary mechanism: Hemorrhagic stroke is caused by the rupture of a weakened blood vessel, resulting in bleeding into or around the brain, which increases intracranial pressure and disrupts normal brain activity.

• Key complication: Both types of strokes can lead to permanent neurological deficits, such as paralysis or speech difficulties, due to the irreversible damage to brain tissue if not promptly treated.

Patient Profile

Demographics:

68-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, facial droop on the right side, headache

• Vital signs: Blood pressure 180/110 mmHg, heart rate 94 bpm, respiratory rate 22 breaths/min, temperature 37.8°C, oxygen saturation 95% on room air

Section 1

In the hours following her initial presentation, the 68-year-old female patient undergoes a CT scan, which confirms an ischemic stroke affecting the left middle cerebral artery territory. Despite receiving prompt medical attention and initiation of clot-dissolving therapy, her neurological status begins to evolve. The patient exhibits increased confusion and disorientation, and her right-sided weakness progresses to complete hemiplegia. Her speech remains slurred, and she is unable to articulate words coherently. Repeat vital signs indicate her blood pressure remains elevated at 175/108 mmHg, heart rate has increased to 102 bpm, respiratory rate is 24 breaths/min, and oxygen saturation has dropped to 92% on room air.

New laboratory results reveal elevated blood glucose levels at 220 mg/dL, and a follow-up lipid panel shows persistently high LDL cholesterol at 145 mg/dL. Electrolyte imbalances are not present, but her renal function tests reveal a slight increase in creatinine to 1.3 mg/dL, suggesting potential renal involvement. As the medical team discusses the case, they consider the possibility of failed reperfusion or evolving cerebral edema as contributing factors to her declining condition. Her care plan is adjusted to include tighter blood pressure control, with an intravenous antihypertensive regimen being initiated, alongside increased monitoring of her neurological status.

The clinical team remains vigilant for signs of further complications, such as hemorrhagic transformation or increased intracranial pressure. They educate the patient's family on recognizing these signs, emphasizing the importance of immediate intervention should her condition deteriorate further. As the hours progress, the team prepares for potential escalation of care, including the possibility of transfer to a higher-level facility with neurosurgical capabilities if her condition does not stabilize. This decision-making process reflects the ongoing need for clinical reasoning as the team balances the risks and benefits of each intervention in the context of her evolving clinical picture.

Section 2

As the medical team continues to manage the patient’s care, they focus on her response to the antihypertensive regimen. After several hours of treatment, her blood pressure begins to stabilize, decreasing to 160/100 mmHg. However, her neurological status remains concerning. The patient becomes increasingly lethargic and less responsive to verbal stimuli, raising suspicion of worsening cerebral edema. In response, the team initiates osmotherapy with intravenous mannitol to reduce intracranial pressure and closely monitors her neurological function for any signs of deterioration.

A repeat CT scan is ordered to evaluate the extent of the stroke and rule out hemorrhagic transformation. The imaging reveals no evidence of bleeding but confirms significant midline shift indicative of increased intracranial pressure. Her brainstem reflexes remain intact, but the team notes a decrease in her pupillary response, further supporting the need for aggressive management of cerebral edema. Given these findings, the decision is made to elevate the head of her bed to 30 degrees to facilitate venous drainage and optimize cerebral perfusion.

Throughout this period, the patient's oxygen saturation continues to be a concern, remaining at 90% despite supplemental oxygen. The medical team considers the possibility of aspiration pneumonia, given her impaired swallowing function and slurred speech, which could be contributing to her respiratory compromise. A chest X-ray is ordered, and empiric antibiotics are initiated to address potential infection. This multifaceted approach underscores the complexity of her condition and the importance of ongoing clinical reasoning in adapting her treatment plan to address both immediate and evolving complications.

Section 3

As the medical team continues to manage the patient's complex clinical picture, they focus on her response to the interventions initiated for cerebral edema and potential aspiration pneumonia. Despite the administration of intravenous mannitol and the elevation of the head of her bed, her neurological status shows minimal improvement, with persistent lethargy and sluggish pupillary response. This raises concerns about the effectiveness of the current approach in reducing intracranial pressure. The team decides to perform frequent neurological assessments, noting any changes in her Glasgow Coma Scale (GCS) score, which remains at 8, indicating severe impairment.

The chest X-ray results return, revealing infiltrates in the right lower lobe, consistent with aspiration pneumonia. This finding correlates with her impaired swallowing function and confirms the need for the empiric antibiotic therapy that has already been initiated. Meanwhile, her oxygen saturation remains suboptimal, fluctuating between 88-90% on continuous supplemental oxygen. The respiratory therapist is consulted, and the team opts to initiate non-invasive positive pressure ventilation to improve her oxygenation and reduce the work of breathing. This decision is made with careful consideration of her neurological status, as the team balances the need for respiratory support with the risk of increased intracranial pressure from positive pressure ventilation.

The situation remains dynamic, requiring the medical team to continuously adapt the patient's care plan. As they address the multifaceted complications, they consider the next steps, including further imaging or potential surgical interventions if her intracranial pressure does not respond to medical management. The multidisciplinary team remains vigilant, recognizing that timely adjustments in her care are critical to preventing further deterioration and optimizing her recovery potential.

Section 4

As the medical team continues to monitor the patient closely, they note a change in her status that prompts immediate attention. Over the course of the afternoon, her GCS score drops from 8 to 6, indicating a further decline in her neurological function. She becomes more difficult to arouse, and her pupillary response is now unequal, with the right pupil becoming more dilated and less reactive to light. These changes suggest worsening intracranial pressure, leading the team to urgently reassess their approach to managing her cerebral edema.

In response to these developments, the team decides to perform an urgent CT scan of the brain to evaluate for any new or worsening conditions such as a hemorrhage or significant midline shift. The scan reveals increased midline shift and worsening edema, but no new hemorrhage is identified. Given these findings and the patient's deteriorating neurological status, the neurosurgery team is consulted to discuss the potential need for more aggressive interventions, such as decompressive craniectomy, to relieve the pressure on her brain.

Meanwhile, the patient's respiratory status remains a concern. Despite the use of non-invasive positive pressure ventilation, her oxygen saturation continues to hover around 88-90%. Arterial blood gas analysis shows a pH of 7.32, PaCO2 of 50 mmHg, and PaO2 of 58 mmHg, indicating respiratory acidosis and hypoxemia. The team considers whether invasive mechanical ventilation might be necessary to better support her breathing while carefully weighing the risks of increased intracranial pressure. As they deliberate on these critical decisions, they remain focused on optimizing her outcomes by integrating their clinical findings with timely, evidence-based interventions.

Section 5

As the medical team deliberates on the need for invasive mechanical ventilation, they also initiate a series of interventions to address the patient's worsening intracranial pressure and respiratory status. Mannitol is administered intravenously to help reduce cerebral edema, and hypertonic saline is considered as an adjunct therapy to further draw fluid out of the brain tissues. Despite these measures, the patient's neurological status continues to deteriorate. Her GCS score further declines to 5, and she becomes unresponsive to verbal stimuli. Vital signs are concerning, with a blood pressure of 160/90 mmHg, heart rate of 98 bpm, and temperature of 37.8°C. Her respiratory rate is irregular, which prompts the team to proceed with intubation to secure her airway and provide mechanical ventilation, aiming to maintain her PaCO2 levels on the lower end of normal to prevent further increases in intracranial pressure.

Following intubation, the patient's arterial blood gas analysis shows some improvement: pH 7.35, PaCO2 45 mmHg, and PaO2 65 mmHg, indicating partial correction of her respiratory acidosis and slight improvement in oxygenation. However, her neurological examination remains poor, and her pupils are now both dilated and non-reactive, suggesting significant cerebral compromise. The neurosurgery team decides to proceed with an emergency decompressive craniectomy to alleviate the increased pressure within her skull.

Despite the timely interventions, the patient's condition illustrates the complexity of managing severe stroke complications. The team remains vigilant, monitoring for signs of potential new complications such as infection, seizures, or further hemodynamic instability. They understand the critical nature of rapid intervention and continuous reassessment to navigate the patient's precarious clinical status and improve her chances of recovery. As they prepare for the surgical intervention, they also coordinate with the ICU team to ensure comprehensive post-operative care, emphasizing the need for meticulous monitoring and support.