CONCEPT: INTRACRANIAL REGULATION TOPIC: Stroke (Answer Key) – answers may vary f
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CONCEPT: INTRACRANIAL REGULATION
TOPIC: Stroke (Answer Key) – answers may vary for most questions
Ms. A is a 64-year-old woman, arrives at the emergency department (ED) with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0730, she stayed in bed, saying she had a mild headache over the right temple and was feeling weak. He went and got coffee, then thinking it was unusual for her to stay in bed, went back to check on her. He found she was having trouble saying words and had a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the ED. Her medical history includes atrial fibrillation (Afib), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test was normal, and her blood pressure is under good control. Ms. A is currently taking amiodarone, amlodipine, aspirin, simvastatin, and lisinopril. The provider suspects Ms. A is having a stroke.
1. What diagnostic procedure would most likely be ordered by the provider and why?
Noncontrast CT scan is needed immediately upon arrival in the facility to identify the size, location, including the type of stroke the client has (either ischemic or hemorrhagic). The result of the imaging will determine what type of treatment would be the most appropriate for the client.
2. Identify the two major types of stroke and a brief description.
Ischemic stroke results from inadequate blood flow to the brain and can be classified either as thrombotic (injury to a blood vessel) or embolic (occurs when an embolus occludes a cerebral artery – originating outside the brain mostly from the heart). Hemorrhagic strokes result from bleeding into the brain tissue itself due to a rupture of a blood vessel.
3. What factors could contribute to the development of stroke?
A. advancing age
B. African-American/black/male
C. uncontrolled hypertension
D. use of illicit/recreational drugs
E. history of chronic disease – DM, CKD
F. family history
G. hyperlipidemia
H. irregular heart rhythm
4. What are the common manifestations of stroke?
BE FAST – B (balance) E (eyes) F (facial drooping) A (arm weakness/paralysis) S (slurred speech) T (time to call 911)
A.aphasia/dysarthria
B.paralysis or body weakness – paresis
C.impaired memory or judgement/including affect
D.balance and coordination problem
E.visual disturbances
5. Outline the focused assessment that you need to obtain.
A.airway
B.vital signs
C.level of consciousness – Glasgow Coma Scale (GCS)
D.cardiac rhythm – EKG
E.motor movements/visual deficits
Your assessment findings are as follows: VS: 168/102, 99, 23, 97.8oF, SaO2 93% on room air. Her lungs are clear, and she is alert and oriented. She is able to follow simple commands, has PERRL with intact extraocular movements, and no vision loss. Her facial movements are asymmetrical, with left-sided drooping. Speech is slightly slurred, although it remains intelligible. She is unable to move her left arm and leg; sensation is intact. There is no ataxia; however she is experiencing some visual and tactile neglect of the left side.
6. Complete the National Institutes of Health Stroke Scale (NIHSS) scores for each of Ms. A’s symptoms.
alert
0
knows months and age
0
able to follow commands
0
no visual loss
0
left-sided facial paralysis
2
left-leg no movement
4
left arm no movement
4
no ataxia
0
sensation intact
0
moderate aphasia
1
neglect of left side
1
7. Describe the following manifestations that can occur to a client with stroke.
aphasia
inability to communicate
dysarthria
difficulty articulating words
alexia
loss of the ability to read
agnosia
inability to recognize familiar objects
apraxia
inability to perform purposeful movements in the absence of motor problems
agraphia
loss of the ability to write
anosognosia
unaware of one’s own condition or situation
A noncontrast CT scan confirms the diagnosis of a cardioembolic stroke. The provider writes the order shown below:
Physician’s Orders
IV 0.9% normal saline at 75 mL/hr
Activase (tPA) per protocol
stat CBCD, coagulation panel, cardiac panel
neuro-VS every hour
obtain patient’s weight
O2 at 2 L per nasal cannula
NPO until swallowing evaluation
8. Give some interventions that you can delegate to your assistive personnel (AP) when caring for Ms. A
A.vital signs
B.blood drawing/phlebotomy
C.running an EKG
D.repositioning
E.hygiene needs
9. What are the contraindications when giving tPA?
A.systolic BP above 185 mm Hg
B.major surgery in the last 14 days
C.platelet count below 100,000
D.blood glucose less than 50
E.INR above 1.7
F.history of myocardial infarction 3 months ago
G.intracranial hemorrhage
10. What are your nursing responsibilities during the administration of tPA?
A.Monitor the client for any signs of bleeding.
B.Maintain the patency of the IV site.
C.Monitor frequently the vital signs.
D.Perform frequent neurologic checks.
11. What signs and symptoms would alert you to the possible presence of an intracerebral hemorrhage as an adverse effect of tPA infusion?
A.sudden increase in BP
B.vomiting
C.new onset headache/neurologic deterioration
Ms. A is admitted to the stroke unit. A second CT scan 24 hours later reveals a small CVA in the right hemisphere. She is placed on aspirin, amiodarone, amlodipine, clopidogrel, simvastatin, and lisinopril.
12. Why was Ms. A placed on clopidogrel post-CVA?
Clopidogrel is usually combined with aspirin to prevent platelet aggregation (clot formation) to prevent reinfarction or another stroke.
13. What is the importance of continuing simvastatin for Ms. A?
Ms. A has a history of hyperlipidemia which puts her at risk for another stroke. The drug stabilize the endothelial wall and prevent plaque ruptures.
14. Ms. A was referred to speech pathologist, physical therapist, and occupational therapist. Which of the following problems or issues post-stroke needs to be addressed by the following healthcare team members:
A. social worker – facilitation of home care or long-term needs/skilled nursing facilities, advance directives
B. speech pathologist – impaired swallowing and speech problems
C. dietitian – create a meal plan appropriate for the client’s condition – low sodium, low-saturated fat diet
D. physical therapist – lower extremity/motor and ambulatory problems
E. occupational therapist – upper extremity and fine motor skill development
Reference: (with modifications, from Clinical Reasoning Cases in Nursing by Mariann Harding and Julie Snyder, 7th ed.)
