A patient with a confirmed ischemic stroke in the left middle cerebral artery territory is experiencing increasing confusion and decreased ability to follow commands, along with persistent hypertension and elevated blood glucose levels. What is the nurse's priority intervention to address these changes and prevent further complications?

B) Administer intravenous antihypertensive medication as ordered to control blood pressure.

A) Increase the dosage of the patient's statin medication to manage elevated LDL levels.

B) Administer intravenous antihypertensive medication as ordered to control blood pressure.

C) Encourage the patient to perform active range of motion exercises to prevent muscle atrophy.

D) Provide a high-carbohydrate snack to address elevated blood glucose levels.

A patient with a confirmed ischemic stroke in the left middle cerebral artery exhibits increasing confusion and decreased ability to follow commands. Her blood pressure is 185/100 mmHg, and her blood glucose is 250 mg/dL. Which nursing intervention should be prioritized to prevent further neurological deterioration?

A) Administer intravenous antihypertensives to manage hypertension.

B) Initiate insulin therapy to control hyperglycemia.

C) Increase monitoring of neurological status every 2 hours.

D) Administer an oral statin to manage elevated LDL cholesterol.

A patient with a history of hypertension and diabetes is being treated for elevated blood pressure and hyperglycemia. After initiating intravenous antihypertensive therapy and a sliding scale insulin protocol, the patient develops a new onset of headache and increased disorientation. Which nursing intervention is the most appropriate to address the potential complication of increased intracranial pressure?

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

A) Administer mannitol as prescribed to reduce cerebral edema

B) Increase the rate of intravenous fluids to improve cerebral perfusion

C) Reassess the patient's medication regimen to identify possible drug interactions

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

A patient receiving intravenous antihypertensive therapy and a beta-blocker for elevated blood pressure and tachycardia, respectively, exhibits signs of a headache and increased disorientation. Which nursing intervention should be prioritized to address the potential complication of increased intracranial pressure?

B) Elevate the head of the bed to 30 degrees to facilitate venous drainage from the brain.

A) Administer a bolus of intravenous fluids to improve cerebral perfusion.

B) Elevate the head of the bed to 30 degrees to facilitate venous drainage from the brain.

C) Increase the rate of antihypertensive medication to lower blood pressure further.

D) Administer an additional dose of beta-blocker to reduce heart rate further.

A patient with a recent ischemic stroke is experiencing a deterioration in neurological status with increased right-sided weakness and a decrease in ability to follow commands. The patient's GCS score is 12, and her oxygen saturation has dropped to 92% on room air. Considering her current condition, which nursing intervention should be prioritized?

A) Increase the frequency of neurological assessments to every 15 minutes

C) Prepare the patient for immediate surgical intervention

D) Increase the dosage of antihypertensive medication

A patient with ischemic stroke exhibits increased cerebral edema and receives mannitol therapy. The nurse observes a decline in the patient's neurological status with a decrease in the ability to follow commands and right-sided weakness. What is the nurse's priority action in response to these findings?

B) Reassess the patient's Glasgow Coma Scale (GCS) score and notify the healthcare provider.

A) Administer a higher dose of mannitol immediately.

B) Reassess the patient's Glasgow Coma Scale (GCS) score and notify the healthcare provider.

C) Increase the patient's supplemental oxygen to improve oxygen saturation.

D) Prepare the patient for immediate transfer to intensive care unit (ICU).

A patient with an ischemic stroke shows a decline in neurological status, with a Glasgow Coma Scale score dropping to 10 and significant cerebral edema indicated by CT scan results. Despite treatment with mannitol, intracranial pressure is inadequately controlled. Which intervention should the nurse anticipate as the priority to address the cerebral edema and prevent further neurological deterioration?

B) Administer hypertonic saline as ordered

A) Increase the dose of mannitol

B) Administer hypertonic saline as ordered

C) Initiate mechanical ventilation

D) Prepare for immediate surgical intervention

A patient with an ischemic stroke presents with a GCS score of 10, significant cerebral edema, and a midline shift. Despite administration of mannitol, the intracranial pressure remains elevated. The healthcare team is considering additional therapy with hypertonic saline. What is the primary reason for choosing hypertonic saline over mannitol in this scenario?

A) Hypertonic saline provides better control of intracranial pressure by drawing fluid out of brain cells.

B) Mannitol is ineffective in reducing cerebral edema in the presence of a midline shift.

C) Hypertonic saline has fewer side effects compared to mannitol.

D) Mannitol is contraindicated in patients with ischemic stroke due to the risk of hemorrhagic transformation.

A patient with ischemic stroke is receiving hypertonic saline to manage cerebral edema. The patient's serum sodium level is 150 mEq/L and the arterial blood gas analysis shows a pH of 7.32, PaCO2 of 48 mmHg, and PaO2 of 68 mmHg. What is the priority nursing intervention to address the current respiratory status?

B) Initiate BiPAP therapy to improve ventilation

A) Increase the flow of supplemental oxygen via nasal cannula

B) Initiate BiPAP therapy to improve ventilation

C) Administer a bronchodilator to enhance airway patency

D) Encourage deep breathing exercises to increase PaO2

A patient with ischemic stroke is receiving hypertonic saline for cerebral edema and is noted to have a serum sodium level of 150 mEq/L and respiratory acidosis with hypoxemia. Despite improved intracranial pressure, the patient's oxygen saturation remains at 90% on 4L of oxygen via nasal cannula. Which intervention should the nurse prioritize at this time?

A) Increase the flow rate of the nasal cannula to 6 liters per minute.

C) Administer a loop diuretic to manage potential fluid overload.

D) Prepare for intubation and mechanical ventilation.

Ischemic Stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs when a blood clot obstructs a cerebral artery, reducing blood flow and oxygen to brain tissue, leading to cell injury and death.

• Secondary mechanism: The blockage triggers a cascade of inflammatory responses and the release of excitotoxic neurotransmitters like glutamate, exacerbating neuronal damage and expanding the infarcted area.

• Key complication: If not promptly resolved, ischemic stroke can lead to irreversible brain damage, resulting in neurological deficits such as paralysis, speech difficulties, and cognitive impairments, emphasizing the urgency of rapid intervention.

Patient Profile

Demographics:

68-year-old female, retired school teacher

History:

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

• Current medications: Lisinopril, Metformin, Atorvastatin, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of right-sided weakness and difficulty speaking

• Key symptoms: Right arm and leg weakness, slurred speech, facial droop on the right side, confusion, headache

• Vital signs: Blood pressure 190/105 mmHg, heart rate 102 bpm, respiratory rate 22 breaths per minute, temperature 37.8°C, oxygen saturation 94% on room air

Section 1

As the medical team initiates the acute management of the ischemic stroke, additional diagnostic tests and monitoring reveal a change in the patient's status. A CT scan of the brain confirms the presence of an ischemic stroke in the left middle cerebral artery territory, correlating with her presenting symptoms of right-sided weakness and speech difficulties. Laboratory results indicate an elevated blood glucose level of 250 mg/dL, which is concerning given her history of Type 2 Diabetes Mellitus. Moreover, her low-density lipoprotein (LDL) cholesterol level is found to be 160 mg/dL, suggesting suboptimal control of hyperlipidemia despite ongoing statin therapy.

During the ongoing assessment, the patient exhibits increasing confusion and a decrease in her ability to follow simple commands, which raises concerns about the potential expansion of the infarcted area. Her vital signs remain concerning, with persistent hypertension (blood pressure 185/100 mmHg) and tachycardia (heart rate 110 bpm). The healthcare team considers these changes indicative of worsening cerebral edema and increased intracranial pressure, common complications following an ischemic stroke. This prompts the team to adjust her treatment plan, emphasizing the need for aggressive blood pressure management and close neurological monitoring.

Given these developments, the team is prompted to initiate additional interventions to stabilize her condition. They consider the use of intravenous antihypertensives to better control her blood pressure and prevent further cerebral damage. Furthermore, they explore options for optimizing her blood glucose levels, potentially involving adjustments to her current diabetic management regimen. These interventions aim to mitigate the risk of further neurological deterioration and improve her overall prognosis. The unfolding situation underscores the critical need for timely and coordinated care to address the complexities of her condition.

Section 2

Response to Interventions:

Following the initiation of intravenous antihypertensive therapy, the patient's blood pressure begins to show signs of improvement, decreasing gradually to a more manageable level of 160/90 mmHg. However, her heart rate remains elevated at 105 bpm, indicating persistent sympathetic nervous system activation. The healthcare team decides to adjust her medication regimen, adding a beta-blocker to address the tachycardia while continuing to monitor for potential side effects such as bradycardia or hypotension.

Concurrently, the team implements a revised diabetes management plan. They initiate a sliding scale insulin protocol to more effectively control her elevated blood glucose levels, which are reduced to 180 mg/dL within a few hours. This intervention not only targets her hyperglycemia but also aims to minimize the risk of further neurological damage, as hyperglycemia can exacerbate cerebral ischemic injury. Close monitoring of her glucose levels is maintained to avoid hypoglycemia, which could complicate her recovery.

Despite these interventions, the patient experiences a new onset of a headache and increased disorientation, suggesting a possible rise in intracranial pressure. The clinical team considers the potential for cerebral edema and evaluates the need for osmotic therapy with agents such as mannitol. A repeat CT scan is ordered to assess any changes in the brain's condition. These developments emphasize the need for continued vigilance and adaptability in her care plan, as the team endeavors to stabilize her condition and prevent further complications.

Section 3

The repeat CT scan reveals a slight increase in cerebral edema, corroborating the clinical suspicion of rising intracranial pressure. In response, the healthcare team initiates osmotic therapy with mannitol, aiming to reduce the edema and alleviate the patient's symptoms. Alongside this intervention, the patient's neurological status is closely monitored, with frequent assessments of her Glasgow Coma Scale (GCS) score. Her GCS score remains at 12, indicating a moderate level of impairment, but there is a concerning decrease in her ability to follow simple commands, suggesting potential worsening of her neurological status.

The nursing team notes a change in the patient's neurological assessment, including increased weakness on the right side, now with a notable drift in her right arm and leg when compared to the initial presentation. This change prompts the team to consider whether the ischemic area has expanded or if there are compounding factors contributing to her deteriorating condition. Her vital signs show a stable blood pressure at 150/85 mmHg due to the antihypertensive therapy and her heart rate has reduced to 90 bpm with the introduction of the beta-blocker. However, her oxygen saturation levels have dropped slightly to 92% on room air, necessitating supplemental oxygen to maintain adequate cerebral perfusion.

Laboratory results show an improvement in her blood glucose levels, now consistently between 140-160 mg/dL, suggesting effective management of her diabetes. However, the team remains vigilant for signs of hypoglycemia, especially given the recent adjustments in her insulin regimen. The patient's family is updated on her condition, and the multidisciplinary team discusses the possibility of further interventions, such as hypertonic saline, if the current measures do not adequately control the intracranial pressure. This situation underscores the complexity of managing ischemic stroke patients and the need for ongoing reassessment and adaptation of the care plan to prevent further complications.

Section 4

As the nursing team continues to monitor the patient closely, they note a further decline in her neurological status. Her Glasgow Coma Scale (GCS) score drops to 10, with decreased verbal response and further reduction in her ability to follow commands. The right-sided weakness has progressed to near-total paralysis, and there is now a noticeable slurring of speech. These changes raise concerns about the potential progression of the ischemic stroke or secondary complications such as hemorrhagic transformation. In response, the healthcare team orders an urgent CT scan to assess for any new developments, including the possibility of hemorrhage or significant increase in cerebral edema.

The CT scan reveals no hemorrhagic transformation but confirms an extension of the ischemic area, with significant midline shift indicating substantial cerebral edema. Despite the administration of mannitol, the intracranial pressure appears to be inadequately controlled, prompting the team to consider additional osmotic therapy with hypertonic saline. Concurrently, the patient's oxygen saturation remains at 92% even with supplemental oxygen, indicating insufficient cerebral oxygenation and the potential need for advanced airway management to optimize oxygen delivery and prevent further neurological deterioration.

Given these findings, the multidisciplinary team convenes urgently to reassess the treatment plan. They consider the potential benefits of hypertonic saline to aggressively manage the cerebral edema and reevaluate the need for mechanical ventilation to ensure adequate oxygenation and cerebral perfusion. The patient's family is informed of the current situation and the proposed interventions, emphasizing the critical nature of these developments and the need for swift action to stabilize the patient's condition. This situation underscores the complexity and dynamic nature of ischemic stroke management, necessitating vigilant monitoring and timely adaptation of the care plan to address emerging complications effectively.

Section 5

Response to Interventions

Following the administration of hypertonic saline, the nursing team observes a gradual stabilization in the patient's intracranial pressure, as evidenced by improved pupil response and a slight increase in her Glasgow Coma Scale (GCS) score to 11. The multidisciplinary team closely monitors her neurological status, noting that while the right-sided paralysis persists, there is a marginal improvement in her speech articulation, suggesting a modest reduction in cerebral edema. Vital signs indicate a blood pressure of 148/90 mmHg, heart rate of 86 bpm, and respiratory rate of 22 breaths per minute. However, despite these positive signs, the patient's oxygen saturation remains concerning at 90% on 4 liters of supplemental oxygen via nasal cannula, necessitating further escalation to non-invasive ventilation support.

Laboratory results reveal a serum sodium level of 150 mEq/L, reflecting the effects of hypertonic saline administration. While this is within an acceptable range for managing cerebral edema, the team remains vigilant for potential complications such as hypernatremia. Additionally, arterial blood gas analysis shows a pH of 7.32, PaCO2 of 48 mmHg, and PaO2 of 68 mmHg, indicative of respiratory acidosis and hypoxemia. These findings underscore the urgency of optimizing the patient's respiratory status to prevent further neurological compromise. The decision is made to initiate BiPAP therapy to improve ventilation and oxygenation, with careful monitoring for any signs of respiratory fatigue.

As the patient continues to receive supportive care, the team reevaluates the overall treatment strategy, considering the balance between aggressive management of cerebral edema and the prevention of secondary complications. The comprehensive plan includes regular reassessment of neurological function, electrolyte monitoring, and maintaining optimal respiratory support. The patient's family is updated on her progress and the critical steps being taken to stabilize her condition, highlighting the importance of ongoing vigilance and adaptability in managing the complexities of ischemic stroke. These developments set the stage for the next phase of the patient's journey, focusing on improving cerebral perfusion and minimizing further neurological damage.