Stroke Case Study (45 min)

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Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”

What nursing assessments should be completed at this time?

  • Full set of vital signs (Temp, HR, BP, RR, SpO2)
  • Should probably get a 12-lead EKG
  • Assess symptoms using PQRST or OLDCARTS

You assess Mrs. Blossom to find she has a left sided facial droop, slurred speech, and is unable to hold her left arm up for more than 3 seconds.

What is/are your priority nursing action(s) at this time?

  • Call a Code Stroke (or whatever the equivalent is at your facility) to initiate response of the neurologist or Stroke team.
  • Notify the charge nurse to help you obtain emergency equipment if you don’t already have it at the bedside to be prepared in case of emergency

What may be occurring in Mrs. Blossom?

  • She may be having a stroke

You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.

What are the possible interventions for Mrs. Blossom at this time?

  • Since there is no bleed evident on scan, Mrs. Blossom would qualify for a thrombolytic like tPA (alteplase) or for surgical intervention, as long as there are no contraindications

What are the contraindications for thrombolytics like tPA (alteplase)?

  • Recent surgery, current or recent GI bleed within the last 3 months, excessive hypertension, evidence of cerebral hemorrhage

You administer tPA per protocol, initiate q15min vital signs and neuro checks. You stay with the patient to continue to monitor her symptoms.

What are possible complications of tPA administration? What should you monitor for?

  • Bleeding, especially into the brain or a GI bleed
  • She may bruise easily or bleed from IV sites or her gums
  • Monitor for s/s bleeding or worsening stroke symptoms, which may indicate a hemorrhagic stroke has developed.

After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.

What would you explain has happened to Mrs. Blossom physiologically?

  • Because of her new onset atrial fibrillation, the blood was likely pooling in her atria because they were just quivering and not contracting. When blood pools, it clots. When she was converted back into a normal rhythm and her atria began contracting again, that likely dislodged a clot, which went to her brain.
  • The clot in her brain caused brain tissue to die → ischemic stroke.

Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker,  with a follow up appointment in 1 week to see the neurologist.

What education topics should be included in the discharge teaching for Mrs. Blossom and her family?

  • Anticoagulant therapy is imperative to prevent further clots from forming within Mrs. Blossom’s atria if she stays in Atrial Fibrillation.
  • They should be taught the signs of a stroke (FAST) and call 911 if they notice them.
  • They should be taught signs of Atrial Fibrillation with RVR and be sure to go to the hospital if this occurs – the patient is at higher risk for stroke.
  • Medication instructions for calcium channel blockers and anticoagulants.

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Nursing Case Studies

Jon Haws

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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