Which of the following is the primary purpose of administering thrombolytic therapy to a patient with an acute ischemic stroke?

C) To manage cholesterol levels

What is the primary nursing intervention for a patient who is receiving thrombolytic therapy for an ischemic stroke?

B) Monitoring for signs of bleeding, especially intracranial hemorrhage

A) Administering aspirin to prevent further clot formation

B) Monitoring for signs of bleeding, especially intracranial hemorrhage

C) Encouraging the patient to perform active range of motion exercises

D) Providing a high-protein diet to promote healing

What is the primary reason for the nursing team to elevate the head of the bed for a patient receiving thrombolytic therapy?

A) To improve respiratory function

C) To reduce the risk of hemorrhage

What is the primary reason for performing a repeat CT scan in a patient who has received thrombolytic therapy and is showing changes in neurological status?

B) To evaluate for hemorrhagic transformation

A) To assess for new or worsening ischemic stroke

B) To evaluate for hemorrhagic transformation

C) To monitor the effectiveness of thrombolytic therapy

D) To check for signs of infection or abscess formation

What is the primary reason for performing regular neurological assessments on the patient following thrombolytic therapy?

B) To assess for signs of hemorrhagic transformation

A) To monitor for changes in vital signs

B) To assess for signs of hemorrhagic transformation

C) To evaluate the patient's pain level

D) To ensure the patient's comfort

Which of the following interventions is most appropriate for a nurse to implement to prevent complications from immobility in a patient with right-sided weakness following a stroke?

C) Assist the patient in performing range-of-motion exercises on the affected side.

A) Encourage the patient to use a bedpan instead of getting up to use the bathroom.

B) Reinforce the importance of deep breathing exercises every two hours.

C) Assist the patient in performing range-of-motion exercises on the affected side.

D) Apply warm compresses to the affected side to increase blood flow.

What is the primary nursing action to help reduce intracranial pressure in a patient with increased right-sided weakness following a stroke?

D) Encourage deep breathing exercises

What is the most appropriate initial nursing action when a patient exhibits a mild increase in right-sided weakness and a noticeable droop in the right corner of the mouth following a recent stroke?

A) Perform a comprehensive neurological assessment

B) Administer a rapid dose of anticoagulant medication

C) Lower the head of the bed to improve comfort

D) Increase the patient's fluid intake to ensure hydration

Which vital sign measurement indicates adequate oxygenation in the patient described in the case?

B) Heart rate of 70 beats per minute

C) Respiratory rate of 15 breaths per minute

What is the most appropriate nursing action to ensure the ongoing improvement of the patient’s neurological status?

A) Increase the frequency of neurological assessments

B) Discontinue monitoring vital signs

C) Restrict the patient’s mobility to prevent fatigue

D) Focus solely on medication management

ischemic stroke - Nursing Case Study

Pathophysiology

• Primary mechanism: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, usually due to atherosclerosis, which is the buildup of fatty deposits in blood vessels. This obstruction prevents oxygen and nutrients from reaching brain tissue, leading to cell death.

• Secondary mechanism: The lack of blood flow triggers a cascade of biochemical reactions, including the release of excitatory neurotransmitters like glutamate, which further harm brain cells and exacerbate the injury.

• Key complication: If not promptly treated, the affected brain area can suffer irreversible damage, potentially leading to long-term disabilities such as paralysis, speech difficulties, or cognitive impairments.

Patient Profile

Demographics:

67, female, retired school teacher

History:

• Key past medical history: Hypertension, hyperlipidemia

• Current medications: Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden weakness in right arm

• Key symptoms: Mild slurred speech, facial droop on right side

• Vital signs: Blood pressure 138/85 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 98.6°F

Section 1

Initial assessment findings reveal that the patient, a 67-year-old retired school teacher, exhibits mild right-sided weakness and slurred speech, indicating a potential ischemic stroke affecting the left hemisphere of the brain. During the neurological assessment, the nurse notes that the patient's facial droop is more pronounced when she attempts to smile, and her grip strength on the right hand is weaker compared to the left. The patient's speech is slow but coherent, suggesting that the stroke's impact on language centers is currently mild. The nurse performs a complete neurological assessment, utilizing the National Institutes of Health Stroke Scale (NIHSS), and documents a score of 4, indicating a minor stroke.

The healthcare team orders a CT scan of the head without contrast to confirm the presence of an ischemic event and to rule out hemorrhage. The results of the CT scan reveal a small area of hypodensity in the left middle cerebral artery territory, consistent with an acute ischemic stroke. Basic laboratory tests, including a complete blood count, electrolytes, and coagulation profile, are within normal limits, except for slightly elevated low-density lipoproteins (LDL) at 140 mg/dL, reinforcing the need for continued use of Atorvastatin. The team determines that the patient is a candidate for thrombolytic therapy, given her stable vital signs and the early presentation of symptoms within the treatment window.

With these findings, the patient is monitored closely in the stroke unit, where the nursing team implements a care plan focused on neurological assessments every two hours, blood pressure management, and the prevention of complications such as aspiration due to weakened swallowing reflex. The patient and her family are educated on the importance of adhering to prescribed medications, lifestyle modifications, and follow-up care to reduce the risk of future strokes. As the patient begins receiving thrombolytic treatment, the team remains vigilant for any signs of hemorrhage, a potential but manageable complication. The next phase of the patient's journey will focus on evaluating her response to the intervention and planning for rehabilitation.

Section 2

As the patient begins receiving thrombolytic therapy, the nursing team remains vigilant, closely monitoring her for any changes in status and potential complications. In the initial hours following the administration of the medication, the patient's vital signs remain stable with a blood pressure of 138/85 mmHg, heart rate of 72 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation at 97% on room air. The nurse continues with the scheduled neurological assessments, noting that the patient maintains a NIHSS score of 4, with no significant changes in her mild right-sided weakness or speech clarity.

However, during the next assessment, the nurse observes a slight increase in the patient's facial droop and a further decrease in grip strength on the right side. The patient also reports a mild headache, which raises a concern for the healthcare team. This change prompts the nurse to immediately notify the attending physician and perform an additional focused assessment. The team decides to order a repeat CT scan to rule out any complications such as hemorrhagic transformation, which can be a risk following thrombolytic therapy.

While awaiting the CT results, the nursing team implements precautionary measures, including positioning the patient with the head of the bed elevated and ensuring a calm environment to manage her blood pressure and reduce the risk of further complications. The team reassures the patient and her family, explaining that these changes are being thoroughly investigated and managed. The results of the repeat CT scan will guide the next steps in her care, allowing the healthcare team to adjust the treatment plan as needed to support her recovery and transition to rehabilitation.

Section 3

As the CT scan results arrive, the attending physician and nursing team review the findings. Fortunately, the scan shows no evidence of hemorrhagic transformation, which provides some reassurance regarding the initial concerns following thrombolytic therapy. However, it does reveal a slightly larger area of ischemia than initially anticipated, correlating with the patient's increased facial droop and decreased grip strength. This information is crucial for the team as it helps refine the care plan and adjust expectations for the patient's recovery trajectory.

With these results, the nursing team focuses on optimizing the patient's current condition and preventing further complications. The patient’s vital signs remain stable, with a blood pressure reading of 136/82 mmHg, heart rate at 70 beats per minute, respiratory rate at 16 breaths per minute, and oxygen saturation still at 97% on room air. The nurse continues to perform regular neurological assessments every hour, carefully monitoring for any new changes in the patient's status. The team also reinforces the importance of early rehabilitation, encouraging the patient to engage in simple range-of-motion exercises with the help of a physical therapist to mitigate right-sided weakness.

The patient is kept comfortable with mild analgesics to manage her headache, and the nurse educates both the patient and her family on the importance of reporting any new symptoms immediately. The care plan includes continued monitoring and supportive care, with the goal of initiating a more comprehensive rehabilitation program as her condition stabilizes. By maintaining a vigilant approach and implementing targeted interventions, the nursing team supports the patient through this critical phase, laying a foundation for a hopeful recovery.

Section 4

As the day progresses, the nursing team observes a slight change in the patient's status. During one of the routine neurological assessments, the nurse notes a mild increase in the patient's right-sided weakness. The patient's ability to grip with her right hand has diminished further, and there is a noticeable droop in the right corner of her mouth. While the patient's speech remains clear, there is a slight delay in her response time, prompting the nurse to perform a comprehensive assessment. Vital signs show a stable blood pressure of 138/84 mmHg, heart rate of 72 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation holding steady at 97% on room air.

The nurse promptly communicates these findings to the attending physician, who orders an additional CT scan to rule out any new developments or complications. Concurrently, the nurse ensures that the patient's head is elevated to help promote cerebral perfusion and reduce intracranial pressure. The patient is reassured and encouraged to continue with the prescribed range-of-motion exercises, with the physical therapist providing additional support to adapt to the increased weakness.

Once the new CT scan results are reviewed, they show no further enlargement of the ischemic area, which is a relief to the team. The physician concludes that the increased weakness may likely be due to temporary fluctuations in the patient's condition rather than a progressive worsening of the stroke. The nursing team is advised to continue with the existing care plan, maintaining close monitoring of neurological status and ensuring consistent communication with the patient and her family. This stability allows the team to focus on gradual rehabilitation efforts, setting the stage for the patient's slow but hopeful journey towards recovery.

Section 5

As the day progresses, the nursing team continues to closely monitor the patient’s condition, particularly focusing on her neurological status. During the afternoon assessment, the nurse observes that the right-sided weakness has slightly improved, with the patient now able to exert minimal resistance during handgrip testing. Encouraged by this positive change, the nurse notes a slight improvement in the symmetry of the patient’s facial muscles, although the droop is still present. Speech remains clear, and the patient’s response time has improved, showing quicker cognitive processing. This progress suggests a positive response to the interventions and supportive care provided.

Vital signs remain stable with a blood pressure of 135/82 mmHg, heart rate of 70 beats per minute, respiratory rate of 15 breaths per minute, and oxygen saturation at 98% on room air. Laboratory results indicate normal electrolyte levels, with no signs of dehydration or imbalances that could affect neurological function. The nurse documents these findings, emphasizing the importance of ongoing monitoring to detect any subtle changes that may require intervention. The current stability allows for a continued focus on rehabilitation, with the physical therapist gradually increasing the intensity of range-of-motion exercises, aimed at enhancing the patient’s strength and mobility.

The positive trend in the patient's condition offers reassurance to her family, who have been updated with the latest developments. The nursing team emphasizes the importance of maintaining a supportive environment, with consistent encouragement to engage in prescribed activities and therapies. This collaborative effort among healthcare providers, the patient, and her family sets a hopeful tone for her recovery journey. Moving forward, the team plans to slowly introduce additional rehabilitation strategies to further support the patient’s progress, with regular re-evaluation to ensure that her care plan remains aligned with her evolving needs.