Case Number 1- Stroke/ CVA Patient M

Case Number 1- Stroke/ CVA Patient M is an active woman, 70 years of age, who lost consciousness and collapsed at home. Her daughter, who was visiting her at the time, did not witness the collapse but found her mother on the floor, awake, confused, and slightly short of breath. The daughter estimated that she called EMS within 5 minutes after the collapse, and EMS responded within 10 minutes. EMS evaluated Patient M, drew blood for a glucose level, and determined that she may have had a stroke. They notified the nearest designated comprehensive stroke center that they would be arriving with the patient within 15 minutes. Patient M’s daughter accompanied her. On presentation in the emergency department, Patient M is immediately triaged. Because Patient M is still somewhat confused, her daughter is asked to provide information on the patient’s history. The daughter reports that her mother had had an episode of sudden-onset numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The episode lasted only 5 minutes, and Patient M had not called her primary care physician. Additional information provided by the daughter indicates that Patient M has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive ? medicine, a diuretic. The patient has never smoke, drinks occasionally, and is of normal weight. On physical examination, Patient M’s blood pressure is 150/95 mm Hg. She has pain in her left arm and a slight headache. There are slight carotid bruits on the right. She is assessed with the use of the NIHSS and found to have left hemiparesis and left visual/spatial neglect. The results of laboratory tests, including a complete blood count, prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal function studies, are all within normal limits. CT of the brain indicates a thrombus in a branch of the right internal carotid artery, with approximately 75% occlusion due to atherosclerosis. There is an area of infarction in the right anterior hemisphere. There is no evidence of a subarachnoid hemorrhage. The diagnosis is made 2 hours after Patient M’s arrival in the emergency department. She is treated with intravenous rt-PA at a dose of 0.9 mg/kg, and aspirin antiplatelet therapy is started at an initial dose of 325 mg, 24 hours after thrombolytic therapy, and a maintenance dose of 75 mg per day. When Patient M’s condition is stabilized, her primary care physician and consultant neurologist provide a referral for stroke rehabilitation, and a multidisciplinary rehabilitation team is formed to assess her rehabilitative needs, recommend the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that include daily antiplatelet therapy. Patient M is again assessed with the NIHSS, and the score is 12. Her fate suddenly shifted when 8 days after discharge Mrs. M was found by her daughter lying in bed difficult to arouse and would not obey commands and cannot even move her limbs and murmured incomprehensible sounds. She was then rushed by her daughter to the nearest hospital. There were no possible signs of trauma seen on body or any significance of a fall or injury. A brain CT scan was conducted right away and revealed a 5 cm intracerebral bleed in the right hemisphere right next to the former infarct. Her blood pressure reading was at 165/70; HR at 58/min. Laboratory results indicate a prolonged PT and PTT. Questions: 1. How would a stroke patient like Mrs. M be considered for transport and classified in the triange? 2. What risk factor for stroke do the patient and her daughter present during the history taking? What are the possible bases of this information? 3. What are the doctor’s bases to qualify Mrs. M as a good candidate for the treatment? 4. What can be a possible reason for Mrs. M’s new diagnosis? 5. As the nurse in the ICU and following the nursing process and order of priority in the care of this patient what would you anticipate the doctor’s orders and your plan of care of this patient? SCIENCE HEALTH SCIENCE NURSING NURS 437

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