A 67-year-old female patient with a confirmed ischemic stroke in the left middle cerebral artery territory is being evaluated for thrombolytic therapy. Considering her recent aspirin use, elevated blood pressure, and history of Type 2 Diabetes, what is the most appropriate nursing intervention to prepare for possible thrombolytic therapy?

A) Administer an antihypertensive medication to lower blood pressure before therapy

B) Hold all medications and consult the physician immediately

C) Prepare to administer insulin for hyperglycemia management

D) Increase the frequency of neurological assessments to monitor changes

A 67-year-old female patient presents with an ischemic stroke in the left middle cerebral artery territory. Her lab results show elevated blood glucose and LDL cholesterol levels, and she has a history of Type 2 Diabetes. The healthcare team is considering thrombolytic therapy. Which of the following actions should the nurse prioritize in preparation for this treatment?

B) Ensure informed consent is obtained and documented for thrombolytic therapy.

A) Administer insulin to address the elevated blood glucose level.

B) Ensure informed consent is obtained and documented for thrombolytic therapy.

C) Monitor the patient's neurological status every hour for changes.

D) Prepare the patient for an immediate carotid endarterectomy.

A patient receiving thrombolytic therapy for an ischemic stroke exhibits a sudden decline in neurological status, with signs of increased cerebral edema but no evidence of hemorrhage on a CT scan. Which nursing intervention is most appropriate to address the patient's condition while maintaining adequate cerebral perfusion?

A) Administering an osmotic diuretic to reduce cerebral edema

B) Increasing the patient's IV fluid rate to improve cerebral perfusion

C) Elevating the head of the bed to 45 degrees to promote venous drainage

D) Initiating a continuous infusion of antihypertensive medication to lower blood pressure

A patient receiving thrombolytic therapy for an ischemic stroke begins to show signs of increased cerebral edema without evidence of hemorrhage. Which nursing intervention is most appropriate to address this patient's condition while ensuring adequate cerebral perfusion?

B) Administer supplemental oxygen and elevate the head of the bed to 30 degrees to optimize cerebral perfusion and oxygenation.

A) Administer mannitol and increase intravenous fluid rates to promote diuresis and reduce edema.

B) Administer supplemental oxygen and elevate the head of the bed to 30 degrees to optimize cerebral perfusion and oxygenation.

C) Initiate continuous blood pressure monitoring and administer antihypertensive medications to maintain systolic blood pressure below 120 mmHg.

D) Encourage the patient to perform deep breathing exercises and monitor for signs of respiratory distress.

A patient with compromised respiratory status and elevated blood glucose levels is being managed in a healthcare setting. Which of the following nursing interventions is most appropriate to prioritize in this scenario to prevent further complications?

B) Initiate non-invasive ventilation to support respiratory function

A) Administer insulin to manage hyperglycemia

B) Initiate non-invasive ventilation to support respiratory function

C) Administer prophylactic antibiotics to prevent infection

D) Monitor blood pressure closely to maintain cerebral perfusion

A patient with compromised respiratory status is being closely monitored. Her oxygen saturation drops to 88% despite supplemental oxygen, and her respiratory rate increases to 28 breaths per minute. The healthcare team escalates her respiratory support to a non-rebreather mask and considers non-invasive ventilation. Which of the following nursing interventions is most appropriate to support the patient's respiratory needs while preventing further complications?

A) Position the patient in a semi-Fowler's position to enhance lung expansion and ease of breathing.

B) Administer a higher concentration of oxygen through the nasal cannula to increase oxygen saturation.

C) Initiate rapid sequence intubation to secure the airway due to the elevated respiratory rate.

D) Contact the physician to discontinue all respiratory support and assess the patient's natural breathing effort.

A patient with worsening respiratory distress and signs of increased intracranial pressure is being managed in an intensive care unit. The multidisciplinary team has initiated BiPAP therapy and is considering further interventions. Which nursing action is the priority for this patient?

B) Administer prescribed osmotic diuretics to manage intracranial pressure.

A) Monitor for signs of ventilator-associated pneumonia.

B) Administer prescribed osmotic diuretics to manage intracranial pressure.

C) Prepare the patient for an urgent CT scan to assess for cerebral edema.

D) Initiate insulin infusion protocol to maintain blood glucose control.

A patient is experiencing worsening respiratory distress with signs of accessory muscle use and nasal flaring. The respiratory therapist recommends the initiation of BiPAP therapy. Concurrently, the patient shows signs of increased intracranial pressure with a new onset of bradycardia and irregular pupillary response. Which nursing intervention is the priority in this situation?

B) Prepare the patient for an urgent CT scan to assess the potential progression of cerebral edema.

A) Initiate BiPAP therapy to improve alveolar ventilation and monitor the patient's respiratory status.

B) Prepare the patient for an urgent CT scan to assess the potential progression of cerebral edema.

C) Administer osmotic diuretics as prescribed to help manage intracranial pressure.

D) Start an insulin infusion to achieve tighter glycemic control and prevent further neurological injury.

A patient with cerebral edema and a midline shift is being monitored in the ICU. The medical team has initiated hypertonic saline and adjusted osmotic diuretics. Which nursing intervention is most critical to prioritize in this situation to prevent further neurological deterioration?

B) Position the patient with the head of the bed elevated at 30 degrees.

A) Monitor serum sodium levels every 6 hours.

B) Position the patient with the head of the bed elevated at 30 degrees.

C) Administer scheduled pain medication to prevent discomfort.

D) Initiate continuous EEG monitoring to assess for seizures.

A patient with cerebral edema is being treated with hypertonic saline and osmotic diuretics. Which assessment finding would indicate a need to adjust the current treatment plan?

A) Decreased urine output and rising blood pressure

B) Improved level of consciousness and stable vital signs

C) Decreased intracranial pressure and normothermia

D) Increased respiratory rate and persistent bradycardia

cva - Nursing Case Study

Pathophysiology

• Primary mechanism: Cerebral ischemia occurs when blood flow to a part of the brain is interrupted or reduced, often due to a thrombus or embolus, leading to a lack of oxygen and nutrients and resulting in cell death and neurological deficits.

• Secondary mechanism: Hemorrhagic stroke involves the rupture of a blood vessel within the brain, causing bleeding into or around the brain tissue, which increases intracranial pressure and disrupts normal brain function.

• Key complication: Both types of strokes can lead to permanent brain damage, resulting in motor and sensory deficits, speech difficulties, and cognitive impairments, significantly impacting a patient's quality of life and requiring extensive rehabilitation.

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 onset of weakness on the right side of the body

• Key symptoms: Slurred speech, facial droop on the right side, mild headache, difficulty in coordination, slight confusion

• Vital signs: Blood pressure 178/95 mmHg, Heart rate 92 bpm, Respiratory rate 22 breaths per minute, Temperature 98.6°F, Oxygen saturation 93% on room air

Section 1

As the healthcare team proceeds with the initial assessment of the 67-year-old female patient, they observe further details that corroborate the suspicion of a cerebrovascular accident (CVA). The patient exhibits pronounced right-sided hemiparesis and continues to have slurred speech, indicative of dysarthria. The facial droop on the right side is confirmed, and she struggles to articulate words clearly. Her Glasgow Coma Scale (GCS) score is 13, reflecting mild confusion but maintaining the ability to follow simple commands. The National Institutes of Health Stroke Scale (NIHSS) score is calculated at 8, suggesting a moderate stroke severity.

Laboratory results reveal elevated blood glucose levels at 220 mg/dL, likely exacerbating her neurological symptoms due to her history of Type 2 Diabetes. Her LDL cholesterol is significantly high at 160 mg/dL, reinforcing the need for continued management of her hyperlipidemia to prevent further vascular events. An urgent CT scan of the head is ordered and performed, which shows evidence of an ischemic stroke in the left middle cerebral artery territory, with no signs of hemorrhage. This finding necessitates the consideration of thrombolytic therapy, keeping in mind the time window for its administration and her current medication regimen.

As the team deliberates on the best course of action, they must weigh the benefits and risks of thrombolytic therapy, given her recent aspirin use and elevated blood pressure. The decision must be made swiftly to optimize her chances for recovery and minimize further neurological damage. This situation presents an opportunity for clinical reasoning, focusing on the integration of her medical history, current presentation, and diagnostic findings to tailor a treatment plan that addresses both her immediate and long-term needs.

Section 2

As the healthcare team administers thrombolytic therapy to the patient, they maintain vigilant monitoring for any adverse reactions or complications. Shortly after the initiation of treatment, the patient begins to exhibit a change in her neurological status. She becomes increasingly lethargic and her speech, which was previously slurred, now becomes incomprehensible. A repeat assessment reveals a decline in her Glasgow Coma Scale (GCS) score to 10, indicating a decrease in her level of consciousness. Her right-sided hemiparesis appears more pronounced, and she is unable to follow simple commands consistently. Vital signs recorded show a blood pressure of 190/110 mmHg, heart rate of 105 beats per minute, respiratory rate of 22 breaths per minute, and an oxygen saturation of 92% on room air.

Concerned about the potential for hemorrhagic transformation, the team orders an emergent repeat CT scan. The scan reveals no evidence of intracranial hemorrhage, but there is a slight increase in cerebral edema around the infarcted area in the left middle cerebral artery territory. This finding prompts a discussion about optimizing her medical management to reduce further swelling and stabilize her condition. The healthcare team considers administering osmotic diuretics and adjusting her blood pressure medications to achieve better control, all while balancing the need to maintain adequate cerebral perfusion.

The patient's elevated blood pressure and reduced oxygen saturation necessitate close monitoring and potential adjustments to her care plan. The team deliberates on the most appropriate interventions to prevent respiratory complications and support her neurological recovery. The situation underscores the importance of integrating her evolving clinical data and maintaining a multidisciplinary approach to address both acute and preventative aspects of her treatment. With the potential for further complications, the team remains proactive in their assessments and interventions, aiming to optimize her outcomes and prepare for the next steps in her recovery journey.

Section 3

As the healthcare team continues to monitor the patient closely, they note that her respiratory status becomes increasingly compromised. Her oxygen saturation drops to 88% despite supplemental oxygen via nasal cannula, prompting the team to escalate her respiratory support to a non-rebreather mask. Additionally, her respiratory rate rises to 28 breaths per minute, suggesting increased work of breathing and potential respiratory distress. Concerned about the risk of aspiration and further neurological decline, the team decides to consult with the respiratory therapy department for a more comprehensive assessment and possible initiation of non-invasive ventilation to support her oxygenation and ventilation.

In parallel, the team reviews the patient's laboratory results, which now show a slight elevation in her white blood cell count, indicating a potential inflammatory response. Her blood glucose levels are also elevated at 220 mg/dL, necessitating tighter glycemic control to minimize additional neurologic complications. The team discusses the need to address these findings with appropriate interventions, including the potential initiation of insulin therapy to manage her hyperglycemia and consideration of prophylactic antibiotics if infection is suspected as a contributing factor.

The focus remains on maintaining adequate cerebral perfusion while addressing her respiratory and metabolic needs. The multidisciplinary team, including neurology, nursing, respiratory therapy, and pharmacy, collaborates to adjust her care plan. They ensure her blood pressure is managed within a target range using carefully titrated antihypertensive medications, while also administering osmotic diuretics to reduce cerebral edema. With these interventions, the team hopes to stabilize her condition and prevent further complications, while remaining vigilant for any changes in her neurological or respiratory status.

Section 4

As the multidisciplinary team continues to monitor the patient, they note a change in her status indicating the development of new complications. Despite the escalation to a non-rebreather mask, her oxygen saturation remains tenuous, fluctuating between 88% and 90%. Her respiratory rate has increased to 32 breaths per minute, and she exhibits signs of accessory muscle use and nasal flaring, suggesting worsening respiratory distress. Concerned about the potential for respiratory failure, the respiratory therapist recommends the initiation of BiPAP (Bilevel Positive Airway Pressure) to enhance alveolar ventilation and improve gas exchange, while closely monitoring her response to this intervention.

Concurrently, the patient begins to exhibit signs of increased intracranial pressure, evidenced by a new onset of bradycardia with a heart rate dropping to 50 beats per minute and irregular pupillary response with unequal pupils. These findings warrant an urgent CT scan to assess for any progression of cerebral edema or hemorrhagic transformation. The team remains vigilant, with the neurology consult emphasizing the importance of maintaining cerebral perfusion pressure through careful management of her blood pressure and continued administration of osmotic diuretics.

The laboratory results also reveal a further rise in her white blood cell count to 14,000/mm³, prompting the consideration of a possible infectious process. Blood cultures are obtained, and empirical broad-spectrum antibiotic therapy is initiated as a precautionary measure while awaiting culture results. The patient's blood glucose level remains elevated at 210 mg/dL, necessitating an insulin infusion protocol to achieve tighter glycemic control, recognizing the potential for hyperglycemia to exacerbate neurological injury. With these evolving complications, the team revises the care plan to prioritize stabilization of her respiratory and neurological status, while remaining prepared for any additional interventions that may be required.

Section 5

As the medical team implements the BiPAP intervention, they observe a gradual improvement in the patient's respiratory status. Her oxygen saturation stabilizes around 94%, and her respiratory rate decreases to 24 breaths per minute, indicating a positive response to enhanced alveolar ventilation. The use of accessory muscles is notably reduced, and nasal flaring subsides, suggesting a partial alleviation of respiratory distress. However, the team remains cautious, aware that her respiratory condition could fluctuate and requires continuous monitoring.

Meanwhile, the results from the urgent CT scan reveal concerning signs of cerebral edema with a midline shift, but fortunately, no evidence of hemorrhagic transformation. This finding underscores the critical need for aggressive management of her increased intracranial pressure. The neurology team recommends an adjustment in the osmotic diuretics regimen, along with the administration of hypertonic saline to reduce cerebral swelling and maintain adequate cerebral perfusion pressure. Despite these measures, the patient's neurological status remains precarious, as evidenced by fluctuating levels of consciousness and continued bradycardia, necessitating close observation for any further deterioration.

The initiation of broad-spectrum antibiotics appears timely, as subsequent blood culture results confirm a Gram-negative bacteremia, likely contributing to the patient's elevated white blood cell count and systemic inflammatory response. This development highlights the importance of early recognition and intervention in preventing sepsis-related complications. As the insulin infusion protocol is adjusted to improve glycemic control, the team notes a gradual reduction in blood glucose levels, which are now trending towards the target range. With these multifaceted interventions underway, the multidisciplinary team remains vigilant, ready to adjust the treatment plan as the patient's complex clinical picture continues to evolve.