A patient with an ischemic stroke affecting the left middle cerebral artery presents with right-sided weakness, aphasia, and a fluctuating level of consciousness. His blood pressure is critically high despite antihypertensive therapy, and he is receiving supplemental oxygen. What is the priority nursing intervention to prevent further neurological decline?

B) Initiate intravenous antihypertensive therapy

A) Administer thrombolytic therapy immediately

B) Initiate intravenous antihypertensive therapy

C) Increase the supplemental oxygen flow rate

D) Perform frequent neurological assessments using the NIH Stroke Scale

A patient receiving thrombolytic therapy for an ischemic stroke begins to exhibit increased confusion, severe agitation, and new-onset bradycardia. The CT scan shows no hemorrhage but indicates worsening cerebral edema. What is the priority nursing intervention at this time?

C) Increase the head of the bed elevation and administer osmotic diuretics

A) Administer additional antihypertensive medication to lower blood pressure

B) Prepare for potential intubation to secure the patient's airway

C) Increase the head of the bed elevation and administer osmotic diuretics

D) Notify the healthcare provider for an urgent neurosurgical consultation

A patient receiving thrombolytic therapy for a stroke is experiencing increasing confusion, severe agitation, and bradycardia. A follow-up CT scan reveals increased midline shift and cerebral edema. What is the most appropriate nursing intervention to prioritize at this time?

B) Administer osmotic diuretics to reduce cerebral edema and monitor neurological status closely.

A) Increase the rate of intravenous antihypertensives to rapidly lower blood pressure.

B) Administer osmotic diuretics to reduce cerebral edema and monitor neurological status closely.

C) Prepare for immediate intubation to protect the airway due to increased intracranial pressure symptoms.

D) Administer a sedative to manage agitation and ensure patient safety.

A patient with elevated intracranial pressure (ICP) is being treated with hypertonic saline therapy. Which of the following clinical assessments is most critical for the nurse to perform to prevent complications associated with this treatment?

A) Monitor serum sodium levels closely

B) Assess for signs of volume overload

C) Evaluate for changes in pupil reactivity

D) Measure urine output frequently

A patient with elevated intracranial pressure (ICP) is receiving hypertonic saline therapy. The nurse notes a rising sodium level in the latest laboratory results. Which nursing intervention is the most appropriate at this time?

B) Implement seizure precautions and monitor neurological status closely.

A) Increase the rate of hypertonic saline infusion to quickly reduce ICP.

B) Implement seizure precautions and monitor neurological status closely.

C) Administer a diuretic to promote excretion of excess sodium.

D) Withhold the next dose of hypertonic saline until sodium levels normalize.

A patient with a recent ischemic stroke is showing signs of neurological deterioration, including lethargy and left-sided weakness, along with an elevated serum sodium level of 155 mEq/L after hypertonic saline therapy. The interdisciplinary team is considering adjusting the treatment plan. What is the most appropriate initial nursing action to address these findings?

D) Implement seizure precautions and closely monitor neurological status.

A) Increase the rate of hypertonic saline to counteract the neurological symptoms.

B) Prepare the patient for a repeat CT scan to assess for hemorrhagic transformation.

C) Administer an immediate diuretic to reduce cerebral edema.

D) Implement seizure precautions and closely monitor neurological status.

A patient with a recent stroke exhibits increasing lethargy, left-sided weakness, and sluggish pupillary reaction. Lab results show hypernatremia with serum sodium at 155 mEq/L after hypertonic saline therapy. Blood gas analysis indicates respiratory acidosis with an arterial pH of 7.32 and CO2 level of 50 mmHg. What is the most appropriate initial nursing intervention?

B) Prepare for intubation to secure the airway and improve ventilation.

A) Increase the rate of hypertonic saline infusion to reduce cerebral edema.

B) Prepare for intubation to secure the airway and improve ventilation.

C) Administer a rapid infusion of hypotonic saline to correct hypernatremia.

D) Encourage deep breathing exercises to reduce CO2 levels.

A patient with cerebral edema and a small hemorrhagic conversion post-ischemic stroke has been intubated and is now on mechanical ventilation. After the repeat CT scan, the interdisciplinary team is considering osmotic therapy to manage increased intracranial pressure. Which nursing action is most essential to perform before initiating osmotic therapy with mannitol?

C) Review the patient's renal function tests

A) Assess the patient's serum sodium levels

B) Monitor the patient's blood pressure closely

C) Review the patient's renal function tests

D) Evaluate the patient's fluid intake and output

A patient with cerebral edema and a small hemorrhagic conversion is being managed in the ICU. The patient is currently receiving mechanical ventilation, and the interdisciplinary team is considering the use of osmotic therapy to manage intracranial pressure. The nurse notes a new pattern of hypertension with blood pressure readings of 180/100 mmHg. What is the nurse's priority action?

D) Perform a focused neurological assessment to evaluate changes in the patient's status.

A) Administer an antihypertensive medication to immediately lower the blood pressure.

B) Consult with the interdisciplinary team about initiating osmotic therapy with mannitol.

C) Increase the settings on the mechanical ventilator to enhance respiratory support.

D) Perform a focused neurological assessment to evaluate changes in the patient's status.

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 delivery to brain tissue. This results in cell death and loss of neurological function.

• Secondary mechanism: Hemorrhagic stroke arises from the rupture of a weakened blood vessel, causing bleeding into or around the brain. This elevates intracranial pressure and disrupts normal cerebral perfusion, leading to tissue damage.

• Key complication: Both types of stroke can lead to cerebral edema, worsening brain injury, and increasing the risk of long-term disability by further impairing neural pathways and brain function.

Patient Profile

Demographics:

67-year-old male, retired construction worker

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, confusion

• Vital signs: Blood pressure 185/110 mmHg, heart rate 98 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

As the medical team initiates the initial assessment, the patient's neurological status is closely monitored. A CT scan is promptly ordered to differentiate between ischemic and hemorrhagic stroke. The scan reveals an ischemic stroke affecting the left middle cerebral artery, correlating with the patient's right-sided weakness and speech difficulties. While awaiting further diagnostic results, the team notes that the patient's blood pressure remains critically high at 190/112 mmHg, despite being on antihypertensive therapy. His oxygen saturation dips to 89% on room air, prompting the initiation of supplemental oxygen to maintain adequate cerebral oxygenation.

During the initial assessment, the nursing team performs a thorough neurological evaluation using the NIH Stroke Scale (NIHSS), scoring the patient at a 12, indicating a moderate stroke. The patient exhibits significant aphasia and right-sided hemiparesis, raising concerns about his ability to protect his airway as his level of consciousness begins to fluctuate. The patient also demonstrates subtle signs of worsening cerebral edema, such as increased confusion and a mild headache that escalates in intensity. The care team considers these findings while formulating an intervention plan to address both the acute ischemic event and the potential complication of cerebral edema.

In response to the initial findings, the medical team prioritizes the management of the ischemic stroke with thrombolytic therapy, given the patient's presentation and the time window since symptom onset. However, the potential risk of hemorrhagic conversion due to his uncontrolled hypertension requires careful monitoring. The nursing staff works closely with the interdisciplinary team to adjust the patient's medication regimen, ensuring adequate blood pressure control with the addition of intravenous antihypertensives. This adjustment aims to minimize further neurological decline while the team remains vigilant for any signs of new complications, such as increased intracranial pressure, which would necessitate immediate intervention.

Section 2

As the medical team administers thrombolytic therapy, the patient's clinical status is carefully observed for both therapeutic effectiveness and the emergence of any complications. Over the next few hours, the patient's right-sided hemiparesis shows mild improvement, with a slight increase in grip strength and the ability to move the right leg against gravity. However, his speech remains severely impaired, and attempts to communicate are largely unintelligible. Despite these promising signs, the nursing team remains vigilant for signs of hemorrhagic conversion, given the persistent challenge of controlling his blood pressure.

New diagnostic results from a follow-up CT scan, performed to assess for potential hemorrhagic transformation, indicate no evidence of bleeding, which is a reassuring finding. However, the imaging reveals increased midline shift consistent with worsening cerebral edema. This finding correlates with the patient's escalating headache and increased confusion, which now includes episodes of severe agitation. In response, the medical team initiates measures to manage the cerebral edema, such as elevating the head of the bed and administering osmotic diuretics, while closely monitoring for changes in neurological status.

The patient's blood pressure remains a critical concern, with readings fluctuating between 180/110 mmHg and 192/118 mmHg, despite intravenous antihypertensives. The nursing team notes a new finding of bradycardia, with heart rates occasionally dropping to the low 50s, suggesting an evolving autonomic dysregulation potentially related to increased intracranial pressure. This development prompts a re-evaluation of the patient's medication regimen and necessitates a collaborative decision-making process with the interdisciplinary team to balance the risks of aggressive blood pressure management against the need to prevent further neurological compromise. As these interventions unfold, the team remains prepared to escalate care, including potential intubation, should the patient's ability to maintain airway patency further deteriorate.

Section 3

As the nursing team continues to monitor the patient, they notice a significant change in his status. The patient's bradycardia worsens, with heart rates now consistently in the mid-40s, coinciding with an increase in his confusion and agitation. Despite efforts to stabilize his blood pressure, the patient's hypertension remains resistant to treatment, with systolic readings now reaching as high as 200 mmHg. In light of these developments, the team re-evaluates the patient's treatment plan, considering the potential for increased intracranial pressure contributing to autonomic instability.

A new diagnostic assessment includes an intracranial pressure (ICP) monitor, which reveals elevated pressures of 25 mmHg, confirming suspicions of worsening cerebral edema. In response, the medical team intensifies their interventions, increasing the dosage of osmotic diuretics and introducing hypertonic saline therapy. Continuous EEG monitoring is also initiated to assess for subclinical seizures, given the patient's altered mental status and potential for further neurological decline. The team also prepares for potential intubation, ensuring that airway management equipment is readily available should the patient's respiratory function deteriorate.

As these interventions take place, the nursing team remains vigilant for any signs of improvement or further complications. They closely monitor the patient's neurological status, noting any changes in pupil reactivity, motor responses, and speech ability. Lab results show a slight improvement in the patient's blood gas analysis, with a decrease in CO2 levels suggesting improved ventilation. However, the patient's sodium levels are rising due to hypertonic saline administration, necessitating careful balance to avoid osmotic demyelination syndrome. The interdisciplinary team collaborates on a comprehensive care plan, emphasizing the need for continuous assessment and real-time adjustments to support the patient's recovery and prevent further complications.

Section 4

As the nursing team continues their vigilant monitoring, they observe a change in the patient's status. Despite the intensified interventions, the patient's neurological condition shows signs of further deterioration. The patient becomes increasingly lethargic, with a noticeable decrease in responsiveness to verbal stimuli. Pupillary assessment reveals sluggish reaction to light, and there is a new onset of left-sided weakness, indicating potential worsening of the stroke or expansion of cerebral edema. These findings prompt the team to consider additional diagnostic imaging, such as a repeat CT scan, to evaluate the possibility of hemorrhagic transformation or additional ischemic damage.

Concurrent lab results indicate a concerning trend: the patient's serum sodium levels have risen to 155 mEq/L, raising alarms about the risk of osmotic demyelination syndrome due to the aggressive hypertonic saline therapy. The interdisciplinary team swiftly convenes to review the patient's fluid management strategy, weighing the benefits of continuing hypertonic saline against the potential for neurological injury due to hypernatremia. A decision is made to adjust the hypertonic saline infusion rate while introducing a more gradual correction approach to the electrolyte imbalance.

While addressing these clinical challenges, the team remains focused on the patient's airway management, particularly as his respiratory drive appears to be waning. Blood gas analysis now reveals a slight respiratory acidosis, with an arterial pH of 7.32 and a CO2 level of 50 mmHg, suggesting hypoventilation. Given these findings, and the patient's declining neurological and respiratory function, the team prepares for possible intubation to secure the airway and ensure adequate ventilation. The immediate priority is to stabilize the patient while minimizing further neurological compromise, guiding the team to continuously reassess and adapt the care plan as the situation evolves.

Section 5

The decision to intubate is made promptly as the patient's respiratory drive continues to decline. The nursing team prepares for the procedure, ensuring all necessary equipment is at the bedside, and the patient's airway is successfully secured. Post-intubation, the patient's ventilation is supported with mechanical ventilation settings tailored to maintain normocapnia and prevent further respiratory acidosis. Arterial blood gas analysis now shows improvement, with the pH rising to 7.38 and CO2 levels normalizing at 40 mmHg, reflecting better respiratory function under mechanical support.

While airway management stabilizes the patient's respiratory status, new complications emerge. A repeat CT scan confirms the presence of cerebral edema, and there is now evidence of a small hemorrhagic conversion within the initial ischemic area. This finding complicates the clinical picture, as the risk of increased intracranial pressure becomes a pressing concern. The interdisciplinary team, including neurology and critical care specialists, discusses the need for osmotic therapy with mannitol or hypertonic saline to manage intracranial pressure while carefully monitoring serum sodium levels to avoid further exacerbation of hypernatremia.

Vital signs reveal a new pattern of hypertension, with blood pressure readings of 180/100 mmHg, likely a compensatory response to the increased intracranial pressure. Careful titration of antihypertensive agents is initiated to maintain cerebral perfusion pressure without compromising cerebral blood flow. The nursing team remains vigilant, closely monitoring neurological status through serial assessments of pupil size and reactivity, limb strength, and overall consciousness level. As the patient's condition evolves, the focus remains on balancing interventions to manage cerebral edema and preventing further neurological deterioration, all while preparing for potential escalation in care if needed.