Nursing Care Plan: Case Study of Cerebrovascular Accident

Case Study: CVA

A Cerebrovascular accident (stroke) is a rapid-onset medical emergency than can cause neurological damage and disabilities. Many people know of or heard of someone having a stroke before; it is very common in the United States. According to Centers for Disease Control and Prevention, stroke kills about 140,000 Americans each year- that’s 1 out of every 20 deaths, also about 87% of all strokes are ischemic strokes, in which blood flow to the brain is blocked. This case study discusses expected signs and symptoms, risk factors, nursing care plan and interventions of the patient who has experienced a CVA. It also describes Patient Mr. B current health and past medical history and basic conditioning factors.

Basic Conditioning Factors

Patient Mr. B is a 79-year-old Caucasian male patient who was admitted on March 8, 2019, at noon. He has a medical history of atrial fibrillation and hypertension. About a year ago, he experienced a cerebrovascular accident also known as a stroke, which has left him having hemiplegia and hemiparesis affecting his right dominant side. His past medical history includes hyperlipidemia and dysphagia, which usually affects the majority of stroke patients. Due to his dysphagia, he also has had a percutaneous endoscopic gastrostomy (PEG) to help get his nutritional needs like liquid, food, and medications. His feeding rate is 60ml/hr. and is held between the hours of 12 pm-4 pm, due to his family visiting him around that time. The consistency of his feeding is honey-thickened liquid His code status is do not resuscitate (DNR), has no known drug allergies and is being withheld from food and fluids (NPO). His development level according to Erikson’s stages is Integrity vs. Despair. He fits more of ego integrity meaning he is looking back on life a feeling a sense of fulfillment leading up to wisdom. His activity level is dependent with attempts to initiate on his own. On September 16, 2019, his vital signs were BP: 126/78 Pulse: 63 Pox 93 Respirations: 22 and no complaints of pain. On September 17, 2019, his vital signs were BP: 117/78 Pulse: 55 Respirations: 20 and no complaints of pain. His pulse fluctuates frequently due to him having atrial fibrillation.

Expected Signs and Symptoms of Primary or Admission Medical Diagnosis

The primary diagnoses for this client is a cerebrovascular accident is the medical term for a stroke. A stroke can be ischemic or transient, the difference between the two is that a transient is a temporary blood clot and is reversible, ischemic isn’t. According to the Center of Disease Control and Prevention (2018), the five most common signs and symptoms of a stroke are sudden numbness or weakness in the face, arm or leg, especially on one side of the body; sudden confusion, trouble speaking, or difficulty understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance, or lack of coordination; severe headache with no known cause. Some nursing considerations when caring for patients is to keep the HOB 30 degrees, frequent neurological assessments, fall prevention measures, prevention of contractions, and promoting cerebral tissue perfusion. ('Nursing Care Plan for Stroke (CVA),' n.d.).

Health Deviations

During the assessment of the nursing process, the abnormal finding for this client was weakness on his right dominant side, unable to communicate, excessive frothy sputum, abdominal distention, generalized weakness, activity intolerant and labored breathing. The patient can suction himself per MD order; the suction device is left at his bedside. Head of the bed should be elevated 30-45 degrees to prevent aspiration.

>ention to get movement going, since the patient is immobile. Also administering a laxative per MD order twill help with constipation to relieve his distention. It is important to encourage the patient to use his left hand, since the right side is weak.

Nursing Diagnosis

Risk for aspiration related to impaired swallowing as evidenced by the patient being unable to swallow or drink any fluids. (Vera, 2013) It is important to monitor the patient throughout the shift for risk for aspiration and to assist the patient with head control and position based on specific dysfunction to reduce the risk of aspiration. (Vera, 2013) Administer tube feedings for fluid replacement and nutrition. (Vera, 2013) Have suction equipment available at the bedside in case the patient starts to aspirate. (Vera, 2013) The goal of care is the patient maintains a patent normal airway and normal breath sounds and patient digest gastric feeding without aspiration. (Vera, 2013) Lastly, the patient is free of aspirations and the risk of aspirations is decreased. (Vera, 2013) Risk for skin break down related to skin friction as evidenced by reddened heels. The patient’s skin should be left clean, dry and intact and he should be repositioned every two hours. Additionally, boney prominences like elbows, heels, and sacrum should be inspected for skin breakdown due to being higher risk because of compression between hard surface and the bone. (Wayne, 2019) The goal is the patient’s skin should remain intact by having no presentation of redness on boney prominences. (Wayne, 2019)

Plan of Care

The plan of care to take into action is to improve Mr. B is to help him with his difficult speaking, immobility, and preventing a secondary stroke. It is beneficial for Mr. B to meet with physical therapy to help him learn exercises that can help lower his blood pressure, lower his body weight, and improve vasodilation. He is at greater risk for a secondary stroke because of his atrial fibrillation. Anticoagulant therapy like aspirin can help thin out of the blood and prevent the risk of blood clots forming in the heart, which can be a cause that leads to a stroke. While in the facility to help him communicate. For example, using a communication board and being able to use a notepad to write out on things he would like to speak of. Since he is unable to communicate with his family over the phone, it is important to remind the family to visit him. Additionally, occupational therapy would be beneficial to help him maintain skills needed for daily living. He should also be encouraged to do independent activities while providing care. For instance, encouraging him to brush his teeth by using his stronger hand or brushing his hair.

Conclusion

Furthermore, this case study illustrates how Mr. B has many things to work on towards his health condition. Cerebrovascular accident is a very serious condition that can be life-threatening to the patient and requires immediate interventions. Teaching the client about his medication, exercising, following up with his specialist, and maintaining a healthy weight can be beneficial to his health and help him understand more how important it is to take care of him. Lastly, it is important for the nurse to notice the signs and symptoms of a potential stroke and what to do when it occurs. The nurse should be able to also consider the patient’s background, education, and different ways to help the patient understand their health condition when barriers are present, for instance, the patient being nonverbal.

Medication List

Medication

Why

Side Effects

Nursing Concerns

Dosage

Atrovastatin

Antihyperlipdemia

Hyperlipidemia

Abdominal cramps, flatus, heartburn

Monitor CK levels, obtain dietary history, monitor liver function test, monitor cholesterol

1 tab 40 mg G-tube

Docusate Sodium

Laxative

Bowel Management

Diarrhea, bitter taste, bloating, gas

Encourage fluids. Monitor bowels (color, consistency, amount)

10 ML G-tube

Dulcolax (Basacodyl)

Laxative

Constipation

Throat irritation, mild cramps, diarrhea, rashes

Don’t use when abdominal pain, nausea, vomiting, or fever is present/ don’t take within 2 hr. of other laxatives.

10 mg (suppository/rectal)

Fleet enema

Laxative (Saline)

Constipation

Dizziness, headache, abdominal pain, bloating

Assess abdominal distension, color/amount/consistency of stools

Rectal

Milk of Magnesium

Laxative

Constipation

Diarrhea, flushing, sweating

Assess for heartburn/indigestion, monitor serum phosphate, potassium and calcium levels

30cc G-tube

Multivitamin + minerals

Supplement

Supplement

Upset stomach, Constipation, Diarrhea

Monitor Bowel movements (form, consistency, color)

10 Ml G-tube

Robitussin

Antitussives

Cough

Dizziness, sedation, nausea

Assess frequency/nature of cough, long sounds, and sputum produced

10ML G-tube

PRN

Tylenol

Analgesic/

Antipyretic

Mild pain (1-3)

Hypotension, agitation, anxiety, headache, fatigue, insomnia, constipation

Assess alcohol usage, assess type/location of pain, assess fever, may alter blood glucose monitoring (lower)

325 mg 2 tabs PRN

TUBER sol

Skin test to determine if pt. has tuberculosis

Generalized rash, fainting, light headedness, redness at injection site

Read after 72 hours, Annual PD test 03/22/2020

0.1 ML intradermal

Aspirin: no steroidal ant inflammatory drug

Fever/Mild Pain

Chest Pain

CVA prophylaxis

GI BLEEDING, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting

Monitor pain/fever. (Type of pain, characteristic, onset, time) (Monitor temperature)

81 mg 1 tablet G-tube

HEMATOLOGY

Date of lab:

January 30, 2019

REFERENCE

RANGE (for your lab)

DAY OF LAB: (+ previous values as pertinent)

IMPLICATIONS: – Why do you think your patient has this lab value, any concerns?

WBC

4.00-10.00

5.30

WNR

RBC

4.63-6.08

3.53

Not enough O2 in the blood

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HGB

13.7-17.5

11.8

Can be an indication of anemia

HCT

40.1-51.0

36.2

Can be an indication of anemia or from medication

PLT

150-400

135

Can indicate anemia, enlarged spleen or iron deficiency

COAGULATION

REFERENCE RANGE (for your lab)

DAY OF LAB:

IMPLICATIONS:

PT

N/A

N/A

N/A

INR

N/A

N/A

N/A

APTT

N/A

N/A

N/A

CHEMISTRY

REFERENCE RANGE (for your lab)

DATE OF LAB:

IMPLICATIONS:

NA

70-99

140

Indication of high blood pressure, dehydration,

K

3.7-4.5

3.7

WTR

CL

98-107

106

WTR

CO2

27

21-31

WTR

GLUCOSE

70-99

140

Infection, illness, under stress, or indication of something wrong within the heart.

BUN (blood urea nitrogen)

7-25

18

WTR

CREAT

0.70-1.30

0.79

WTR

CA

8.6-10.3

8.6

WTR

PHOS

N/A

N/A

N/A

MAG

N/A

N/A

N/A

PROTEIN

6.4-8.9

5.6

WTR

ALBUMIN

3.4-5.7

3.4

WTR

ALT

7-52

23

WTR

AST

13-29

22

WTR

TRIGLYCERIDE

N/A

N/A

N/A

References

1. High Blood Pressure | Hypertension. (2019, September 4). Retrieved from https://medlineplus.gov/highbloodpressure.html.
2. Hyperlipidemia. (n.d.). Retrieved from https://vascular.org/patient-resources/vascular-conditions/hyperlipidemia.
3. Nursing Care Plan for Stroke (CVA) - NRSNG Nursing Courses. (n.d.). Retrieved from https://academy.nrsng.com/lesson/nursing-care-plan-for-stroke/.
4. Stroke Symptoms. (n.d.). Retrieved from https://www.stroke.org/en/about-stroke/stroke-symptoms.
5. Stroke, Acute (Cerebrovascular Accident [CVA]): 5-Minute Clinical Consult. (n.d.). Retrieved from https://www.unboundmedicine.com/5minute/view/5-Minute-Clinical-Consult/1688020/all/Stroke__Acute__Cerebrovascular_Accident_[CVA]_.
6. Vera, M., & Vera, M. (2019, June 3). 8 Cerebrovascular Accident (Stroke) Nursing Care Plans. Retrieved from https://nurseslabs.com/8-cerebrovascular-accident-stroke-nursing-care-plans/2/.
7. Villines, Z. (n.d.). What Is The Difference Between Hemiplegia And Hemiparesis? Retrieved from https://www.spinalcord.com/blog/what-is-the-difference-between-hemiplegia-and-hemiparesis.
8. What is Atrial Fibrillation (AFib or AF)? (n.d.). Retrieved from https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af.