Question

create a case study over a pt reporting to the Er with a stroke. then make a nursing care plan.

Answer 1

History of Presenting Condition

Michael is a 61 year old Senior Partner in a Law Firm. While eating breakfast Michael experienced sudden onset slurring of speech, had facial droop on his left hand side with weakness in left side upper and lower limbs. Michael's wife Mary spotted these sudden onset of symptoms and immediately called for an ambulance, which arrived within 15 mins.

Past Medical History

Asthma - Dx Aged 8

Hypertension Grade 1 - Dx 5 years ago

Prediabetes - Dx 3 years ago

Medication History

Seretide Accuhaler

Ventolin (As Required - Not Required for over 1 Year)

Thiazide

Social History

61 Year Old Senior Partner at a Law Firm, recently reduced working hours 20 - 30 hours per week, previously worked 50 - 60 Hours

Planning on retirement in 1 - 2 years

Lives in a Bungalow with his wife Mary, who is a recently Retired Teacher.

2 Adult Children, both married with their own children - 1 lives close by, the other lives overseas.

Lifestyle Changes implmented over past 2 - 3 Years foloowing Dx Prediabetes.

Outside work he enjoys golf, usually playing at least 2-3 per week. Also enjoys playing Bridge with Friends.

Took up walking 3 Years ago following Dx Prediabetes. Walks 5 - 6 days per week for between 30 - 45 mins

Ex-Smoker - Hx Smoking 30 Years x 10 - 15/day - Quit 3 Years ago following Dx Prediabetes

Social Beer Drinker 10 - 15 Standard Drinks per week with 3 - 4 per session, although sometimes after Golf may be more.

Pre-Hospital Assessment

Vitals:

• BP 140/90 mmHg
• Pulse 75

Physical Exam:

FAST +ve

• Left Facial Droop
• Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5
• Slurred Speech

Pre Hospital Assessment Scale:

Los Angeles Prehospital Stroke Screen (LAPSS) & Los Angeles Motor Scale (LAMS)

Criteria	Yes	No	Unknown
1. Age greater than 45 years	Yes
2. History of Seizures or Epilepsy		No
3. Onset of Neurological Symptoms is less than 24 hours	Yes
4. Patient was Ambulatory prior to onset of symptoms	Yes
5. Blood Glucose between 60 and 400 mg/dl	Yes 125mg/dl
6. Motor Exam: Examine for Motor Asymmetry Based on Exam below, patient has Unilateral 'Weakness:	Yes
	Equal	Right	Left	LAMS SCORE
Facial Smile / Grimace			Droop	1
Grip Strength			No Grip	2
Arm Srength			Falls Rapidly	2
				5

Acute Hospital Assessment

Vitals:

• BP 145/90 mmHg
• Pulse 82

Physical Exam:

• Confusion
• Left Facial Droop
• Slurred Speech  
• Left Motor Weakness Upper Limb 0/5, Lower Limb 2/5
• Decreased Tone
• Altered Sensation
• Mild Left Sided Neglect

Acute Assessment Scale:

NIH Stroke Scale: 19

Test Elements	On Admission	12 Hours post tPA	24 Hours post tPA
Level Of Consciousness	1	0	0
LOC Questions	2	1	0
LOC Commands	1	1	0
Best Gaze	1	1	1
Visual Field Testing	1	1	1
Facial Palsy	2	2	1
Motor Function Arm Right	0	0	0
Motor Function Arm Left	4	3	2
Motor Function Right Leg	0	0	0
Motor Function Left Leg	2	2	1
Limb Ataxia	0	0	0
Sensory	1	1	1
Aphasia	1	1	0
Dysarthria	2	1	1
Extinction & Inattention	1	1	1
Total Score	19	15	9

Investigations

Labs:

• INR 1.2

CT:

• Hyperdensity in the M1 Segment of the Right Middle Cerebral Artery, with no other signs suggestive of an Ischemic Stroke noted.
  Provisional diagnosis of Acute Ischemic Stroke secondary to occlusion of the M1 was made
  Patient was treated with intravenous Tissue Plasminogen Activator (tPA) at 1 h 54 min after symptom onset

MRI:

• Multimodal MRI Scan completed at 3 h 09 min after symptom onset demonstrated Ischemic Changes confined predominantly to the Right Middle Cerebral Artery
• Perfusion-weighted MRI showed larger perfusion abnormality, indicating presence of a substantial volume of potentially salvageable penumbral tissue.
• Time-of-flight magnetic resonance angiography showed a loss of signal in the Right Internal Carotid Artery and Middle Cerebral Artery.

Cerebral Angiography

• Cerebral angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery Origin through the Right Middle Cerebral Artery Trunk.
• Recanalization was attempted by Endovascular Thrombectomy performed 4 h 19 min after symptom onset

Medical Management

Thrombolysis & Endovascular Mechanical Thrombectomy:

• Discussed with Family & Patient
• tPA Prescribed and Initiated within 1hr 54mins After Onset Symptoms
• Endovascualr Thrombectomy Initiated at 3hr

Stroke Unit:

• Admitted to Acute Stroke Unit
• 24 Hour Monitoring
• MDT Referral Received within 24 Hours - OT, SLT & PT

nursing care plan

Nursing diagnosis	related to	possibly evidenced by	desired outcome	nursing interventions
Ineffective Cerebral Tissue Perfusion	Interruption of blood flow: occlusive disorder	Altered level of consciousness; memory loss Changes in motor/sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs	Maintain usual/improved level of consciousness, cognition, and motor/sensory function. Demonstrate stable vital signs and absence of signs of increased ICP. Display no further deterioration/recurrence of deficits	Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP. Closely assess and monitor neurological status frequently and compare with baseline. Monitor vital signs Evaluate pupils, noting size, shape, equality, light reactivity. Document changes in vision: reports of blurred vision, alterations in visual field, depth perception. Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures. Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity Administer medications as indicated
Impaired Physical Mobility	Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis Perceptual/cognitive impairment	Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased musclestrength/control	Maintain/increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures, foot drop. Demonstrate techniques/behaviors that enable resumption of activities. Maintain skin integrity	Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale. Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head. Observe affected side for color, edema, or other signs of compromised circulation. Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet.
Communication, impaired verbal [and/or written]	Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue	Impaired articulation; does not/cannot speak (dysarthria) Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language Inability to produce written communication	Indicate an understanding of the communication problems. Establish method of communication in which needs can be expressed. Use resources appropriately.	Assess extent of dysfunction Provide alternative methods of communication: writing, pictures. Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by yes or no. Progress in complexity as patient responds. Consult and refer patient to speech therapist.