CVA case study
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New York Institute of Technology, Westbury *
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MISC
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Medicine
Date
Apr 3, 2024
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6
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CHAPTER 6 INTRACRANIAL REGULATION CASESTUDY 77 Case Study 77 Name Class/Group Date b Scenario N.T, a 79-year-old woman, arrives at the emergency department with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0700, she stayed in bed, saying she had a mild headache over the right temple and was feeling weak. He went and got coffee, then thinking it was unusual for her to stay in bed, went back to check on her. He found she was having trouble saying words and had a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency depart- ment. Her medical history includes atrial fibrillation, hypertension, and hyperlipidemia. A recent cardiac stress test was normal, and her blood pressure is under good control. N.T. is currently taking amiodarone, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). The provider suspects N.T. is hav- ing an acute cerebrovascular accident (CVA). 1. What role do diagnostic tests play in evaluating N.T. for a suspected CVA? 2. Explain how knowing the type of CVA is an important factor in planning care. 3. Which factor in N.Ts history is the most likely contributor to her having a CVA and why? 4. The primary factor influencing the manifestations of a CVA is the: a. Area of the brain affected b. Speed of onset of the CVA c. Amount of brain tissue affected d. Type of CVA the patient experienced 343
| | CHAPTER 6 INTRACRANIAL REGULATION 5. What are the common manifestations of a CVA? 6. How should you position N.T.? 7. Outline the focused assessment you need to obtain. gulation LE acranial tra CASE STUDY PROGRESS Your assessment findings are as follows: VS are 164/98, 94, 24, 97.2° F (36.2° C), Sao, 94% on room air. Her lungs are clear, and she is alert and oriented. She is able to follow simple commands, has PERRL with intact extraocular movements, and no vison loss. Her facial movements are asymmetrical, with left-sided droop- ing. Speech is slightly slurred, although it remains intelligible. She is unable to move her left arm and leg; sensation is intact. There is no ataxia; however, she is experiencing some visual and tactile neglect of the left side. 8. Complete the National Institutes of Health Stroke Scale (NTHSS) scores for each of N.T’s symptoms. Symptom Score Alert Knows month and age Able to follow commands Extraocular movements (EOMs) intact No visual loss Partial left facial paralysis Left leg no movement Left arm no movement No ataxia Sensation intact Moderate aphasia Neglect of left side TOTAL SCORE 344
CHAPTER 6 INTRACRANIAL REGULATION CASESTUDY 77 9. Based on your scoring, what level of CVA did N.T. experience? 10. There are a number of manifestations of a CVA. Match the description of various losses with the term describing the loss: A Alexia 1. Total inability to communicate ___ B.Wernicke aphasia 2. Difficulty articulating words _____C.Dysarthria 3. Inability to perform purposeful movements in the absence of motor problems __D.Apraxia 4, Sentences contain words that are irrelevant or non-existent __E.Agraphia 5. Loss of the ability to read ____F Agnosia 6. Inability to recognize familiar objects ___ G.Global aphasia 7. Loss of the ability to write CASE STUDY PROGRESS A noncontrast CT scan confirms the diagnosis of a thrombolytic CVA. The provider writes the orders shown in the chart. Chart View Physician’s Orders IV 0.9% NaCl at 75 mL/hr Activase (tPA) per protocol Stat CBC, PT/INR, CPK isoenzymes Neurologic assessment every hour Obtain patient weight VS every hour 0, at 2 L per nasal cannula (NC) NPO until swallowing evaluation PP 1 11. Outline a plan of care for implementing these orders. 345 - : = et e = (=) [ (o= © -— | e < S o < - L fom
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CHAPTER 6 INTRACRANIAL REGULATION 12. Which interventions can you delegate to the UAP? Select all that apply. a. Obtaining N.T’s weight b. Obtaining a manual BP per protocol c. Initiating O, therapy by nasal cannula d. Assisting N.T. in repositioning every 2 hours e. Performing N.T’s neurologic checks every hour 13. What is the purpose of monitoring the CK isoenzyme levels? @ 14. The instructions on the tPA vials read to reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. N.T. weighs 143 pounds. What is the amount of the bolus dose, in both milligrams and milliliters, you will give in the first minute? What is the amount of the remaining dose you will need to give? 15. Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply. . Systolic BP of 150 . Worsening neurologic status Major surgery in the last 14 days . Platelet count of less than 100,000 (100 x 10%/L) Blood glucose of less than 50 mg/dL (2.8 mmol/L) Currently on warfarin with an INR of 1.4 . History of myocardial infarction 3 months ago @ o an o 16. What are your responsibilities during the administration of Activase (tPA)? 346
CHAPTER 6 INTRACRANIAL REGULATION CASESTUDY 77 17. What signs and symptoms would alert you to the possible presence of an intracerebral hemorrhage during the tPA infusion? CASE STUDY PROGRESS N.T. is admitted to the neurology unit. A second CT scan 24 hours later reveals a small CVA in the right hemisphere. She is placed on aspirin, amiodarone, amlodipine (Norvasc), clopidogrel (Plavix), simvastatin (Zocor), and lisinopril (Zestril). 18. During the first 24 hours after Activase (tPA), the primary concern is controlling N.T’s: a. Glucose level b. Blood pressure c. Cardiac rhythm d. Oxygen saturation 19. Why was N.T. placed on clopidogrel (Plavix) post-CVA? 20. Because N.T. had a thrombolytic infusion, how many hours had to pass before starting any anticoagulant or antiplatelet drugs? 21. Is there any benefit from continuing simvastatin? 22. While assessing N.T., you note the following findings. Which one is unrelated to the CVA? a. Lethargy b. Headache ¢. Lumbar pain d. Blurred vision 347 = =1 — Jas = (=] L (o' = (= < = < —_ o = ?
6 Intracranial Regulation 348 CHAPTER 6 INTRACRANIAL REGULATION 23. Asyouwalk into the nurses’ station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallow study and referral for a speech-language pathologist (SLP). Give the rationale for these orders. 24, If N.T’s deficits are temporary, how long might it take before they completely reverse? CASE STUDY OUTCOME After spending 1 week on the neurology unit, N.T. is discharged to a rehabilitation center for continued therapy. Though she is still experiencing some mild deficits, she is able to go home after 6 weeks.
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