unfolding clinical reasoning case study: answer · pdf file© 2013 keith rischer/...

© 2013 Keith Rischer/www.KeithRN.com

Unfolding Clinical Reasoning Case Study: ANSWER KEY

Cerebral Vascular Accident (CVA)

I. Data Collection History of Present Problem:

John Gates is a 59-year-old male who was at work when he had sudden onset of right-sided weakness, right facial

droop, and difficulty speaking (dysarthric speech). He was transported to the emergency department (ED) where these

symptoms persisted. During transport, he had increased agitation and became confused to place and time. It has been 30

minutes from the onset of his neurologic symptoms when he presents to the ED.

Personal/Social History:

John lives with his wife in their own home in a small rural community. He owns his own hardware store where he

remains active and involved in the day-to-day operations. John’s wife is with him along with his son who also works in

the hardware store. His wife insists on being by his side and talking to John despite John’s frustration in not being able to

answer her questions. John has been trying to quit smoking over the past week and began using a nicotine patch. John has

been complaining of pain on the right foot for the past week according to his wife.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

Sudden onset of right-sided weakness, right

facial droop, and difficulty speaking

(dysarthric speech)

During transport, he had increased agitation

and confusion to place and time

It has been 30 minutes from the onset of

neurologic symptoms when he presents to the

ED

All of these symptoms are reflecting acute neurologic changes that are

due to disruption in cerebral blood flow either because of embolism or

hemorrhagic event. The location of the affected area will determine the

type and severity of symptoms.

ASK…Are we are able to localize what side of the cerebral

hemisphere this CVA is taking place on?

It is clearly the LEFT cerebral hemisphere because of the right-sided

motor deficits. This is a good time to highlight the relevance of A&P and

remember the corpos callosum and what this does!

All of these symptoms are reflecting acute neurologic changes that are

due to disruption in cerebral blood flow either because of embolism or

hemorrhagic event and is a clinical RED FLAG because it is a change

that is reflecting a worsening in status.

Has been only 30 minutes since onset of neuro symptoms. Is now in ED

and if not contraindicated, he is a candidate for thrombolytic therapy

such as tPA that can re-establish cerebral blood flow and limit severity

of CVA deficits dramatically. TIME IS NEURONS as it is estimated that

millions of neurons are lost every minute that tPA therapy is delayed!

RELEVANT Data from Social History: Clinical Significance:

His wife insists on being by his side and

talking to John despite John’s frustration in

not being able to answer her questions

Nicotine patch use

pain on the right foot for the past week

The wife’s attitude MAY be a problem. Will need further assessment.

Regarding his speech; is he expressive or receptive aphasia or both?

This is reflecting EXPRESSIVE aphasia

Is the patch still on him?…. May elevate BP and should be removed

during the acute episode for now. The nurse needs to find it!

Be sure to take his shoes off and perform a skin and joint assessment.

Think gout or potential for skin breakdown. He is a diabetic and

clustering these 2 pieces of clinical data requires the nurse to assess this

once the dust settles with his primary problem


What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect)

PMH: Home Meds: Pharm. Classification: Expected Outcome:

Diabetes mellitus type II-

poorly controlled

Hypertension

Hyperlipidemia

Gouty arthritis

Smokes 1 pack per day x

40 years (40 pack years)

1. Indomethacin (Indocin)

25 mg tid

2. Aspirin 81 mg daily

3. Lisinopril (Prinivil) 20

mg daily

4. Simvastatin (Zocor) 40

mg daily

5. Metformin(Glucophage)

500 mg bid

6. Nicotine patch 21 mg

transdermal

Pharm. Classification

1. NSAID

2. NSAID

3. ACE inhibitor

4. Anti-hyperlipidemic

5. Hypoglycemic

6. Nicotine replacement

Expected Outcome:

1. Decrease inflammation

2. Prevent thrombus in

those at risk for CV disease

3. Lower BP

4. Lower LDL and elevate

HDL chol.

5.Lower blood glucose

6. Smoking cessation

(Which medication treats which condition? Draw lines to connect)

DM type II-poorly controlled>>>Metformin

Hypertension>>>Lisinopril, ASA

Hyperlipidemia>>>Simvastatin

Gouty arthritis>>>Indocin

Smokes 1 ppd>>>Nicotine patch

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their

life?

Circle what PMH problem started FIRST

DM-II o This is where it all began! This is a direct contributor to the development of hyperlipidemia and eventual

vascular complications. You will see this similar scenario repeatedly in practice!

Underline what PMH problem(s) FOLLOWED as domino’s

Hyperlipidemia

HTN

o Domino that falls after development of hyperlipidemia as the arteries become stiff and noncompliant as a

result of atherosclerosis. Hypertension is the end result!

Gouty arthritis

o NO domino-isolated problem

Smokes 1 ppd x 40 years

o Smoking is like adding gas to this fire of vascular complications with known diabetes! This will

accelerate the progression of vascular complications including cardiac and neurologic complications.

Knowing that he is poorly controlling his diabetes in addition to being a smoker, this current problem

comes as no surprise!

II. Patient Care Begins:

Current VS: WILDA Pain Scale (5th VS):

T: 99.2 (oral) Words: Ache

P: 118 (irregular) Intensity: 3/10

R: 20 (regular) Location: Right foot

BP: 198/94 Duration: continuous

O2 sat: 99%

room air (RA) Aggreviate:

Alleviate:

Walking/movement

Rest


What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT VS data: Clinical Significance: P: 118 (irregular)

BP: 198/94

O2 sats: 99% RA

This is a clinical RED FLAG because it is reflecting the most common reason for embolic

strokes…unrecognized/untreated atrial fibrillation. The irregular rate must be recognized for

this likelihood and placing the patient on a cardiac monitor and obtaining a 12 lead EKG

are essential standards of care to validate your initial clinical impression.

An elevated BP after a CVA is not uncommon. However, when too high, it can actually

impede cerebral blood flow and perfusion or lead to a hemorrhagic stroke., Managing BP

closely is an essential standard of care. Goal is to have BP not too high or too low.

Neurologists typically want to see SBP 150–180 to maintain optimal cerebral perfusion in

the acute phase of a CVA. Specific goals and BP parameters are individualized for each

patient.

Though normal, this is RELEVANT VS data in the context of confusion and agitation in this

patient. Hypoxia can also cause the same symptoms, and knowing that sats are 99%, you can

be confident that the confusion/agitation is being driven by the acute CVA not hypoxia.

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT assessment data: Clinical Significance: GENERAL APPEARANCE: appears

anxious

CARDIAC: Rhythm: atrial fibrillation

NEUROLOGIC: Confused to place and

why he is in the hospital, is notably

anxious, restless, and agitated, speech is

currently slurred and difficult to

understand, facial droop present on right

side, pupils equal and reactive to light

Anxiety will increase BP. Make it a priority to educate, comfort, and support

during this time in the ED to bring down naturally, and TREND this

response to this intervention!

SEE RHYTHM STRIP BELOW: This is confirming your suspicion of the

rapid irregular rate that was present initially and may have precipitated the

embolic stroke . At this time, the goal is not to change this rhythm, but to

manage the complications of further embolic events related to atrial

fibrillation.

As a whole all of these acute neurologic changes are reflecting a left

hemisphere CVA that is likely significant in size based on the degree and

scope of neurologic changes and hemiparesis.

Current Assessment:

GENERAL

APPEARANCE:

Appears anxious–he is aware and concerned about changes in neuro status

RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds irregular–S1S2, pulses strong, equal with

palpation at radial/pedal/post-tibial landmarks

NEURO: Confused to place and why he is in the hospital, is notably 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 in comparison to left, which is strong, 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

GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity appears intact, right foot not assessed at this time


(PEARL), both right upper extremity

(RUE) and right lower extremity (RLE)

notably weak in comparison to left,

which is strong, right pronator drift

present, unable to hold right arm up,

right visual deficit cut present

GI: Able to swallow saliva

Any patient with a likely CVA is also at high risk for dysphagia and

aspiration, therefore this normal assessment finding is clinically significant!

Cardiac Telemetry Strip:

Interpretation:

Atrial fibrillation with RVR (rapid ventricular response; HR >100)

Clinical Significance:

Clinical RED FLAG as it is reflecting the most common reason for embolic strokes…unrecognized/untreated atrial

fibrillation. AFib is common with the elderly, so it important to review medical history and see if they have had this in

the past or not. In this case there is NO documented history. This clinical RELATIONSHIP must be recognized by the

nurse

III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with?

Acute CVA of the left hemisphere. Do not know yet if is embolic or hemorrhagic in origin, but more likely to be embolic

based on assessment finding of new atrial fibrillation.

2. What is the underlying cause/pathophysiology of this concern?

There are 2 major categories of stroke: hemorrhagic and ischemic. Hemorrhagic is too much blood within the cranial

cavity due to a ruptured blood vessel. Ischemic is too little blood supply to parts of the brain. Ischemic stroke is caused

by either a thrombus or embolus. A thrombotic stroke is often due to atherosclerosis developing over time in either the

cerebral arteries or the main arteries that supply the brain (usually the carotid arteries). Because of the gradual

occlusion, the onset of symptoms tend to occur gradually and slowly.

An embolic stroke is caused by a thrombus that breaks off from one area of the body and travels to the arteries that

supply blood to the brain. Because the sudden blockage of blood flow, the onset of symptoms tend to be abrupt and faster.

Whether thrombotic or embolic, it It is ischemic tissue but is salvageable with timely intervention and reperfusion within 3

hours of onset (time extended to 4.5 hours in some cases). If reperfusion is not established in 3 hours (4.5 hours in some

cases) or contraindicated, most of these neurologic deficits will be permanent, though the severity of motor deficits may

be decreased over time with therapy.i

In the context of atrial fibrillation, because the atria are fibrillating (quivering) and do not have a synchronized atrial

kick, blood will not readily empty from the lower portion of the atria and will coagulate and form a clot that will

eventually make its way into the ventricle and be pumped either into the lungs if in the right ventricle and cause a

pulmonary embolus or if a clot makes it to left ventricle, will be pumped through the aorta and up to the brain causing an

embolic stroke.


3. What nursing priority will guide your plan of care? (if more than one-list in order of PRIORITY)

It must be noted that in the context of a crisis, NANDA nursing diagnostic statements cannot capture the urgency of this

critical situation! Though “ineffective tissue perfusion (neurologic)” does “fit” it does NOT communicate the URGENCY

of this scenario! Therefore clinical reasoning that I use in practice is to simply state the problem as it is and the nursing

interventions readily follow.

Knowing that millions of neurons are being lost every minute that there is lack of perfusion to the brain, and since this

patient was a witnessed change in symptoms, thrombolytic therapy is indicated if no contraindications. NURSING

PRIORITIES right now are multifold…get to CT ASAP to r/o hemorrhagic CVA, continue to monitor and treat

elevated BP to maximize cerebral perfusion. The following NANDA statements also have relevance in this scenario:

Ineffective tissue perfusion (neurologic)

Acute confusion

Risk for falls

4. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

1. Will expedite transfer for head CT–

make sure they are aware and obtain

ASAP!

2. Perform frequent neuro check–-

usually every 15–30" in the acute

phase or per MD orders to trend for

any changes

3. Frequent monitoring of BP of at least

every 15minutes

4. Continuous monitoring of cardiac

rhythm. Afib can accelerate into the

130–150’s readily. Anticipate this

possibility

5. Seizure pads on side rails

6. NPO so won’t aspirate until this is

evaluated

1. Time is neurons! Must r/o

hemorrhagic CVA to determine if

thrombolytic candidate

2. Status can change quickly, must assess

for any subtle changes that could

reflect a complication!

3. Goal is to keep SBP 160–180. Do not

want too high or too low to optimize

cerebral perfusion

4. May need to slow HR if develops rapid

rate and drops BP

5. At risk for possible seizures secondary

to CV and an increase in intracranial

pressure (ICP). A. Anticipate the most

likely/worst possible complication! It is

vital to situate your knowledge and

ANTICIPATE vs. REACT!

6. Any patient with a likely CVA is also at

high risk for dysphagia and aspiration,

therefore this normal assessment

finding is clinically significant!

CT facilitated

No change in neuro

status

SBP in range of 160-

180

HR remains <100

No seizure activity

Free of aspiration

5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Neurologic

6. What is the worst possible/most likely complication to anticipate?

Knowing that this patient is having a large CVA and is at risk for increasing ICP, further deterioration in neuro status

that could include seizures, respiratory arrest or declining level of consciousness (LOC) that would lead to need for

intubation to protect the airway are all possible and need to be anticipated!

An EARLY assessment finding related to increasing ICP is a decrease in level of consciousness. This must be recognized

by the nurse!


7. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

This is why it is essential for the nurse to be diligent and vigilant in neuro assessments. It is imperative to TREND over

time and from the last assessment any concerning trends as to the direction the patient is heading. This is where the

bedside nurse can make a huge difference in patient outcomes and will successfully RESCUE their patient!

Remember how important it is to be thorough in your assessments and to assess for SUBTLE neurologic findings that are

extremely clinically significant. For example, in this patient the last assessment was BRISK pupillary response to light. In

the next assessment you assumed this wasn’t needed and you focused on the more apparent deficit in motor strength. An

early sign of increased intercranial pressure (ICP) is SLUGGISH pupillary responses to light. If this assessment was not

done or done quickly and not noted, this trend will continue until a dramatic change presents itself, such as

unresponsiveness or even respiratory arrest! The professional nurse must embrace the responsibility to carefully and

diligently assess every patient and recognize and identify these SUBTLE changes BEFORE the patient goes over the

proverbial cliff and it becomes too late to make a difference.

As a rapid response nurse, I see this illustrated in clinical practice. For example, a patient begins to deteriorate into

sepsis and has had an elevated HR from their baseline for the last 4–6 hours, but was not recognized as significant until

the patient drops their BP to 70/40! At this point the bedside nurse realizes their patient is septic. In reality you can see

that the patient’s symptoms weretrying to tell the nurse they were septic hours ago, but the nurse was unable to recognize

the significance of their subtle VS changes!

Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome:

Establish peripheral IV

Labetalol 10-20 mg IV prn

every 15" to keep SBP 160-

180

Haldol 2.5-5 mg IV prn

excess agitation

CT head stat

Cardiac monitor continuous

NPO

IV is a standard of care that is a given in a patient who

is this critical. Will need to give IV meds to control BP

and agitation and can usually be initiated by the nurse

by a standing order in most ED’s

Labetolol is a beta blocker that will work to lower BP

by inhibiting beta stimulation as well as alpha 1, which

will cause arterial vaso-dilation. Remember cardiac

pathophys…Is this mechanism of action impacting

PRELOAD or AFTERLOAD? AFTERLOAD IS

CORRECT

Haldol is an excellent choice to decrease agitation

without causing excess sedation in comparison to

benzodiazepines (Ativan). Mechanism is to alter the

effect of dopamine in the CNS. Is this dose of Haldol

low…med… or high range of normal?

Need to r/o hemorrhagic vs. embolic CVA to confirm

that is embolic and no other contraindications can

receive tPA

Assess AFib closely as can go into RVR (any

amount >100) at any time which lowers blood pressure

and decreases cardiac output as a result

Dysphagia is very common post-stroke and puts the

patient at risk for aspiration. Mr. Gates is presenting

with facial droop and difficulty speaking which are

signs of possible dysphagia due to muscle weakness of

the mouth and throat. After priorities are addressed

and the patient is more stable, a speech therapy consult

IV established, patent

SBP maintained in 160–180

range

Agitation/restlessness

controlled and does not cause

excessive sedation

Hopefully no hemorrhage so

thrombolytic therapy can be

initiated to save neurons!

HR remains <100

No aspiration


tPA IV

(if CT negative for bleed)

may be initiated for a swallow evaluation. A barium

swallow study identifies abnormal movement of

food/fluid, anatomic structures, and various food

consistencies to determine patient’s swallowing

potential and ensure safety.

Thrombolytic therapy is the gold standard of medical

management and can give us the best hoped for outcome

if done in a timely manner. Mechanism is to bind fibrin

and convert plasminogen to plasmin, which stimulates

dissolving of the clot.

WHAT IS THE WORST POSSIBLE

COMPLICATION OF tPA THERAPY THAT NEEDS

TO BE ASSESSED FOR?

Bleeding of any kind (6.4% prevalence), but what the

nurse needs to assess and anticipate is a massive

intracerebral hemorrhage that can be life threatening.

What the nurse must assess for is any change in LOC

that is declining. An early sign that must be determined

is decrease in arousability

Tolerates therapy with no

adverse reactions including

massive cerebral hemorrhage

or other lesser bleeding

complications

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale:

1. Establish peripheral IV

2. Labetalol 10-20 mg IV prn

every 15" to keep SBP

160-180

3. Haldol 2.5-5 mg IV prn

excess agitation

4. CT head stat

5. Cardiac monitor

continuous

6. tPA IV (if CT negative for

bleed)

1. CT head stat 2. Establish peripheral IV

3.tPA IV

4. Labetalol 10-20 mg IV

prn every 15" to keep SBP

160-180

5. Cardiac monitor

continuous

6. Haldol 2.5-5 mg IV prn

excess agitation

1. Must rule out hemorrhagic source of neuro changes so

tPA can be considered to save neurons and minimize life

long deficits

2. Must have in order to administer tPA if candidate as

well as need for antihypertensives

3. If CT negative this must be administered ASAP!

4. Bringing down BP is a HIGH priority in this context

5. Potential for cardiac dysrhythmias with an acute neuro

event. Not as high a priority as the other orders

6. No agitation present at this time therefore is not

currently needed. If he becomes more agitated this will

become a much higher priority!

Medication Dosage Calculation:

Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Labetolol

20 mg IV push (5 mg/mL vial)

Normal Range: (high/low/avg?)

Blocks stimulation of beta

1 (myocardial)-

adrenergic receptors.

Does not usually affect

beta2 (pulmonary,

vascular, uterine)-

receptor sites.

Therapeutic Effects:

Decreased BP and heart

rate.

4 mL over 2 minutes

IV Push:

Volume every 15 sec?

0.5 mL

*Obtain BP and HR before

administering-hold typically if SBP <90.

HR <60 *Change position slowly–especially with

elderly to prevent orthostatic changes *Contraindicated in worsening CHF,

bradycardia of heart block…use with

caution in diabetes, liver diseaseii


Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Haldol 2.5

mg IV push (5 mg/mL vial)

Normal Range: (high/low/avg?)

Average to high

Complex action is not

completely understood.

Known to produce a

selective effect on the

central nervous system

and an increased

turnover of brain

dopamine to produce its

tranquilizing effects. With

diminished firing rate of

the dopamine neuron

(decreased release)

results in the

antipsychotic action.

0.5 mL over 1 minute

IV Push:

Volume every 15 sec?

Appx. 0.1 mL

*Most common side effects to assess for

include hypotension and somnolence.

*Prolongs QT. This is relevant with a

patient with cardiac diseaseiii

Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Results: Clinical Significance:

Head CT No abnormalities noted,

no mass, no bleed, no

shift present

The CT is normal. Embolic strokes, which are much more common take 24 hours or so to

begin to see abnormalities visible on CT, therefore the reason that we are doing a CT is to r/o

a hemorrhagic event. This is an absolute contraindication to receiving thrombolytic therapy

such as tPA to dissolve the embolus that we now know is there because the CT immediately

reveals the presence of intracerebral bleeding if present

Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Each of the labs on this

CBC are relevant and

must be noted. Though

normal, this still gives the

nurse rich clinical data

that will help put the

clinical puzzle together.

A CBC is done routinely for most acute

medical patients. In this CBC it is important

to note that there are no findings that are

clinically significant. All is within normal

range.

No concerns

Complete Blood Count (CBC) Current High/Low/WNL? Most Recent

WBC (4.5-11.0 mm 3) 6.8 WNL 7.9

Hgb (12-16 g/dL) 14.8 WNL 16.1

Platelets(150-450x 103/µl) 228 WNL 201

Neutrophil % (42-72) 71 WNL 79

Band forms (3-5%) 1 WNL 2

Basic Metabolic Panel (BMP) Current High/Low/WNL? Most Recent

Sodium (135-145 mEq/L) 131 LOW-barely 139

Potassium (3.5-5.0 mEq/L) 4.1 WNL 4.5

Chloride (95-105 mEq/L) 94 LOW-barely 99

CO2 (Bicarb) (21-31 mmol/L) 22 WNL 25

Anion Gap (AG) (7-16 mEq/l) 8 WNL 10

Glucose (70-110 mg/dL) 198 HIGH 88


RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Sodium: 131

Glucose: 198

Creatinine: 1.5

BUN: 38

INR: 1.1

Could be low because he is on an ACE

inhibitor and this class of drugs can cause

low sodium. This needs to be assessed

closely because hyponatremia can also

influence and contribute to cerebral edema

Knowing that there is a history of diabetes

present, this is expected and will need sliding

scale to cover.

Research shows that high glucose levels

decrease the body’s ability to reperfuse the

infarcted area. If there is adequate blood

flow to the affected area, there’s a good

chance those neurologic deficits can be

reversed. The National Stroke Association

recommend blood glucose levels be <140.iv

The creatinine is slightly elevated and will

need to note the last level and trend as may

have chronic renal insufficiency secondary to

diabetes and HTN, but again is not an

imminent concern, but will need to closely

monitor and assess urine output.

Though a BUN is not always relevant, in this

context of an elevated creatinine, the nurse

must recognize the need to cluster this result

that is also rising and the reason why. In this

scenario, it is a worsening of the renal

status.

This is important for a patient with this

presentation to determine if this is WNL or

not and what their baseline is before

considering thrombolytics.

Worsening

Worsening…just like BP’s that need to

be trended over time to establish a

clinical pattern of hypertension, the same

is true for blood glucose. The prior

reading of 88 is WNL, and the current is

much more elevated. Will need to

continually monitor to determine

significance of this trend.

Worsening

Because of its strong relevance to renal

function, this must be closely assessed.

Worsening

WNL

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab: Normal

Value:

Why Relevant? Nursing Assessments/Interventions Required:

Creatinine

Value:

1.5

0.5-1.3

Critical value:

>1.5

End product of

metabolism which is

performed in skeletal

muscle *Small amount of is

converted to

creatinine, which is

then secreted by

THINK FLUID BALANCE *Assess I&O closely *Fluid restriction *Assess for signs of fluid retention/edema

*Daily weightsv

Calcium (8.4-10.2 mg/dL) 9.2 WNL 8.8

BUN (7 - 25 mg/dl) 38 HIGH 20

Creatinine (0.6-1.2 mg/dL) 1.5 HIGH 1.1

Coag

PT/INR (0.9-1.1 nmol/L) 1.1 WNL n/a


kidneys *Amount of creatinine

generated proportional

to mass of skeletal

muscle

IV. Evaluation: You obtain this clinical data 30 minutes after the tPA has completed… Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been

implemented that are listed under medical management.

1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance: P: 74 reg.

BP: 178/86

HR is now REGULAR…check the monitor because this patient may have

gone back into sinus rhythm. Some patients go into AFib and stay there the

rest of their lives. Some have paroxysmal atrial fib so they go in and out on

their own or will respond readily to medications such as beta blockers or

diltiazem to slow HR and allow AV node to dominate.

BP is essentially where it needs to be so you have accomplished this

objective. Continue to watch because what goes down can also come back

up!

RELEVANT Assessment Data: Clinical Significance: NEURO: Right facial droop no longer

present, speech is not as slurred,

weakness persists in both RUE and RLE

but is stronger than before tPA started

The sudden improvement in these key neurologic assessments are reflecting

that perfusion and blood flow is being restored to the brain and therefore the

improvement in status!

Current VS: Most Recent:

T: 99.0 (oral) T: 99.2 (oral)

P: 74 (regular) P: 118 (irregular)

R: 16 (regular) R: 20 (regular)

BP: 178/86 BP: 198/94

O2 sat: 96% RA O2 sat: 99%

room air (RA)

Current

Assessment:

GENERAL

APPEARANCE:

Resting comfortably, appears in no acute distress

RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses

strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO: Right facial droop no longer present, speech is not as slurred, weakness persists in both RUE

and RLE but is stronger than before tPA started

GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

GU: Voiding without difficulty, urine clear/yellow

SKIN: Right heel has 1x1 cm stage II pressure ulcer with redness of the entire heel that is

blanchable, no drainage noted


SKIN: Right heel has 1x1 cm stage II

pressure ulcer with redness of the entire

heel that is blanchable , no drainage

noted

This finding confirms the suspicion that of impaired skin integrity. Any PRE-

EXISTING skin breakdown MUST be documented by the nurse or else the

hospital or institution must take responsibility in reporting this to the state.

This is an example of a “small” thing from a nursing perspective becomes a

BIG thing!

Blanchable redness is clinically significant because it represents blood flow

that is NOT impaired to the site.

Cardiac Telemetry Strip:

Interpretation:

Normal Sinus Rhythm

Clinical Significance:

Spontaneously converted but needs to be continually monitored as this patient can switch back and forth and will still

likely need anti-coagulation

2. Has the status improved or not as expected to this point?

Obviously improving and going in the right direction!

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Not really. The nursing priorities identified earlier are still relevant… continue to assess neurologic status closely

and treat elevated BP to maximize cerebral perfusion. But because there has now been an improvement in

status, must closely assess this TREND to ensure that it continues in the right direction!

a. Based on your current evaluation, what are your nursing priorities and plan of care?

Transfer out of the ED! This patient will require ICU level of close monitoring and assessment. Until he is transferred out

of the ED, continue to do frequent neuro assessment every 15" as well as VS/rhythm monitoring and assessment.

Remember the most likely/worst possible complication! Just because things are looking better does not mean that he will

stay this way. There is still a chance that he may develop a hemorrhagic brain bleed as a result of the TPA and therefore

continues to need VIGILANT assessments.

Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of

this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to

the ICU nurse who will be caring for this patient:

Situation:

59-year-old male who was at work when he had sudden onset of right-sided weakness, right facial droop, and

difficulty speaking (dysarthric speech). He was transported to the ED where these symptoms persisted.

CT confirmed embolic CVA with NO bleed

Initial neuro assessment: Confused to place and why he is in the hospital. Is notably anxious, restless, and

agitated. Speech is currenly slurred–difficult to understand. Facial droop on right side present, PEARL, both

RUE and RLE notably weak in comparison to left, which is strong. Right pronator drift present–unable to hold

right arm up. Right visual deficit cut present.

New onset of atrial fib-initial rate in the 110’s, BP 198/94


V. Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with his medical condition to

prevent future readmission with the same problem?

Strict control of blood glucose to prevent further progression of atherosclerotic changes

o Reinforce diet, medications

Strict control of hypertension to prevent possible neurologic events

o Reinforce diet–low sodium as well as importance and role of medications

o Medication education to control a. fib and help prevent neurologic event (anticoagulants, diltiazem, beta

blockers

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

After any education has been completed with the patient or family, one of the more effective strategies to assess

effectiveness of teaching is to have them restate the essence or most important points of your teaching after it has been

taught and then later in the shift to ensure retention.

VI. Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation?

The nurse needs to put her/himself in the place of the patient to identify what is being experienced in this situation. The

patient is likely aware of the seriousness of the current change in status and is likely fearful and anxious. A practice of

intentionally supporting both the patient and family by giving them as much information about their current status and

explaining the plan of care from both a nursing and medical perspective is important. KNOWLEDGE is POWER from a

patient’s perspective, and when the nurse provides this information it will DECREASE anxiety and fear and make a real

difference in her well-being.

Even in the context of a patient who is critically ill, when you simply and matter-of-factly share what you are doing and

why, it demonstrates the caring and support that is needed.

Caring for John’s spouse

This is an excellent example of what the nurse will encounter in practice with family members who can be difficult or need

to set FIRM limits as needed. The nurse must remember that in addition to caring for the patient, you are also responsible

to care compassionately for the family as able and address their needs and concerns as able in the context of what the

Received labetolol 20 mg IVP x1

Background:

No prior hx of CVA…relevant history of DM-II and HTN

Assessment:

Received TPA 1 hour ago

Converted to NSR spontaneously 30" ago–rate in the 70’s

Current neuro assessment has shown significant improvement with the following findings: right facial droop no longer

present, speech is not as slurred, weakness persists in both RUE and RLE but is stronger than before TPA started.

BP has responded to labetolol and is currently and is 178/86. Goal is to keep SBP 160–180

Right heel has 1x1 cm stage II pressure ulcer with redness of the entire heel that is blanchable , no drainage

noted

Wife has been uncooperative and unwilling to leave the room unless firmly instructed by nurse. Is obviously

anxious and contributes to escalating anxiety of John

Recommendation:

Continue to closely assess neuro status for any changes as well as rhythm changes

Currently stable

Set firm limits with wife and support as able


patient needs at any given time. Remember that families are also under duress and need support by the nurse as well.

Practical ways to support families include taking the time to update them in a non-hurried manner with what they need to

know at their level of understanding, conveying availability by making it clear they can call anytime for an update,

speaking in a gentle, respectful tone of voice, and involving them as much as possible in the care of the patient.

1. What can you do to engage yourself with this patient’s experience and show that he/she matter to you as a

person?

Regardless of the clinical setting, remember the importance of touch and your presence as you provide care. If you are

using Swanson’s Caring framework (which I encourage you to do!), the following practical caring interventions can be

“tools” in your caring toolbox to use depending on the circumstance and the patient needs:

o Comforting

Little things to comfort–whatever it may be– are needed and appreciated!

o Anticipating their needs

Staying one step ahead and not behind, especially in a crisis is essential!

o Performing competently/skillfully Remember that when a nurse or student nurse does their job well and competently, this

demonstrates caring to the patient!

o Preserving dignity

Maintaining privacy at all times when in crisis and vulnerable is essential and is all too easily

forgotten due to the pressing physical needs that may be present. Pulling the curtain is all that is

needed as well as covering genitalia when exposed are little things but so important to preserve

human dignity.

o Informing/explaining-patient education

Even in a crisis, explaining simply all that you are doing is needed. If your patient is not able to

respond but if family are present, do not forget to include explaining all that you are doing and

why. This is truly the “art” of nursing and makes such a difference when done in practice!vi

i Palmieri, R. L. & Ignatavicius, D. D. (2013). Care of critically ill patients with neurologic problems. In D. D.

Ignativicius & M. L. Workman (Eds.), Medical-surgical nursing: Patient-centered collaborative care (7th ed., pp. 1004-1038). St.

Louis: Elsevier. ii Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2013) Davis’s Drug Guide for Nurses. (13th ed.). Philadelphia, PA: F.A. Davis

Company. iii

Ibid iv National Stroke Association. (2012). Retrieved October 5, 2012, from http://www.stroke.org

v Van Leeuwen, A. & Poelhuis-Leth, D.J. (2009). Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing

Implications. (3rd ed.). Philadelphia, PA: F.A. Davis Company. vi

Swanson, K.M, (1991). Empirical Development of a Middle Range Theory of Caring. Nursing Research, 40(3), 161-166.

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