Cerebral Vascular Accident (CVA) Verified Study and Exams Guide

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 spe ...

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: onset of right-sided weakness, right facial droop, and difficulty speaking During transport, he had increased agitation and confusion to place and time symptoms are reflecting acute neurologic changes that are due to disruption in cerebral blood flow either because of embolism or hemorrhagic event. Signs and symptoms that are reflecting neurologic changes may be due to blockage of cerebral blood flow maybe caused by an embolism RELEVANT Data from Social History: Clinical Significance: Nicotine patch use pain on the right foot for the past week Is he still wearing the patch on him take his shoes off and perform a skin assessment. because he is a diabetic Lab/ diagnostic Results: Basic Metabolic Panel (BMP) Current High/Low/WNL? Sodium (135-145 mEq/L) 131 LOW-barely Potassium (3.5-5.0 mEq/L) 4.1 WNL Glucose (70-110 mg/dL) 198 HIGH Creatinine (0.6-1.2 mg/dL) 1.5 HIGH Complete Blood Count (CBC) Current High/Low/WNL? WBC (4.5-11.0 mm 3) 6.8 WNL Hgb (12-16 g/dL) 14.8 WNL Platelets (150-450x 103/µl) 228 WNL Neutrophil % (42-72) 71 WNL RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Sodium: 131 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 Worsening Glucose: 198 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 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. Creatinine: 1.5 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. Worsening Because of its strong relevance to renal function, this must be closely assessed. BUN: 38 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. Worsening INR: 1.1 This is important for a patient with this WNL presentation to determine if this is WNL or not and what their baseline is before considering thrombolytics. 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. II. Nurse Collected Clinical Data: 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 The irregular rate must be recognized for this likelihood and placing the patient on a cardiac monitor An elevated BP after a CVA is not uncommon. Though normal. Hypoxia can also cause the same symptoms 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 What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT assessment data: Clinical Significance: GENERAL APPEARANCE: appears anxious 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! These acute neurologic changes are reflecting a left brain CVA that is likely significant in size based on the neurologic changes GI: Able to swallow saliva CVA patient is also at high risk for dysphagia and aspiration, therefore this normal assessment finding is clinically significant! 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 kidneys THINK FLUID BALANCE *Assess I&O closely *Fluid restriction *Assess for signs of fluid retention/edema *Daily weightsv Sodium Value: 131 Pharmacology: Home Meds: Pharm. Classification: Mechanism of Action Nursing Consideration 1. Indocin 1. 2. Aspirin 2. 3. Lisinopril 3. 4. Simvastatin 4. NSAID NSAID ACE inhibitor Anti-hyperlipidemic 1. involves inhibition of cyclooxygenase (COX-1 and COX- 2). 2. causes several different effects in the body, mainly the reduction of inflammation, analgesia (relief of pain), the prevention of clotting, and the reduction of fever. 3. Angiotensin Converting Enzyme Inhibitors (ACE-I) prevent the conversion of angiotensin I to angiotensin II, which disrupts the renin-angiotensin-aldosterone system (RAAS). 4. competitively inhibiting HMG-CoA reductase, the first and key rate- limiting enzyme of the cholesterol biosynthetic pathway. 1. use is contraindicated with history of proctitis or recent bleeding 2. Do not use aspirin during pregnancy (category D), especially in third trimester; lactation 3. Give before dialysis; lisinopril is removed from blood by hemodialysis 4. active liver disease; pregnancy (category X), lactation 5. Metformin 5. Hypoglycemic 5. decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization 5. Withhold metformin 48 h before and 48 h after receiving IV contrast dye Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Labetolol 20 Blocks stimulation of 4 mL over 2 minutes Obtain Blood Pressure and Heart Rate before administering-hold typically if SBP <90. HR <60 -Change position slowly -Contraindicated in worsening CHF, bradycardia of heart block mg IV push (5 mg/mL vial) Normal Range: (high/low/avg?) beta 1(myocardial) adrenergic receptors. Does not usually affect beta2 (pulmonary, vascular, uterine) receptor sites. IV Push: Volume every 15 sec? 0.5 mL IV. Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS 1. What is the RELATIONSHIP of your patient’s past medical history and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Diabetes mellitus type II-poorly controlled Hypertension Hyperlipidemia Gouty arthritis Smokes 1 ppday x 40 years -Indocin -Aspirin -Lisinopril -Simvastatin 2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem? (which disease is likely developed FIRST that then began a “domino effect”) PMH: What Came FIRST: Diabetes mellitus type II-poorly controlled Hypertension Hyperlipidemia Gouty arthritis Smokes 1 ppday x 40 years Smoking What Then Followed: Hyperlipidemia 3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem? Establish peripheral IV Labetalol (Trandate) 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 -Labetalol is a beta blocker that will work to lower BP by inhibiting beta stimulation as well as alpha 1, which will cause arterial vasodilation. -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. -Need to r/o hemorrhagic vs. embolic CVA to confirm that is embolic and no other contraindications can receive tPA -Assess Arterial Fib 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. A V. Developing Nurse Thinking by Identifying Clinical Priorities 4. What interventions will you initiate based on this priority? 1 2 3 4 5 6 5. What is the priority problem that your patient is most likely presenting with? Neurologic 6. What is the worst possible/most likely complication to anticipate? patient is having a CVA and is at risk for increasing Intra Cranial Pressure, declining level of consciousness 7. What nursing priority will guide your plan of care? the patient’s neurologic status 8. What interventions will you initiate based on this priority? Nursing interventions: Rationale: Expected Outcome: - Asses pts LOC ad changes n behavior to provide baseline -monitor neurologic status on a regular basis to detect any improvement or decline in pts neurologic function -maintain stable neurologic status -report feeling increasingly calm and improved ability to cope with confused state