Stroke Case Study By Cindy Fenske M.S.,R.N. Scenario Norma James was admitted to your unit this afternoon after waking up with her right arm feeling numb and tingly. Over the next couple of hours she developed right leg weakness, aphasia, and progressive weakness of her right arm. Her neighbor called for an ambulance to bring her to the ED. A CT scan revealed a left frontal/parietal stroke. An angiogram revealed left carotid artery stenosis with very stagnant flow. What is a CVA? Brain attack Interruption in cerebral blood flow What are the main causes of a CVA? Ischemic/non-hemorrhagic Thrombotic Embolic Ischemic Hemorrhagic CVA risk factors What should Norma James have done when she first awoke with the arm tingling and numbness? Why? Why do you think Norma James had a stroke? CVA clinical manifestations Neuromotor Destruction of motor neurons in the pyramidal pathways Pathways cross at medulla Right CVA affects left extremities/vice versa Clinical Manifestations - Neuromotor Right CVA Left sided paralysis Spacial-perceptual defects Quick, impulsive behavior Memory deficits R/T performance Indifference to the disability Clinical Manifestations - Neuromotor Left CVA Right sided paralysis Speech, language deficits Slow, cautious behavior Memory deficits R/T language Distress and depression R/T disability Clinical Manifestations Communication Aphasia Expressive - can formulate words in mind but what comes out is totally different Receptive - patient can hear what you are saying but cannot comprehend the information Global (both) Fluent/non-fluent Dysarthria - slurred speech Clinical Manifestations Affective functioning changes Loss of control of emotions Responses may be exaggerated May laugh at things that are sad and cry and things that are supposed to be funny Brain does not allow them to have control over the proper emotions Can recognize that it is inappropriate but cannot control it Clinical Manifestations Intellectual function Right sided: lose ability to make good judgment Memory R/T spatial perceptual Quick and impulsive Left sided Memory R/T language Overly cautious Worries and frets; can?t make any decisions (even simple ones) Clinical Manifestations ? Rt? Spatial-Perceptual Alterations Perception of self and illness: will deny the illness, deny affected body parts Perception of self in space: Don?t acknowledge where things are around them or things that are occurring on affected side May have visual field cuts, altered depth perception Agnosia: inability to recognize an object by sight, touch, or hearing Apraxia: inability to carry out learned sequential movements on command Steps involved in bathing, brusing teeth, and other adls Diagnostic Tests Angiogram: inject dye, look at circulation of carotids and those going up into brain CT MRI Based on the results of Norma James? angiogram, she may be a candidate for a carotid endarterectomy. Carotid endarterectomy Procedure Post op care Primary complications Neurological assessment What are your priorities R/T neurologic assessment? Orientation, Glascow coma scale (EMV), signs of increased ICP, What findings are you expecting to see in Mrs. James? Acute management Prevention Surgery Acute management: short term (24-48hrs) Airway ? effected by LOC changes Increased ICP Fluid & electrolyte balance Decrease cerebral edema Anticoagulants/thrombolytic agents ? long term coumadin Unless it?s a hemorrhagic stroke Atrial fibrillation Asynchronous contraction of the atria and ventricle. Supportive measures Mrs. James lives alone with her 6 cats. She has two sons, with whom she has been estranged. She has been very depressed and passive, wanting the nurses to take care of all of her needs. How will you deal with this patient? Rehabilitation Goal Team members ? PT, OT, speech, nurses, physicians, social workers Meet and talk about goals, problems, and progress What are Mrs. James? priority issues at this point? Nursing plan of care Respiratory Airway Swallowing issues Dysphagia/aspiration pneumonia Muscles of swallowing are effected by stroke and l/t aspiration Atelectasis Nursing Plan of Care Neurological Signs & symptoms of increasing ICP Nursing Plan of Care Cardiovascular Decreased cardiac reserve Risk for DVT HTN/dysrhthmias **r/t immobility Nursing Plan of Care Musculoskeletal Immobility Hemiplegia Prevention of contractures DO ROM EXERCISES Nursing Plan of Care Integument Watch for pressure ulcers Gastrointestinal Dysphagia Pocket food/pills in effected side; can choke when you lay them down Make sure mouth is cleared Constipation All should be on bowel program; should be what is normal/typical for them; med interventions Nursing Plan of Care Urinary Incontinence Retention ? increases risk for UTI Infection ? get rid of foley as soon as possible Communication Aphasia Nursing diagnoses Home care issues Do home visit to assess any problems with her house that we need to change; same thing with Parkinson?s patients from last week Preparing for discharge
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