A patient with an ischemic stroke has recently undergone thrombolytic therapy. Six hours post-intervention, the patient exhibits increasing confusion, decreased level of consciousness, and a further drop in oxygen saturation. Given these changes, what is the nurse's priority action?

C) Notify the physician immediately regarding the patient's deteriorating status.

A) Administer supplemental oxygen to improve oxygenation.

B) Perform a neurological assessment to evaluate for any changes.

C) Notify the physician immediately regarding the patient's deteriorating status.

D) Reassess vital signs to determine the effectiveness of current interventions.

A patient who recently received thrombolytic therapy for an ischemic stroke is now presenting with confusion, decreased level of consciousness, and worsening right-sided weakness. Which nursing intervention should be prioritized based on these findings?

A) Administer prescribed mannitol to reduce intracranial pressure.

B) Increase oxygen supplementation to improve oxygen saturation.

C) Prepare the patient for another dose of tissue plasminogen activator (tPA).

D) Reassess blood glucose levels and administer insulin if necessary.

A patient in the ICU post-stroke exhibits persistent elevated intracranial pressure (ICP) despite treatment and fluctuating blood pressure that remains high. What nursing intervention is the priority to address these concerns and prevent further complications?

C) Collaborate with the healthcare team to optimize the nicardipine infusion for better blood pressure control.

A) Increase the rate of mannitol administration to reduce ICP more effectively.

B) Monitor the patient's blood glucose levels hourly and adjust insulin coverage as needed.

C) Collaborate with the healthcare team to optimize the nicardipine infusion for better blood pressure control.

A patient in the ICU post-stroke is experiencing elevated intracranial pressure and persistent hyperglycemia despite appropriate medical interventions. The nursing team is planning to address these concerns in an interdisciplinary meeting. Which nursing intervention should be prioritized to help stabilize the patient's condition?

B) Collaborate with the respiratory therapist to initiate non-invasive positive pressure ventilation to improve oxygenation.

A) Increase the rate of mannitol infusion to reduce intracranial pressure more quickly.

B) Collaborate with the respiratory therapist to initiate non-invasive positive pressure ventilation to improve oxygenation.

C) Request an endocrinology consult to adjust the insulin regimen for better glycemic control.

D) Suggest increasing the dosage of nicardipine to achieve tighter blood pressure regulation.

A patient with worsening cerebral edema and acute kidney injury is under your care. The healthcare team is considering a decompressive craniectomy. As a nurse, what is the most critical nursing priority when preparing this patient for potential surgical intervention?

A) Monitoring and managing blood pressure to prevent further intracranial pressure increases.

B) Ensuring the patient is well-hydrated to improve renal perfusion.

C) Administering osmotic diuretics to reduce cerebral edema prior to surgery.

D) Educating the patient and family about the risks and benefits of the surgery.

A patient with worsening cerebral edema and acute kidney injury is being managed with osmotic agents and nephrotoxic medications. What is the most appropriate nursing intervention to prioritize at this time?

C) Monitor the patient's fluid intake and output closely to assess kidney function and avoid fluid overload.

A) Administer an additional dose of osmotic diuretics to reduce intracranial pressure.

B) Collaborate with the healthcare team to discuss the potential need for decompressive craniectomy.

C) Monitor the patient's fluid intake and output closely to assess kidney function and avoid fluid overload.

D) Increase the frequency of neurological assessments to detect early signs of deterioration.

A patient in the ICU with increased intracranial pressure is showing signs of Cushing's triad. The healthcare team has started osmotic diuretics and hypertonic saline infusion. Which nursing intervention is most critical to monitor for potential complications related to the treatment plan?

A) Monitor the patient's serum sodium and osmolality levels closely.

B) Assess for signs of fluid overload and pulmonary edema.

C) Evaluate the patient's neurological status every four hours.

D) Check for signs of infection at the intravenous access site.

A patient with increased intracranial pressure (ICP) is showing signs of Cushing's triad. The healthcare team has adjusted the treatment plan to address cerebral edema and enhance renal function. Which nursing intervention is most appropriate to prioritize in this scenario?

B) Administer osmotic diuretics and hypertonic saline as prescribed

A) Monitor the patient’s Glasgow Coma Scale (GCS) score every 4 hours

B) Administer osmotic diuretics and hypertonic saline as prescribed

C) Assess and document urine output and renal function indicators every 6 hours

D) Prepare the patient for an urgent decompressive craniectomy

A patient with acute kidney injury (AKI) secondary to fluid overload is receiving continuous renal replacement therapy (CRRT). Which nursing intervention is most critical to ensure effective management of both the patient's renal and cerebral conditions?

D) Collaborate with the healthcare team to adjust fluid intake and CRRT settings to maintain hemodynamic stability.

A) Administer prescribed diuretics and report any changes in urine output to the physician.

B) Monitor and document serum electrolyte levels every four hours and notify the healthcare provider of significant changes.

C) Adjust the CRRT settings based on urine output to optimize fluid removal and prevent cerebral edema.

D) Collaborate with the healthcare team to adjust fluid intake and CRRT settings to maintain hemodynamic stability.

A patient with acute kidney injury (AKI) secondary to critical illness is receiving continuous renal replacement therapy (CRRT) due to fluid overload and uremia. Which nursing intervention is most important to prevent further complications while maintaining cerebral perfusion?

B) Monitoring serum electrolytes and adjusting CRRT settings accordingly

A) Administering antihypertensive medication to maintain a low blood pressure

B) Monitoring serum electrolytes and adjusting CRRT settings accordingly

C) Restricting fluid intake to prevent further fluid overload

D) Increasing the rate of hypertonic saline to reduce cerebral edema

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs when a blood clot obstructs a cerebral artery, leading to reduced blood flow and oxygen supply to brain tissue, resulting in cell death and neurological deficits.

• Secondary mechanism: Hemorrhagic stroke arises from the rupture of a blood vessel in the brain, causing bleeding and increased intracranial pressure, which compresses brain structures and disrupts function.

• Key complication: Both types of stroke can lead to cerebral edema, exacerbating neurological damage by further compressing brain tissue and impairing blood flow, necessitating urgent intervention to minimize long-term deficits.

Patient Profile

Demographics:

67-year-old male, retired electrician

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, headache

• Vital signs: Blood pressure 180/95 mmHg, heart rate 96 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

Following the initial assessment, the patient underwent a CT scan without contrast to determine the type of stroke. The imaging confirmed an ischemic event in the left middle cerebral artery territory, correlating with the patient's right-sided weakness and facial droop. Concurrently, laboratory tests revealed elevated blood glucose levels at 220 mg/dL, indicating poorly controlled diabetes, which can exacerbate complications in stroke patients. His lipid profile showed elevated LDL cholesterol at 160 mg/dL, despite atorvastatin therapy, suggesting the need for further medication adjustment to improve vascular health. Given these findings, the primary team initiated thrombolytic therapy with tissue plasminogen activator (tPA) to dissolve the clot, while also addressing hyperglycemia with an insulin sliding scale.

Approximately six hours post-intervention, the patient's condition shifted. His blood pressure remained elevated at 185/100 mmHg, despite initial management attempts, highlighting the risk of hemorrhagic transformation. The nurse noted increasing confusion and a decreased level of consciousness, alongside a further drop in oxygen saturation to 88% on room air. Repeat neurological assessment revealed worsening speech difficulties and increased right-sided weakness. These changes necessitated an urgent repeat CT scan to rule out hemorrhagic conversion, which confirmed new findings of cerebral edema with midline shift, a significant complication requiring immediate escalation of care.

The presence of cerebral edema prompted the implementation of osmotic therapy with mannitol and hypertonic saline to reduce intracranial pressure. The medical team also considered the addition of corticosteroids to manage inflammation, while ensuring continuous monitoring in the intensive care unit. This development emphasizes the importance of aggressive management of blood pressure and glucose levels in stroke patients to prevent further neurological decline. The evolving complications highlight the need for vigilant monitoring and prompt intervention to stabilize the patient's condition and mitigate long-term deficits. This critical juncture in the patient's journey underscores the complexity of stroke management and the necessity for interdisciplinary collaboration to optimize outcomes.

Section 2

As the patient remained in the intensive care unit, the nursing team continued their vigilant monitoring, particularly focusing on neurological status and vital signs to assess the response to interventions. Despite the administration of mannitol and hypertonic saline, the patient's intracranial pressure remained concerningly elevated. The medical team also noted a lack of significant improvement in the patient's level of consciousness, which hovered between a Glasgow Coma Scale (GCS) score of 8 and 9, indicating severe impairment. Repeat laboratory tests revealed persistent hyperglycemia, with blood glucose levels fluctuating between 200 and 250 mg/dL, despite aggressive insulin therapy. This suggested a potential need to re-evaluate the insulin regimen and consider additional measures to achieve better glycemic control.

On the second day post-stroke, the patient's blood pressure remained labile, with readings reaching as high as 190/105 mmHg at times, despite intensive antihypertensive management. The fluctuating blood pressure raised concerns about further cerebral edema and the risk of re-bleeding or new ischemic events. Consequently, the team decided to initiate a continuous infusion of nicardipine, a calcium channel blocker, to achieve more stable blood pressure control. Additionally, the patient's oxygen saturation remained borderline at 90% on 2 liters of oxygen via nasal cannula, prompting the consideration of non-invasive positive pressure ventilation to improve oxygenation and reduce respiratory effort.

By the end of the shift, the patient's neurological examination showed slight improvement in speech, with the ability to form simple phrases, although right-sided weakness persisted with minimal change. This marginal progress, coupled with ongoing challenges in managing blood pressure and glucose levels, highlighted the complexity of the patient's condition. It underscored the necessity for ongoing interdisciplinary discussions to refine the treatment plan, with a view toward preventing further complications and promoting recovery. The team planned a multidisciplinary case conference to reassess the treatment strategy and explore additional avenues, such as consulting endocrinology for diabetes management and reconsidering the current statin therapy to address dyslipidemia more effectively.

Section 3

As the patient's condition continued to evolve, new diagnostic results provided additional insights into the complexity of their medical status. A repeat CT scan of the brain was performed to assess the progression of cerebral edema and potential secondary complications. The imaging revealed a slight increase in midline shift, suggesting worsening cerebral edema, despite the ongoing administration of osmotic agents. This finding raised the level of concern among the healthcare team, prompting a reevaluation of the current therapeutic approach. The team deliberated on the potential benefits of surgical intervention, such as decompressive craniectomy, to alleviate intracranial pressure and prevent further neurological deterioration.

In parallel, the patient's laboratory workup uncovered a new set of challenges. A comprehensive metabolic panel indicated worsening kidney function, with creatinine levels rising to 2.1 mg/dL from a baseline of 1.0 mg/dL. This acute kidney injury was likely multifactorial, possibly exacerbated by the use of nephrotoxic medications and the aggressive management of blood pressure and hyperglycemia. The team recognized the need for a delicate balance in treatment to avoid further renal compromise while continuing to address the critical issues of intracranial pressure and systemic hypertension. A nephrology consultation was requested to provide expertise in optimizing renal support and adjusting the pharmacological regimen to mitigate further kidney damage.

These developments underscored the intricate interplay between the patient's neurological and systemic conditions, challenging the healthcare team to prioritize interventions that would stabilize the patient's status without precipitating additional complications. The new findings necessitated a swift and coordinated response, incorporating insights from multiple specialties to refine the treatment plan and anticipate further challenges in the patient's recovery trajectory.

Section 4

As the healthcare team continued to monitor the patient closely, there was a notable change in the patient's status that required immediate attention. Overnight, the patient became increasingly lethargic, with a significant decline in their Glasgow Coma Scale (GCS) score from 13 to 9, indicating a deterioration in neurological function. Upon assessment, the patient exhibited sluggish pupillary reactions and a decrease in motor response on the right side, raising concerns about worsening intracranial pressure and possible herniation. Vital signs revealed hypertension with a blood pressure of 180/100 mmHg, bradycardia with a heart rate of 55 beats per minute, and irregular respirations, further suggesting the development of Cushing's triad, a classic sign of increased intracranial pressure.

The clinical team swiftly responded to these alarming changes by increasing the dosage of osmotic diuretics and initiating hypertonic saline infusion to attempt to reduce cerebral edema. In addition, they expedited the previously considered surgical consultation for decompressive craniectomy. The patient's worsening renal function, however, posed a significant challenge. The nephrology team recommended adjusting the osmotic agent regimen to minimize nephrotoxicity while maintaining adequate cerebral perfusion pressure. They also advised the initiation of renal protective strategies, such as maintaining optimal hydration status and monitoring electrolyte levels closely, to prevent further renal impairment.

These developments highlighted the complexity of managing a critically ill patient with multiple organ involvement, necessitating a multidisciplinary approach to balance the risks and benefits of each intervention. The team prioritized stabilizing the patient’s neurological status while cautiously managing renal function, understanding that each decision had the potential to impact the patient's overall recovery trajectory significantly. As the patient’s condition remained precarious, the healthcare team prepared for the possibility of additional complications, necessitating continuous evaluation and adaptation of treatment strategies.

Section 5

As the healthcare team continued to manage the patient’s critical condition, they observed a new complication: the development of acute kidney injury (AKI). The patient’s serum creatinine levels had risen sharply from 1.2 mg/dL to 2.8 mg/dL within 24 hours, and urine output had decreased to less than 0.5 mL/kg/hour, indicating oliguria. Blood urea nitrogen (BUN) levels also increased, further confirming renal impairment. The nephrology team assessed the patient and noted signs of fluid overload, such as peripheral edema and mild pulmonary congestion evident on a chest X-ray. These findings prompted a reevaluation of the current fluid management strategy, considering the delicate balance required to reduce cerebral edema while preventing further renal deterioration.

In response to the AKI, the team adjusted the treatment plan by tapering the osmotic diuretics and modifying the hypertonic saline infusion to avoid exacerbating the renal injury. They initiated low-dose diuretics specifically targeting fluid overload and engaged in careful monitoring of the patient's fluid balance and electrolyte levels. The decision was made to initiate continuous renal replacement therapy (CRRT) to manage uremia and fluid overload without causing hemodynamic instability, which could further compromise cerebral perfusion.

This development underscored the intricate interplay between the patient’s neurological and renal statuses, challenging the team to maintain equilibrium between interventions. The healthcare team recognized the critical need for vigilant monitoring and rapid adaptation to the evolving clinical picture, emphasizing the importance of interprofessional collaboration. As the patient’s journey progressed, the team remained alert to the potential for further complications, prepared to adjust their strategies to navigate the complex path to stabilization and recovery.