Case Study: Cerebrovascular Disorders

Kaorou Kashin, a 74-year-old patient, is admitted to the telemetry unit with the diagnosis of acute ischemic stroke. The patient is experiencing paroxysmal atrial fibrillation with a controlled ventricular rate on the monitor. The CT of the head without contrast reveals no evidence of hemorrhage. The transesophageal echocardiogram reveals moderate mitral valve insufficiency and embolism as a primary cause of the stroke. The patient is on a weight-based heparin protocol. The patient received digitalis to keep the ventricular rate of the atrial fibrillation controlled. The patient has right-sided paralysis and global aphasia. The patient has unilateral neglect of her right side and has right field homonymous hemianopsia. There is papilla edema present bilaterally. The patient is drooling from the right side of her mouth and coughs periodically. The patient was found by her daughter after her daughter had gotten out of work and arrived at her mother’s home. The daughter stated her mother was normal before she left for work, and 10 hours later the mother exhibited the symptoms described above. The time of onset for the stroke could not be safely determined so no interventions could be used to treat the stroke.

What principles of nursing management should the nurse provide the patient during the acute stage of the ischemic stroke based on the assessment findings from the case study? Place the assessment findings that are supported by the nursing principle(s) in parenthesis.

Right-sided paralysis – (ROM – To help maintain or increase joint function and prevent contractures.)

Global aphasia – (Speech therapy – To help aphasic patient)

Embolism

Unilateral Neglect (right) –

Hemianopsia

Papilla Edema – Assess Glasgow Coma Scale

Drooling (right side of mouth) –

Coughing – (Back Clapping –

Case study 2

Luke Skywalker, a 71-year-old male patient, is being discharged from the rehab unit 8 weeks after an ischemic stroke. The patient’s spouse stated that they used to enjoy going to golf outings with their friends, but the patient has not golfed since her husband had the stroke, and she does not want to try to golf once her husband is discharged home because he has to use a walker and can barely ambulate. She also states that her husband still has trouble speaking, and his short-term memory is not very astute so it would be embarrassing to be on a golf outing with him. The patient’s spouse has worn the same outfit to the rehab unit the past 3 days, and the nurse notices the patient’s hair is unkempt and her affect is flat. The rehab nurse has made arrangements with the social worker for a physical therapist, speech therapist, and occupational therapist to provide three sessions of therapy at the patient’s home for the next 4 weeks, and then a reevaluation will follow to determine if the patient will need further therapy. The patient is able to sit independently, stand independently, and use a walker. The patient is able to ambulate 30 feet with the walker, and then he requires a short rest before he is able to ambulate another 30 feet. The patient slurs words occasionally and has hesitant speech. The patient has problems with short-term speech.

What educational topics should the nurse provide the family about home care for the patient after stroke?

When providing patient-family teaching, it should focus on sensory information. We should include verbal and written information about the following:

Symptoms that needs prompts attention: sudden weakness, numbness (especially on one side of the body), vision loss or dimming, trouble talking or understanding speech, unexplained dizziness, unsteadiness, or severe headache.

Interventions for safe swallowing and aspiration prevention.

Significance of minimizing or treating the following risk factors: diabetes mellitus, hypertension, high cholesterol, high Sodium intake, obesity, inactivity, smoking, prolonged bed rest, and stressful lifestyle.

Importance of taking prescribed medications regularly and on schedule. Do not discontinue medications abruptly.

Encourage patient/family to keep drug and seizure chart diary.

Reinforce drug administration instructions.

Importance of keeping with the appointments.

Explain or inform family side effects of medications.

Notify health care provider if there is a significant weight gain or loss.

Teach to avoid alcoholic drinks and OTC drugs.

Encourage oral hygiene

What assessment of the spouse does the nurse need to make, and what should the nurse suggest?

Can barely ambulate – Positioning: Bedrest, it will help improve the patient’s condition, which will help increase activity level.

Trouble speaking – Speech therapy; Encourage patient to perform facial muscles exercises; provide a supportive and relaxed environment for patient; provide alternative methods of communication

Short term memory

Same outfit and unkempt hair – assist performing independently self-care; demonstrate ability to adaptive devices

Affect is flat

GROUP OUTPUT CHAPTER 63 EO4

Case Study 2

Luna Lovegood, a 23-year-old-patient, is admitted to the neuro intensive care unit after a diving accident leading to a C-6 spinal cord injury. The patient is diagnosed with neurogenic shock. The patient has the following vital signs: T: 97°F, BP: 84/44, P: 40 bpm, 16 breaths per minute. The patient has lower extremity edema and peripheral vasodilation. The patient is perspiring above the C-6 lesion, but there is no perspiration below the C-6 lesion and the skin is warm and dry. The patient has a paralytic ileus.

What clinical management should the nurse anticipate for the patient?

The care given to a patient with a neurologic shock is also similar to the general management provided for any patient with shock. Airway control should be secured with spinal immobilization and protection. The patient should be immobilized to minimize further movement and injury to the spine. We should keep the patient warm because spinal injury can disrupt the thermoregulatory mechanisms of the body. Another concern is related to fluid therapy. We determine the needed IV fluids based on the patient’s hemodynamic status. We maintain the patient’s adequate hydration and volume status to keep at 90 mm Hg/higher. General hemodynamic resuscitation includes volume loading with normal saline IV fluid. If possible, warm fluid is given to prevent hypothermia. Profound bradycardia in extreme cases become asystole and some patient needs to have a pacemaker fitted. Medications such as vagal blockers, for example atropine, by rapid IV push is given if the pulse remains bradycardic, while pressor agents, such as dopamine drip, may be used for better hydrating the patient. We should monitor the patient’s response to vasopressors because it may compromise the sympathetic nervous system.

What are signs that the neurogenic shock is resolving?

The symptoms resolve when spinal cord edema resolves. Another sign of resolving shock is Spasticity, which is the return of reflexes. Improved cardiac output of the patient is also a sign of resolving neurogenic shock.