Samantha Allen
Age: 78
Weight: 58 kg
Situation:
The patient is a 78-year-old woman brought in to the ED by ambulance with right upper and lower extremity hemiplegia. She also has a right visual field loss in both eyes. The patient’s granddaughter, with whom she lives, states she noticed a change in the patient approximately one hour prior to calling emergency medical services. At this time, the patient was last at her baseline or symptom-free state one hour and 20 minutes ago.Admission orders have been written.
Background:
The patient has a history of transient ischemic attacks, the last one occurring six months ago. At that time, she experienced right-sided weakness, which completely resolved. She has atrial fibrillation, coronary artery disease, hypertension and hyperlipidemia. She is awake, responds appropriately.
Past Medical History: Has TIA’s, atrial fibrillation (AF), coronary artery disease (CAD), hypertension (HTN), and hyperlipidemia.
Allergies: No known drug allergies
Medications: Home medications include
diltiazem hydrochloride XR 180 mg PO once daily,
atorvastatin 10 mg PO once daily and warfarin 5 mg PO once daily.
Code Status: Full Code
Social/Family History: Lives with granddaughter, granddaughter at the bedside.
Assessment:
Vital Signs: HR 94 and irregular, BP 210/120, RR 18, SpO 94% on room air,
Temp 37.3°C
General Appearance: Frail, appears stated age
Cardiovascular: Atrial fibrillation
Respiratory: Clear
GI: Normoactive, abdomen soft and flat
GU: Has not voided
Extremities: Motor function arms: no drift in left arm, drifts before five seconds in right arm. Grip strong on left, no grasp on right. Motor function legs: Able to lift both legs slightly off bed; no drift in left leg, right leg drifts at two seconds, no limb ataxia.
Skin: Pink, warm and dry
Neurological: Alert and oriented to person, place and time; pupils are equal, round, and reactive to light and accommodation. Right visual field loss in both eyes, complete hemianopia and visual inattention to right side. Mild sensory loss in right arm and right leg. Answers questions appropriately, speech slurredbut understandable
IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened
Labs: Lab values are pending
Fall Risk: High-risk
Pain: Denies pain
Recommendations:
Complete admission orders and monitor for changes.
Initial Healthcare Provider’s Orders:
Neurological consult STAT
Head CT (non contrast) STAT
12-lead ECG
Cardiac monitor
Capillary blood glucose STAT
Labs: CBC with platelets, INR, PT, PTT, Serum glucose, Na, K, Cl, CO , BUN, Creatinine, Troponin STAT
Continuous oxygen saturation monitoring
Titrate oxygen to maintain SpO2 greater than 92%
IV 0.9% NS at 30 mL/hour
Blood Pressure, Pulse every 15 minutes
Neurological checks every 15 minutes
Temperature
Weight
Intake and Output every 8 hrs
Swallow evaluation
Bedrest
Anti-embolic stockings
Labetalol 20 mg IVP over 2 minutes if SBP > 220 or DBP > 120.
May repeat dose in 10 minutes if needed. Maximum dose is 300 mg.
Cerebral Vascular Accident (CVA)
1. Compare the pathophysiological processes involved in the following types of CVA: Ishcemic and Hemorrhagic.
2. What risk factors contribute to the two types of CVA?
3. What are classic clinical manifestations of CVA?
4. Describe the components of a full neurological assessment.
5. What is the goal of therapy in the treatment of a client experiencing an acute CVA?
6. How are the results of a head CT used to determine therapy in the patient with CVA?
7. Discuss the use of rtPA. Include the indications for use, potential complications and exclusion criteria.
8. Why is it critical to obtain a serum glucose level when ruing out a CVA?
9. What nursing interventions are required for the patient with possible swallowing deficits and peripheral visual deficits?
10. What potential complications may result in a patient following an acute CVA? How might the nurse prevent/manage these complications?