Cerebral Vascular Accident (CVA) John Gates is a 59-year-old male -Answered

Cerebral Vascular Accident (CVA) John Gates is a 59-year-old male -Answered Cerebral Vascular Accident (CVA) John Gates, 59 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Stress 2. Coping 3. Clinical Judgment 4. Patient Education 5. Communication 6. Collaboration UNFOLDING Clinical Reasoning Case Study: STUDENT Cerebral Vascular Accident (CVA) History of Present Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic symptoms when he presents to the ED. You are the nurse responsible for his care. Personal/Social History: John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has been complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has been using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants. He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9). What data from the histories are RELEVANT and 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. 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 food 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 Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable P: 118 (irregular) Quality: R: 20 (regular) Region/Radiation: BP: 198/94 Severity: O2 sat: 99% room air Timing: What VS data is RELEVANT and must be recognized as clinically significant by 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. 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 Current Assessment: GENERAL APPEARANCE: Appears anxious–he is aware and appears to be 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, telemetry rhythm is atrial fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Is 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 (3/5) in comparison to left, which is strong (5/5), 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, 700 mL urine clear/yellow, SKIN: Skin integrity appears intact, right foot not assessed at this time 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: 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! This is confirming the 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. Cardiac Telemetry Strip: Interpretation: Atrial fibrillation with RVR (Rapid ventricular response; HR >100) Clinical Significance: Red flag for embolic strokes, AFib is common with elderly so it is important to review medical history and see if they have had this in the past or not. There is no documented history of this with the patient so this clinical issue should be recognized immediately. Radiology Reports: Head CT What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Results: Clinical Significance: No abnormalities noted, no mass, no bleed, no shift present CT is normal, Embolic strokes which are more common take at least 24 hours or so to begin to see abnormalities visible on a CT so the reason to do a CT is to rule out a hemorrhagic event. Patient cannot receive thrombolytic therapy such as tPA to dissolve the embolus because the CT would show the presence of an intracerebral bleed. Lab Results: Complete Blood Count (CBC) Current: High/Low/WNL? Previous: 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 What lab results are RELEVANT and must be recognized as clinically significant by 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 at the moment Basic Metabolic Panel (BMP) Current: High/Low/WNL? Previous: Sodium (135-145 mEq/L) 133 Low 139 Potassium (3.5-5.0 mEq/L) 4.1 WNL 4.5 Glucose (70-110 mg/dL) 222 High 128 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 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Sodium: 131 Glucose: 198 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 Worsening Worsening, prior result was 88 and the current is slowly getting higher