A 67-year-old male patient presents with right-sided hemiplegia, expressive aphasia, facial droop, and elevated blood pressure. His oxygen saturation is 88% on room air, and he shows signs of potential aspiration pneumonia. What is the priority nursing intervention to address the patient's current condition?

B) Initiate supplemental oxygen therapy to improve oxygen saturation.

A) Administer antihypertensive medication to lower blood pressure.

B) Initiate supplemental oxygen therapy to improve oxygen saturation.

C) Perform a swallowing assessment to prevent aspiration.

D) Prepare the patient for a CT scan to confirm the type of stroke.

A 67-year-old male patient presents with right-sided hemiplegia, expressive aphasia, facial droop, and elevated blood pressure. His oxygen saturation is 88% on room air, and he has bilateral crackles upon lung auscultation. What is the priority nursing intervention for this patient?

B) Administer supplemental oxygen to maintain adequate oxygenation.

A) Initiate thrombolytic therapy immediately.

B) Administer supplemental oxygen to maintain adequate oxygenation.

C) Prepare the patient for immediate CT imaging.

D) Administer antihypertensive medication to lower blood pressure.

A patient with an ischemic stroke in the left middle cerebral artery territory is being treated with thrombolytic therapy. The nurse notes that the patient becomes increasingly lethargic and less responsive to verbal stimuli. What is the nurse's priority action?

B) Perform a repeat neurological assessment.

A) Increase the patient's oxygen flow rate.

B) Perform a repeat neurological assessment.

C) Administer additional antihypertensive medication.

D) Request an order for sedative medication.

A patient with an ischemic stroke in the left middle cerebral artery territory is receiving thrombolytic therapy. Despite this, they present with increasing lethargy and decreased responsiveness. What should be the nurse's priority action to address these changes in the patient's neurological status?

C) Conduct a repeat neurological assessment and notify the healthcare provider immediately.

A) Administer a sedative to ensure patient comfort.

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

C) Conduct a repeat neurological assessment and notify the healthcare provider immediately.

D) Elevate the head of the bed to 90 degrees to enhance respiratory effort.

A patient with a recent ischemic stroke presents with a decreased Glasgow Coma Scale score, right-sided facial droop, increased motor weakness, and worsening respiratory status with oxygen saturation at 90%. What is the nurse's priority intervention?

B) Prepare the patient for a stat CT scan to reassess brain status

A) Administer a bolus of intravenous fluids to improve circulation

B) Prepare the patient for a stat CT scan to reassess brain status

C) Increase supplemental oxygen flow rate to improve oxygenation

D) Initiate continuous positive airway pressure (CPAP) therapy to support breathing

A patient with a recent ischemic stroke presents with a decreased GCS score, right-sided weakness, facial droop, and worsening respiratory status. Which nursing intervention should be prioritized to prevent further complications?

D) Initiate noninvasive ventilation to improve oxygenation and prevent respiratory failure

A) Increase supplemental oxygen to maintain saturation above 95%

B) Prepare the patient for immediate CT scan to assess cerebral changes

C) Administer antihypertensive medication to lower blood pressure gradually

D) Initiate noninvasive ventilation to improve oxygenation and prevent respiratory failure

A patient with increased cerebral edema and a midline shift of 3 millimeters is receiving intravenous mannitol to manage intracranial pressure. The nurse notes that the patient's urine output has significantly decreased over the past two hours. What is the most appropriate nursing action?

C) Notify the healthcare provider about the decreased urine output.

A) Administer an additional dose of mannitol to enhance diuresis.

B) Increase the rate of intravenous fluids to promote renal perfusion.

C) Notify the healthcare provider about the decreased urine output.

D) Monitor the patient's blood pressure and heart rate before taking further action.

A patient with significant cerebral edema and a midline shift is being treated with intravenous mannitol. What is the most critical nursing intervention to ensure the effectiveness of this treatment?

B) Maintain strict intake and output records

A) Monitor the patient's blood glucose levels every 4 hours

B) Maintain strict intake and output records

C) Assess the patient's pupillary response every shift

D) Administer supplemental oxygen via nasal cannula as needed

A patient with elevated intracranial pressure (ICP) is not responding adequately to IV mannitol. The healthcare team is considering the use of hypertonic saline. Which clinical assessment finding would best indicate a positive response to hypertonic saline therapy?

A) Decrease in midline shift on the CT scan

B) Improvement in the patient's respiratory acidosis

C) Reduction in the patient's blood pressure

A patient with elevated intracranial pressure remains confused despite the administration of IV mannitol. Arterial blood gas analysis shows pH 7.32, PaCO2 48 mmHg, and HCO3- 22 mEq/L. Which of the following interventions should the nurse prioritize to address the patient's condition?

B) Initiate mechanical ventilation to correct respiratory acidosis

A) Administer hypertonic saline to reduce intracranial pressure

B) Initiate mechanical ventilation to correct respiratory acidosis

C) Increase the dose of mannitol to enhance diuresis

D) Prepare the patient for decompressive craniectomy

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 death and neurological deficits. This is often caused by atherosclerosis or cardiac embolism.

• Secondary mechanism: Hemorrhagic stroke results from the rupture of a blood vessel in the brain, leading to bleeding and increased intracranial pressure, which damages brain tissue and disrupts normal function.

• Key complication: Both types of stroke can lead to cerebral edema, which exacerbates brain injury by further restricting blood flow and increasing pressure on brain structures, potentially resulting in severe disability or death.

Patient Profile

Demographics:

67-year-old male, retired accountant

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 180/105 mmHg, heart rate 102 bpm, respiratory rate 22 breaths per minute, temperature 37.3°C, oxygen saturation 90% on room air

Section 1

As the healthcare team initiates the initial assessment of the 67-year-old male patient, they observe several key findings that provide further insight into his current condition. The patient's neurological assessment reveals pronounced right-sided hemiplegia, with a complete inability to lift his right arm and significant weakness in his right leg. His speech remains slurred, and he struggles to articulate words, indicative of expressive aphasia. The facial droop on the right side is evident, and he is unable to close his right eye completely, suggesting cranial nerve involvement. His gaze is deviated towards the left, a potential indicator of a left hemispheric stroke.

Further examination shows that the patient's pupils are equal and reactive to light, but his right-sided visual field is compromised, indicating a possible visual field cut. Auscultation of the lungs demonstrates bilateral crackles, raising concerns about potential aspiration pneumonia due to impaired swallowing function. His blood pressure remains elevated at 182/108 mmHg, and repeat oxygen saturation is now 88% on room air, prompting the initiation of supplemental oxygen therapy. The patient's blood glucose is elevated at 250 mg/dL, necessitating tighter glycemic control given his diabetic history.

These findings highlight the complexity of his condition, necessitating a rapid decision-making process to prioritize interventions. The team considers the potential for thrombolytic therapy, weighing the benefits against contraindications such as the risk of hemorrhagic transformation. The assessment further outlines the importance of managing his hypertension and hyperglycemia to prevent further cerebral damage and complications. As the team prepares for imaging studies, including a CT scan to confirm the type of stroke, they remain vigilant for signs of increased intracranial pressure and other complications, which will guide the next steps in his management plan.

Section 2

As the healthcare team continues to monitor the patient, they observe new diagnostic results that provide further clarity on his condition. The CT scan of the brain reveals an ischemic stroke in the left middle cerebral artery territory, confirming the initial suspicion. This finding solidifies the team's decision to cautiously proceed with thrombolytic therapy, given the absence of any hemorrhagic transformation. Concurrently, the lab results show a slight increase in white blood cell count, suggesting an inflammatory response, likely due to the developing aspiration pneumonia. The team initiates broad-spectrum antibiotics to address this complication, aiming to prevent further respiratory compromise.

Despite the commencement of supplemental oxygen therapy, the patient's oxygen saturation remains suboptimal at 92% on 2 liters of nasal cannula, indicating the need for closer respiratory monitoring. His blood pressure continues to pose a challenge, fluctuating around 180/105 mmHg, despite the administration of antihypertensive medication. The team recognizes the critical need to balance blood pressure control to mitigate the risk of exacerbating cerebral edema, while avoiding aggressive reductions that could compromise cerebral perfusion. Additionally, his blood glucose level gradually decreases to 200 mg/dL after initiating an insulin sliding scale, reflecting initial progress in managing his hyperglycemia.

However, as the team focuses on these aspects of care, they notice a subtle change in the patient's neurological status. He becomes increasingly lethargic and less responsive to verbal stimuli, raising concerns about potential progression of the stroke or development of cerebral edema. These changes prompt immediate reevaluation, including a repeat neurological assessment and consideration of further neuroimaging, to determine the cause and adjust the treatment plan accordingly. The evolving situation underscores the importance of continuous monitoring and readiness to adapt the management strategy as new information emerges.

Section 3

As the team conducts a repeat neurological assessment, they observe that the patient's Glasgow Coma Scale (GCS) score has decreased to 10, indicating a marked decline in his level of consciousness. In addition, a right-sided facial droop and increased motor weakness in the right arm and leg become more pronounced, suggesting a possible extension of the ischemic event or development of significant cerebral edema. The urgency of the situation prompts the team to order a stat CT scan to reassess the brain, aiming to identify any progression of the initial stroke or new complications such as hemorrhagic transformation or worsening edema.

Simultaneously, the patient's vital signs reveal further instability. His blood pressure spikes to 190/110 mmHg, and his heart rate increases to 110 beats per minute. Despite the administration of broad-spectrum antibiotics, his white blood cell count climbs to 15,000/mm³, indicating a persistent inflammatory response, likely due to the aspiration pneumonia. The respiratory status remains concerning, with oxygen saturation hovering around 90% despite increasing supplemental oxygen to 4 liters via nasal cannula. These findings highlight the need for aggressive management of potential respiratory complications and reevaluation of antibiotic therapy to ensure appropriate bacterial coverage.

The healthcare team quickly convenes to integrate these findings into the evolving treatment plan. They consider increasing the intensity of antihypertensive therapy, while cautiously optimizing fluid management to address the risk of cerebral edema. The possibility of initiating noninvasive ventilation, such as continuous positive airway pressure (CPAP), is discussed to enhance respiratory support and improve oxygenation. The team also explores the need for potential escalation to intensive care for closer monitoring and more advanced interventions. These critical decisions underscore the complexity of managing ischemic stroke with concurrent complications, emphasizing the importance of dynamic clinical reasoning and adaptability in response to the patient's changing status.

Section 4

New Diagnostic Results

Shortly after the stat CT scan is performed, the results are promptly reviewed by the healthcare team. The imaging reveals a significant increase in cerebral edema surrounding the initial ischemic area, which is now exerting pressure on adjacent brain structures, a condition known as mass effect. Additionally, there is no evidence of hemorrhagic transformation at this stage, which provides some relief but still indicates a critical need to manage the swelling. The radiologist notes the presence of midline shift of approximately 3 millimeters, emphasizing the urgency of addressing the cerebral edema to prevent further neurological compromise.

In light of these findings, the team swiftly adjusts the treatment plan. They decide to initiate intravenous mannitol to reduce intracranial pressure and closely monitor the patient’s fluid balance to prevent exacerbating the edema. Simultaneously, the patient's respiratory status remains a major concern, prompting the initiation of CPAP to improve oxygenation and reduce the risk of further respiratory complications. This decision is supported by the patient's elevated respiratory rate of 28 breaths per minute and persistent oxygen saturation of 90%, despite supplemental oxygen.

As the treatment is implemented, the healthcare team remains vigilant, frequently reassessing the patient's neurological status and vital signs. They continue to explore the potential need for transfer to the intensive care unit, where more aggressive monitoring and management options are available. This step-wise approach reflects the team's proactive clinical reasoning, aiming to stabilize the patient while remaining adaptable to any further changes in his condition. The next hours are critical, and the team's coordinated efforts are crucial in navigating the complexities of this evolving clinical scenario.

Section 5

As the team continues to monitor the patient closely, new complications begin to emerge. Despite the administration of IV mannitol, the patient's intracranial pressure remains elevated, as evidenced by a persistent headache and increased confusion. A follow-up neurological assessment reveals a decrease in responsiveness, with the patient now only responding to painful stimuli and exhibiting a sluggish pupillary reaction on the right side. This change in neurological status prompts the team to order an urgent repeat CT scan to assess the progression of cerebral edema and midline shift.

The repeat CT scan confirms a slight increase in the midline shift to 4 millimeters, indicating that the cerebral edema is not resolving as anticipated. In response to these findings, the healthcare team initiates a more aggressive intervention plan. They consider the potential benefits of hypertonic saline administration to draw fluid out of the brain tissue more effectively. Concurrently, discussions about potential surgical interventions, such as decompressive craniectomy, are initiated in consultation with the neurosurgical team, should medical management fail to achieve the desired reduction in intracranial pressure.

The patient's respiratory status remains a priority as well, with continuous CPAP support ensuring adequate oxygenation. However, the healthcare team remains vigilant for signs of respiratory fatigue, as the patient's increased work of breathing could further compromise his neurological condition. Arterial blood gas analysis shows a concerning trend with a pH of 7.32, PaCO2 of 48 mmHg, and HCO3- of 22 mEq/L, indicating respiratory acidosis and the need for potential intubation and mechanical ventilation if the situation does not improve. The team's coordinated efforts highlight the importance of dynamic clinical reasoning and adaptability in managing this complex case, recognizing the need for timely interventions to prevent further deterioration.