A 67-year-old female patient is being treated for an ischemic stroke with intravenous tissue plasminogen activator (tPA) and has a history of Type 2 Diabetes and Hyperlipidemia. She begins to exhibit worsening confusion and difficulty with verbal communication. Her oxygen saturation decreases to 85% on supplemental oxygen. What is the priority nursing action?

B) Notify the healthcare provider of the patient's change in status immediately.

A) Increase the rate of supplemental oxygen delivery.

B) Notify the healthcare provider of the patient's change in status immediately.

C) Administer a dose of intravenous diuretics to reduce cerebral edema.

D) Perform a bedside swallow assessment to evaluate for dysphagia.

A 67-year-old female patient who recently experienced an ischemic stroke and is within the therapeutic window for tPA administration develops worsening confusion and difficulty with verbal communication. Her oxygen saturation is 85% despite supplemental oxygen. Based on these symptoms, which nursing intervention should be prioritized to address the potential complications?

C) Perform a bedside swallow assessment to evaluate the risk of aspiration.

A) Administer additional doses of aspirin to prevent further thrombotic events.

B) Increase the rate of intravenous fluids to manage potential cerebral edema.

C) Perform a bedside swallow assessment to evaluate the risk of aspiration.

D) Discontinue insulin therapy to prevent further hypoglycemia.

A patient with a recent ischemic stroke is experiencing decreased oxygen saturation and has been diagnosed with aspiration pneumonia. Which nursing intervention is most appropriate to prevent further respiratory complications in this patient?

B) Position the patient in a high Fowler's position during meals.

A) Encourage the patient to increase oral fluid intake.

B) Position the patient in a high Fowler's position during meals.

C) Assess the patient's gag reflex before administering oral medications.

D) Recommend the use of incentive spirometry every hour.

A patient with a recent ischemic stroke presents with decreased oxygen saturation, patchy infiltrates on chest X-ray, and is diagnosed with aspiration pneumonia. The healthcare team initiates broad-spectrum antibiotics and high-flow nasal cannula oxygen therapy. What is the nurse's priority intervention to prevent further aspiration in this patient?

D) Consult with a speech therapist for a swallowing evaluation

A) Elevate the head of the bed to 30 degrees

B) Administer antipyretics to control fever

C) Encourage the patient to cough and deep breathe

D) Consult with a speech therapist for a swallowing evaluation

A patient with recent aspiration pneumonia and suspected sepsis is showing signs of hypotension with a blood pressure of 95/60 mmHg. Considering her current symptoms and laboratory findings, which nursing intervention should be prioritized to address her hypotension while minimizing risks associated with her condition?

D) Reassess fluid balance and adjust IV fluids to manage cerebral edema

A) Administer a rapid bolus of normal saline to increase blood pressure

B) Initiate norepinephrine infusion to support blood pressure

C) Elevate the head of the bed to 45 degrees to improve ventilation

D) Reassess fluid balance and adjust IV fluids to manage cerebral edema

A patient with recent aspiration pneumonia and signs of sepsis presents with hypotension, hyponatremia, and a Glasgow Coma Scale score of 11. Which nursing intervention is the most critical to address the patient's current condition?

A) Administer 0.9% normal saline bolus to improve blood pressure.

B) Increase the rate of high-flow nasal cannula to improve oxygenation.

C) Administer a hypertonic saline solution to correct hyponatremia.

D) Monitor neurological status every 2 hours to detect changes in consciousness.

A patient with a recent ischemic stroke is experiencing increasing lethargy and a drop in Glasgow Coma Scale (GCS) score to 9. The healthcare team is concerned about the potential for cerebral edema and has initiated norepinephrine for persistent hypotension. Which intervention should the nurse prioritize to effectively manage the patient's condition?

C) Administer hypertonic saline cautiously to manage hyponatremia and minimize cerebral edema

A) Increase the rate of fluid resuscitation to quickly correct hypotension

B) Prepare for intubation to protect the airway due to declining neurological status

C) Administer hypertonic saline cautiously to manage hyponatremia and minimize cerebral edema

D) Discontinue norepinephrine and switch to dopamine for better hemodynamic support

A patient with a recent ischemic stroke is being monitored for complications. She exhibits increasing lethargy and hypotension, with a Glasgow Coma Scale (GCS) score of 9 and a blood pressure of 90/55 mmHg. Repeat CT imaging shows mild cerebral edema. Which of the following interventions should the nurse prioritize to address both her neurological status and hemodynamic instability?

B) Initiate norepinephrine to support blood pressure.

A) Administer mannitol to reduce cerebral edema.

B) Initiate norepinephrine to support blood pressure.

C) Increase fluid resuscitation to address hypotension.

D) Administer IV antibiotics to treat suspected infection.

A patient with worsening aspiration pneumonia and respiratory acidosis is receiving high-flow nasal cannula oxygen therapy. Despite treatment, her blood pressure remains low, and she has a decreased level of consciousness. Which nursing intervention is most critical to address her current condition?

C) Monitor neurological status closely and prepare for potential intubation.

A) Increase the rate of norepinephrine infusion to stabilize blood pressure.

B) Administer a bolus of normal saline to improve fluid status.

C) Monitor neurological status closely and prepare for potential intubation.

D) Switch antibiotics to cover for potential Gram-positive organisms.

A patient with worsening aspiration pneumonia and respiratory acidosis is receiving high-flow nasal cannula oxygen therapy. Her blood pressure remains unstable despite norepinephrine, and she has a GCS score of 8. Which nursing intervention is most critical to prioritize at this time?

D) Closely monitor her respiratory status and adjust oxygen therapy as needed.

A) Increase the norepinephrine dose to further stabilize blood pressure.

B) Implement seizure precautions due to her low GCS score.

C) Administer piperacillin-tazobactam as ordered to address the Gram-negative infection.

D) Closely monitor her respiratory status and adjust oxygen therapy as needed.

stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: Ischemic stroke occurs due to an obstruction in a cerebral blood vessel, often from atherosclerosis or an embolus, leading to reduced blood flow and oxygen delivery to brain tissue, causing cell death.

• Secondary mechanism: Hemorrhagic stroke results from the rupture of a weakened blood vessel, such as in hypertension or aneurysms, leading to bleeding within or around the brain, increasing intracranial pressure and further damaging brain tissue.

• Key complication: Both types of stroke can cause a cascade of cellular events, including excitotoxicity and inflammation, potentially leading to long-term neurological deficits and disability.

Patient Profile

Demographics:

67-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, facial droop on the right side, difficulty walking, confusion

• Vital signs: Blood pressure 190/110 mmHg, heart rate 95 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 90% on room air

Section 1

As the healthcare team continues to monitor the 67-year-old female patient following her initial stroke symptoms, new diagnostic results have emerged that indicate further insights into her condition. A CT scan of the brain reveals a significant ischemic area in the distribution of the left middle cerebral artery, confirming the suspicion of an ischemic stroke. The imaging results also show no evidence of hemorrhagic transformation at this time, which is crucial for guiding treatment options. Additionally, blood tests reveal elevated blood glucose levels at 220 mg/dL and increased LDL cholesterol at 150 mg/dL, both of which are consistent with her history of Type 2 Diabetes and Hyperlipidemia. These findings underscore the need for aggressive management of her cardiovascular risk factors.

In light of these results, the medical team decides to initiate treatment with intravenous tissue plasminogen activator (tPA) to dissolve the clot and restore cerebral blood flow, given that she is within the therapeutic window for this intervention. Concurrently, her antihypertensive regimen is adjusted to more effectively lower her blood pressure, aiming for a target of less than 140/90 mmHg to minimize further vascular damage. Aspirin therapy is continued to prevent additional thrombotic events. The patient is also started on an insulin sliding scale to manage her hyperglycemia, as tight glucose control is necessary to improve her neurological outcomes.

Despite these interventions, the patient begins to exhibit new complications. She develops worsening confusion and increasing difficulty with verbal communication, suggesting the possibility of cerebral edema or evolving infarction. Her oxygen saturation decreases further to 85% even with supplemental oxygen, indicating potential pulmonary complications such as aspiration pneumonia, a common concern in stroke patients with dysphagia. These developments require immediate re-evaluation of her treatment plan, including potential escalation of care to address respiratory challenges and additional imaging to assess for changes in her neurological status. The healthcare team must prioritize a multidisciplinary approach, integrating neurology, respiratory therapy, and potentially critical care, to navigate these new challenges effectively.

Section 2

As the healthcare team addresses the patient's worsening confusion and difficulty with verbal communication, they decide to perform a repeat CT scan to assess for any changes in her neurological status. The imaging reveals a slight increase in the size of the ischemic area, suggesting evolving infarction. There is no evidence of cerebral hemorrhage, which is a relief, but the presence of mild cerebral edema is noted. Clinically, her level of consciousness has decreased, and she is now only responsive to verbal stimuli with a Glasgow Coma Scale (GCS) score of 11. Her blood pressure remains elevated at 165/95 mmHg despite adjustments to her antihypertensive regimen, indicating the need for further optimization of her blood pressure control.

In light of her decreased oxygen saturation to 85% on supplemental oxygen, a chest X-ray is performed, revealing patchy infiltrates in the right lower lobe consistent with aspiration pneumonia. This finding correlates with her dysphagia and highlights the need for aggressive pulmonary management. The patient is immediately started on broad-spectrum antibiotics to address the infection and placed on a high-flow nasal cannula to improve her oxygenation. A speech therapist is consulted to evaluate her swallowing function and to recommend safe dietary modifications or the temporary use of a feeding tube to prevent further aspiration.

The healthcare team continues to monitor the patient closely, integrating input from neurology, respiratory therapy, and speech therapy. The focus is on stabilizing her neurological status and improving her respiratory function. The patient's evolving condition underscores the need for vigilant multidisciplinary management to prevent further complications. The team is prepared to escalate care to an intensive care setting if her respiratory or neurological status deteriorates further. As they work to stabilize her, they also begin to discuss long-term rehabilitation strategies to address the deficits resulting from her stroke, aiming to optimize her recovery and quality of life.

Section 3

As the healthcare team continues to manage the patient's condition, they closely monitor her response to the interventions implemented. Over the next 24 hours, her oxygen saturation shows signs of improvement, rising to 92% on the high-flow nasal cannula. Her respiratory rate stabilizes at 18 breaths per minute, and her breath sounds are slightly clearer upon auscultation, suggesting a positive response to the antibiotics and respiratory support. However, her neurological status remains a concern. The patient is still only responsive to verbal stimuli, and her GCS score remains at 11, indicating no significant improvement in her level of consciousness.

Laboratory results provide additional insights into her condition. Her white blood cell count is elevated at 14,500/mm³, supporting the diagnosis of infection, while her C-reactive protein level is also high, reflecting ongoing inflammation. Blood cultures are pending, but the empirical antibiotic regimen is maintained to cover a broad range of possible pathogens. Her electrolytes reveal mild hyponatremia, with a sodium level of 132 mEq/L, possibly contributing to her confusion and lethargy. These findings prompt the team to carefully manage her fluid balance and consider the need for sodium supplementation.

Despite the intensive supportive care, a new complication arises: the patient develops hypotension with blood pressure readings dropping to 95/60 mmHg. This unexpected change prompts an urgent review of her fluid status and antihypertensive regimen. The healthcare team considers the possibility of sepsis as a driving factor behind her hypotension, given her recent aspiration pneumonia. Fluid resuscitation is initiated cautiously to avoid exacerbating her cerebral edema. This development necessitates reevaluation of her current treatment plan and highlights the complexity of managing multifaceted complications in stroke patients. The team remains vigilant, ready to adjust their approach as needed to stabilize her condition and prevent further deterioration.

Section 4

As the healthcare team continues to monitor the patient's condition, a change in her status becomes apparent. Over the next several hours, the patient exhibits increasing lethargy and a further decline in her neurological status. Her Glasgow Coma Scale (GCS) score drops to 9, indicating a concerning decrease in her level of consciousness. This change prompts an immediate neurological assessment and further imaging studies to evaluate for potential complications such as cerebral edema or hemorrhagic transformation, which are known risks in the context of her recent ischemic stroke.

A repeat CT scan of the head is ordered and reveals mild cerebral edema, with no signs of hemorrhagic conversion at this stage. However, the edema is concerning enough to warrant close monitoring and potential intervention to prevent further neurological deterioration. The patient's blood pressure remains a challenge, with persistent hypotension despite cautious fluid resuscitation. Her latest blood pressure reading is 90/55 mmHg, which raises the suspicion of septic shock, possibly linked to her aspiration pneumonia. The healthcare team considers initiating vasopressor support to maintain adequate cerebral perfusion pressure, while continuing to explore the appropriate balance of fluids and electrolytes to address her hyponatremia.

In light of these developments, the team engages in critical clinical reasoning to adjust the patient's management plan. They decide to escalate her care with the introduction of norepinephrine to support her blood pressure, alongside careful titration of hypertonic saline to address her sodium imbalance. The goal is to stabilize her hemodynamic status while minimizing the risk of exacerbating her cerebral edema. Additionally, they prioritize the review of her antibiotic regimen once blood culture results become available, ensuring optimal coverage for her suspected septicemia. These interventions reflect a nuanced approach to managing the complex interplay of stroke, infection, and hemodynamic instability, as the team works diligently to guide the patient toward recovery.

Section 5

Despite the initiation of norepinephrine, the patient's blood pressure response remains suboptimal, with readings fluctuating between 88/52 mmHg and 92/56 mmHg. This instability prompts the healthcare team to reassess her fluid status and vasopressor dosing. Concurrently, her oxygen saturation has decreased to 88% on 2L nasal cannula, necessitating an increase in supplemental oxygen and further evaluation of her respiratory function. A repeat arterial blood gas (ABG) analysis shows a pH of 7.32, PaCO2 of 48 mmHg, and PaO2 of 62 mmHg, indicating respiratory acidosis and hypoxemia. These findings suggest that her aspiration pneumonia might be worsening, potentially contributing to her continued hemodynamic instability and altered mental status.

In light of the ABG results and the patient's unresponsive blood pressure, the team decides to escalate respiratory support by transitioning her to high-flow nasal cannula oxygen therapy. Meanwhile, they order a chest X-ray to assess the extent of her pneumonia. The X-ray reveals bilateral infiltrates consistent with worsening aspiration pneumonia. The team also receives preliminary blood culture results indicating Gram-negative rods, prompting an adjustment in her antibiotic regimen to include broader Gram-negative coverage with piperacillin-tazobactam.

The patient's hyponatremia has shown mild improvement with the cautious administration of hypertonic saline, with serum sodium levels rising from 126 mmol/L to 130 mmol/L. However, her neurological status remains concerning, with a GCS of 8, necessitating ongoing close monitoring. The team recognizes the delicate balance required to manage her cerebral edema while addressing her infectious and hemodynamic challenges. They continue to refine her treatment plan, emphasizing the importance of regular reassessment and a multidisciplinary approach to guide her through this critical phase toward stabilization.