Question

Case Study

Mr. J is 78-year-old black man who arrived in the emergency department lethargic, vomiting, unable to speak clearly, and with weakness on the right side of his body. Mr. J has a medical history of hypertension and diabetes mellitus type 2. His family (wife and daughter) reported that for the past 3 months he has been having right-sided weakness and slurred speech that resolved within an hour of onset. Mr. J also has glaucoma, gout, and a history of atrial fibrillation (managed with drugs). Mr. J’s family reported that he was taking the following drugs at home: digoxin, allopurinol, furosemide, NPH (neutral protamine Hagedorn) insulin twice a day, lisinopril, baby acetylsalicylic acid, potassium chloride, and eye drops.

Mr. J’s wife, 77 years old, reported that approximately 3 days ago Mr. J stopped taking his blood pressure drugs (lisinopril and furosemide) because he had spent the money on a horse race. Two nights ago, he started to experience more frequent numbness of the right arm and slurred speech, but she did not think it was important because it disappeared after several hours. Today, she had difficulty waking him up, and her daughter told her to call the ambulance.

Mr. J’s blood pressure on admission was 220/120 mm Hg; his heart rate was 126 beats/min; respiratory rate was 28 breaths/min; and temperature was 98.9° F (37° C). He had right-sided hemiparesis and hemiplegia. His speech was slurred and at times incomprehensible. Mr. J was able to maintain his airway at this time.

Oxygen via nasal cannula is started at 2 liters per minute (L/min), and a peripheral intravenous line is started with normal saline intravenous fluid therapy at 80 milliliters per hour (mL/hr). A 12-lead electrocardiography (ECG) is performed, and Mr. J is sent for computed tomography (CT) of the head.

1.  Which one of Mr. J’s symptoms supports a diagnosis of stroke?

2.  What are the risk factors that Mr. J presents for the development of stroke?

3.  Indicate the type of stroke Mr. J most likely had and support your answer.

4.  What evidence is presented to support that Mr. J had experienced previous TIAs?

5.  Why is atrial fibrillation a risk factor for embolic stroke?

6.  Identify a nursing diagnosis based on Mr. J’s assessment and develop an appropriate nursing care plan.

Answer 1

1. Which one of Mr. J’s symptoms supports a diagnosis of stroke?

• Mr. J had more frequent numbness of the right arm and slurred speech, it disappeared after several hours.
• On next day he had difficulty waking
• Mr. J’s blood pressure on admission was 220/120 mm Hg
• He had right-sided hemiparesis and hemiplegia

2. What are the risk factors that Mr. J presents for the development of stroke?

• Approximately 3 days ago Mr. J stopped taking his blood pressure drugs (lisinopril and furosemide)
• Mr. J has a medical history of hypertension and diabetes mellitus type 2.
• For the past 3 months he has been having right-sided weakness and slurred speech that resolved within an hour of onset
• He has the history of atrial fibrillation (managed with drugs).

3. Indicate the type of stroke Mr. J most likely had and support your answer.

Hemorrhagic stroke

Very high blood pressure can cause weakening of the small blood vessels in the brain and result in bleeding into the brain as well. This is called Hemorrhagic stroke.

Here Mr J had high blood pressure of 220/120 mm of Hg

4. What evidence is presented to support that Mr. J had experienced previous TIAs?

A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke.

For the past 3 months he has been having right-sided weakness and slurred speech that resolved within an hour of onset.

5.  Why is atrial fibrillation a risk factor for embolic stroke?

The most common cause of stroke is a blood clot.

Atrial fibrillation leads to increased risk for stroke because blood may not be properly pumped out of the heart, which may cause it to pool and form a clot.

This clot can then travel to the brain and block the flow of blood to part of the brain which can result in a stroke.

6.  Identify a nursing diagnosis based on Mr. J’s assessment and develop an appropriate nursing care plan.

Nursing Diagnosis

• Ineffective cerebral tissue perfusion related to hemorrhage of blood vessels to the brain secondary to hypertension as evidenced by right side hemiplagia and slurred speech

•    Impaired physical mobility related to hemiparesis, loss of balance and coordination as evidenced by difficulty in moving

Nursing care plan

Assessment	Nursing Diagnosis	Expected outcome	Interventions	Rationale	Evaluation
Subjective Data: Patient verbalized that he has difficulty for moving the right side limbs Objective data: High blood pressure, right side hemiparesis	Ineffective cerebral tissue perfusion related to hemorrhage of blood vessels to the brain secondary to hypertension as evidenced by right side hemiplagia and slurred speech	Patient maintains adequate cerebral tissue perfusion	Assess the neurological status of the patient Check the vital signs Position with head slightly elevated and in neutral position. Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Provide rest periods between care activities. Limit duration of procedures.	Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain. Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.	Patient has improved the right side hemiparesis and slurring of speech
Subjective data:Patient verbalized that he has difficulty for walking and doing daily activities Objective data: Right side hemiparesis and hemiplagia	Impaired physical mobility related to hemiparesis, loss of balance and coordination as evidenced by difficulty in moving	Patient maintains normal physical activity	Use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies. Apply a splint at night Prevent adduction of the affected shoulder with a pillow placed in the axilla. Elevate affected arm Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.	Position to prevent contractures Splint is to prevent flexion of affected extremity. To prevent the contractures Arm is elevated to prevent edema and fibrosis. Change the position to promotes the blood flow and prevents the pressure sore.	Patient has improved his physical activity level