Cerebral Vascular Accident Case Study

Cerebral Vascular Accident (CVA) History of Present Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic symptoms when he presents to the ED. You are the nurse responsible for his care. Personal/Social History: John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has been complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has been using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants. He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9). What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: History of hypertension Sudden onset right-sided weakness, R facial droop, difficulty speaking History of Diabetes II History of hypertension along with current S/S indicate Mr. Gates is experiencing a stroke/CVA. Pt Diabetes II status requires close Bl Glucose monitoring, possible re-evaluation of status & treatment plan. RELEVANT Data from Social History: Clinical Significance: For the past week Pt has complained of episodes of irregular HR & pain in R foot. Pt using Nicotine patch, history of smoking. Pt S/S were warning signs of impending CVA. Pt history of smoking & Nicotine patch places him at high risk for Cardiovascular events. Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins: Current VS: T: 99.2 F/37.3 C (oral) P: 118 (irregular) R: 20 (regular) BP: 198/94 O2 sat: 99% room air P-Q-R-S-T Pain Assessment: Provoking/Palliative: Unable Quality: Region/Radiation: Severity: Timing: What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS data: Clinical Significance: T: 99.2 F P: 118- irregular R: 20 BP 198/94 Pt Temp slightly elevated, Pulse 118 & irregular (A-Fib), increased respirations & HBP indicates Cardiovascular distress. Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: Appears anxious–he is aware and appears to be concerned about changes in neuro status. Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds irregular–S1S2, telemetry rhythm is atrial fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Is anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light (PEARL), both right upper extremity (RUE) and right lower extremity (RLE) notably weak (3/5) in comparison to left, which is strong (5/5), right pronator drift present, unable to hold right arm up, right visual deficit cut present GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Able to swallow saliva Voiding without difficulty, 700 mL urine clear/yellow, Skin integrity appears intact, right foot not assessed at this time GU: SKIN: What assessment data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT assessment data: Clinical Significance: Pt anxious & concerned. (Non-labored respir. effort = good,O2 not nec. at this time). Irregular heart sounds. Slurred speech, facial droop R side, RUE & RLE weakness 3/5. R pronator drift, unable to hold R arm up. R visual deficit. All S/S indicate pt suffering a stroke/CVA. Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes: Lab/diagnostic Results: Radiology Reports: Head CT What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Results: Clinical Significance: No abnormalities noted, no mass, no bleed, no shift present Indicates no inter-cranial bleed, no tumor, No mid-line shift of the brain (past it's center line) which can occur due to a CVA. Lab Results: Complete Blood Count (CBC) WBC (4.5-11.0 mm 3) Hgb (12-16 g/dL) Platelets(150-450x 103/µl) Neutrophil % (42-72) Current 6.8 14.8 228 71 High/Low/WNL? WNL WNL WNL HIGH Previous: 7.9 16.1 201 79 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Neutrophil % elevated, though lowering. Pt may be recovering from a previous infection, not related to current medical status. Basic Metabolic Panel (BMP) Sodium (135-145 mEq/L) Potassium (3.5-5.0 mEq/L) Glucose (70-110 mg/dL) Creatinine (0.6-1.2 mg/dL) Coag PT/INR (0.9-1.1 nmol/L) Current 133 4.1 222 1.5 Improving. High/Low/WNL? HIGH Previous: 139 4.5 128 1.1 WNL n/a WNL WNL HIGH 1.1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Bl Gluc- 222 Bl Glucose elevated, indicates Hyperglycemia/Diabetes. Slightly elevated Creatinine level, may be due to dehydration in this case. Cr- 1.5 Worsening Worsening, not critical at this level. Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Creatinine Value: RED FLAG: 1.5 Why Relevant? Elevated Creatinine can indicate Kidneys may not be functioning properly. However, Pt's current level is not critical, may be due to dehydration. Nursing Assessments/Interventions Required: Give IV fluids & encourage Pt to drink more water. Pharmacology: Home Med: Indomethacin Aspirin Classification: Mechanism of Action (in own words): Nursing Considerations: NSAID Relieves pain & inflammation, joint stiffness. Given PRN, over use can damage liver. NSAID Reduces pain & inflammation, thins the blood. Aspirin-Give with food,may cause increased bleeding or GI bleed. Lisinopril-Give at same time daily. Simvastatin-may cause muscle pain, weakness, liver damage. Metformin-Do not crush. Lisinopril Simvastatin Metformin ACE Inhibitor Lisinopril-Treats Hypertension/ lowers HBP. Simvastatin- Lowers cholesterol Metformin- Maintains Bl Glucose levels Aspirin-Give with food,may cause increased bleeding or GI bleed. Lisinopril-Give at same time daily. Simvastatin-may cause muscle pain, weakness, liver damage. Metformin-Do not crush. HMG-CoA Reductase Inhibitor Lisinopril-Treats Hypertension/ lowers HBP. Simvastatin- Lowers cholesterol Metformin- Maintains Bl Glucose levels Aspirin-Give with food,may cause increased bleeding or GI bleed. Lisinopril-Give at same time daily. Simvastatin-may cause muscle pain, weakness, liver damage. Metformin-Do not crush. Biguanide Lisinopril-Treats Hypertension/ lowers HBP. Simvastatin- Lowers cholesterol Metformin- Maintains Bl Glucose levels Aspirin-Give with food,may cause increased bleeding or GI bleed. Lisinopril-Give at same time daily. Simvastatin-may cause muscle pain, weakness, liver damage. Metformin-Do not crush. Pathophysiology: 1. What is the primary problem that your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem? (Relate initial manifestations to the pathophysiology of the primary problem) Pathophysiology of Primary Problem: Rationale/Relationship to Manifestations: 1)CVA/Stroke (from blood clot or arterial blockage). 2) The primary pathophysiology of a stroke is an underlying heart or blood vessel disease or risk factors including: hypertension(HBP), arteriosclerosis (hardening, narrowing or thickening of arterial walls), leading to coronary artery disease, heart disease & dyslipidemia or hyperlipidemia. The two types of stroke that result from these disease states are: ischemic & hemorrhagic. Pt has history of HBP, lifestyle choices such as smoking, diet & lack of exercise (being overweight) also contribute to HBP & high cholesterol which can cause coronary artery disease. Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS 1. What is the RELATIONSHIP of the past medical history and current medications? (Which medication treats which condition? Draw lines to connect) Past Medical History (PMH): Home Meds: Diabetes mellitus type II-poorly controlled Lisinopril Lisinopril- hypertension Hypertension Indomethacin Metformin-Type II Diabetes Hyperlipidemia Aspirin Simvastatin- hyperlipidemia Gouty arthritis Metformin Aspirin/Indomethacin-Gouty arthiritis Smokes 1 ppd x 40 years Simvastatin Nicotine patch- Smoking Cessation Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem? (Which disease likely developed FIRST then began a “domino effect”?) PMH: What Came FIRST: Diabetes mellitus type II-poorly controlled What then followed: First: Smoking & lifestyle choices (mainly diet) were then followed by: Diabetes Type II, Hypertension Hyperlipidemia, Hypertension, & Gouty Hyperlipidemia arthritis. Gouty arthritis Smokes 1 ppd x 40 years 2. 3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem? Care Provider Orders: How it Will Resolve Primary Problem/Nursing Priority: Establish peripheral IV Provides needed hydration (also helps bloodflow) Monitors irregular heart rate 12 lead EKG stat Labetalol 10-20 mg IV prn every 15 minutes to keep SBP 160-180 Beta blocker to slow heart rate, making it easier to pump blood Shows any irregularities in head such as an intracranial bleed, clots or tumors. CT head stat To monitor heart rate & rhythm until it returns to therapeutic range. Cardiac monitor continuous Ordered because a stroke pt's ability to swallow even liquids or saliva, resulting in silent aspiration (no visual indications) (into the lungs) causing pneumonia. NPO Alteplase IV dose per pharmacy (if CT negative for bleed) Given intravenously to treat clotting of blood, never given until after a CT scan (of the head in this case), to be sure there is no intracranial bleed present, as this would worsen the bleed. Developing Nurse Thinking by Identifying Clinical PRIORITIES 1. Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: 1. Establish peripheral IV 1 Rationale: IV first to give fluids & portal for meds, because Pt is NPO 2. Labetalol 10-20 mg IV prn 2 every 15" to keep SBP 160-180 Give med to regulate HR (into IV) 3. CT head stat 4 To check for intracranial bleed, etc. (before giving clot-buster med- Alteplase 4. Cardiac monitor continuous 3 Place cardiac monitor to continuously monitor HR, due to irregularity. 5. Alteplase IV (if CT negative for bleed) 5 To break up any blood clots. 2. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Vitals (always first)- Pt is NPO due to CVA. Place IV port, give fluids & med to stabilize HR. Place heart monitor for continuous monitoring. 3. What interventions will you initiate based on this priority? Nursing Priority: Nursing Interventions: Rationale: Vitals/HR Place continuous heart monitor. Pt has irregular HR Expected Outcome: HR will stabilize after medication intervention. 4. What are the PRIORITY psychosocial needs that this patient and/or family likely have that will need to be addressed? Pt showing frustration when he cannot respond to wife's questions/talking. Pt needs rest and quiet. 5. How can the nurse address these psychosocial needs? Gently suggest to wife that her husband needs to rest, and she is welcome to stay, but maybe she could read quietly or take a break herself, and let him rest. 6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family? Be sure Pt and his wife understand medication orders and the importance of following Dr's recommendations, provide nutrition information for Diabetics, Recommend a smoking cessation Caring & the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? Understandably, he is likely feeling anxiety regarding his health status. 2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? When speaking to the Pt make eye contact, be empathetic, touch his shoulder, ask him to verbalize any concerns or questions he may have, listen to what he is saying or asking, and ans er his q estions or find o t the ans er if nkno n Gi e him information abo t the Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment and transfer what is learned to improve nurse thinking and patient care in the future. 1. What did I learn from this scenario? I imagined myself as the nurse responsible for this Pt's care, and realized how crucial it is to remain calm, and focus on the plan of care, and how to prioritize the nursing interventions. 2. How can I use what has been learned from this scenario to improve patient care in the future? I am still learning how to prioritize nursing interventions, but I am sure that will come with time