SuperHumanOkapiMaster471
CONCEPT: Intracranial Regulation EXAMPLAR: Cerebral Vascular…
CONCEPT: Intracranial Regulation
EXAMPLAR: Cerebral Vascular Accident
CASE: John Gates
PART 1 of 1 – Student Version
Please feel out the case study.
HPI: History of Present Problem:
John Gates is a 59-year-old male with a history of Type II Diabetes Mellitus (T2DM) and hypertension who was at work when he had sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported via EMS (IV placed) 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.
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. He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9).
Home Medications: atenolol, atorvastatin, lisinopril, metformin, sitagliptin
PMH: HTN, T2DM, Hyperlipidemia, CAD
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. John is a 20 pack-year smoker who has been trying to quit smoking the past month using a nicotine patch. His wife reports that he does not regularly check his blood glucose, sporadically takes his oral glucose-lowering medication, and eats what he wants.
1. After reviewing the client information, highlight parts of the paragraph that are most concerning.
2. From the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Actions to take (select 2) Potential condition Parameters to monitor (select 2)
Administer morphine Hypoperfusion syndrome Blood pressure
Bolus intravenous fluids Hypovolemic shock Level of consciousness
Give supplemental oxygen Ischemic stroke Patency of airway
Initiate code stroke Meningitis Serum glucose
Initiate seizure precautions Range of motion
3. For each finding, place an “X” to specify if the finding is a risk factor or not a risk factor for stroke.
Assessment/Finding Risk factor Not risk factor
20 pack-year smoker
BMI 33.9
Does not check blood sugar
Facial weakness
Hypertension
Lives in rural area
Nicotine patch
T2DM
Active lifestyle
4. Review and interpret the client’s VS and assessment data. What is the clinical significance of each value relative to the client’s clinical status?
Data Clinical Significance
T: 99.2 F/37.3 C
P: 118 (irregular)
R: 20 (regular)
BP: 198/94 MAP 129
O2 sat: 99% room air
Neuro: Anxious, restless, and agitated, speech is currently slurred and difficult to understand, right facial droop with drooling, pupils (PERRL), right upper extremity and right lower extremity notably weak (3/5) in comparison to left, which is strong (5/5), right pronator drift present
Cardiac: no edema, heart sounds irregular, pulses strong, equal with palpation. PIV left antecubital space.
Resp: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
GU: has not voided since admission
5. Interpret the rhythm strip in lead II:
Regular rhythm: Y/N Rate: P wave for every QRS: Y/N, PR interval: ____ QRS:__
6. Use an X to indicate whether the nursing actions below are:
I = Indicated (appropriate for necessary)
D = Contraindicated (could be harmful)
Non-essential = (make no difference or not necessary)
Nursing Action Indicated Contraindicated Non-essential
Apply supplemental O2
Call for stat head CT
Perform NIH stroke scale exam
Obtain CMP
Provide low stimulation room
Keep HOB less than 30 degrees
Establish IV access
Place on falls precaution
Maintain bedrest
Request nicotine patch
Request consistent carb diet
NPO
Bedside swallowing screen
Continuous cardiac monitoring
7. The provider orders the following. What is the rationale for each order?
Provider orders Rationale:
CBC, CMP, HgA1C
Continuous cardiac monitoring
CT head STAT
GFR
PT/INR
IV NS @ 75 125 mL/hr.
Labetalol 10-20 mg IV prn every 15 minutes to keep SBP 160-180
Alteplase 0.9 mg/kg IV – per protocol (if CT negative for bleed)
8. Which orders are priority? Which orders must be completed before proceeding with additional interventions?
9. Review and interpret the lab data. What is the clinical significance of each lab value relative to the client’s clinical status? For current data list if N = normal, A=abnormal, AA-abnormal but anticipated, C= critical
Lab Current
N, A,
AA, C
Clinical Significance
WBC 6.8
Hgb 14.8
Platelets 228
Neutrophil 71
Sodium 133
Potassium 4.1
Glucose 222
HgbA1C 11
BUN/Creatinine 24/1.5
GFR 58
PT/INR 1.0
Head CT no bleed, no shift
10. The client is prescribed alteplase infusion 0.9 mg/kg IV; not to exceed 90 mg total dose; administer 10% of the total dose as an initial IV bolus over 1 minute and the remainder infused over 60 minutes. The client’s weight is 88 kg. Pharmacy sends alteplase 100 mg/100mL vial.
How many mg will be administered in the bolus dose? Round whole number. ________
For the remainder of the dose, you set the infusion pump to infuse at _____ml/hr. Round to whole number.
The client’s condition has improved the next day and the nurse evaluates the client’s understanding of the instructions provided.
11. Specify whether the statement indicates an understanding, or no understanding of the teaching provided.
Statement
Understanding
No understanding
“I will use the call bell and wait for someone to help me get out of bed.”
“A speech and swallow test will determine if I can eat and drink.”
“I will switch to an electric razor instead of straight razor to shave.”
“The physical therapist will determine my functional ability.”
“At discharge, I will no longer need an anticoagulant .”
