Cerebral Vascular Accident (CVA): John Gates, 59 years old, Quizzes of Nursing

Download Cerebral Vascular Accident (CVA): John Gates, 59 years old and more Quizzes Nursing in PDF only on Docsity! Cerebral Vascular Accident (CVA) John Gates, 59 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Stress 2. Coping 3. Clinical Judgment 4. Patient Education 5. Communication 6. Collaboration UNFOLDING Clinical Reasoning Case Study: STUDENT Cerebral Vascular Accident (CVA) History of Present Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic symptoms when he presents to the ED. You are the nurse responsible for his care. Personal/Social History: John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has been complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has been using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants. He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9). What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: *history of diabetes type II *hypertension *sudden onset of right-sided weakness *right facial droop *difficulty speaking *it has been one hour from the onset of his neurologic symptoms when he presents to the ED John is showing neurological changes that show signs of an embolism or hemorrage incident. Bases on the location in the brain it will determine how bad the damage is.It has also been one hour from onset of his neurologic symptoms showing signs of CVA. Irregular signs of heartbeat showing signs of A-fib. Feeling signs of pain with type 2 diabetes so may RELEVANT Data from Social History: Clinical Significance: *complains of irregular heaertbeat *pain in his right foot *using nicotine patch to stop smoking Irregular signs of heartbeat showing signs of A-fib. Feeling signs of pain with type 2 diabetes so may have a possible infection. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable P: 118 (irregular) Quality: R: 20 (regular) Region/Radiation: BP: 198/94 Severity: O2 sat: 99% room air Timing: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS data: Clinical Significance: 118 P BP 198/94 Pulse is Outside normal range. Possible signs of A-fib it is the most common sign for an embolic stroke. Blood pressue elevated it is uncommon in CVA, can impede cerebral blood flow. Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting? The primary problrm is he has a stroke 2. What is the underlying cause/pathophysiology of this primary problem? (Relate initial manifestations to the pathophysiology of the primary problem) Pathophysiology of Primary Problem: Rationale for Manifestations: A stroke occurs when the blood flow to an area of the brain is interrupted, resulting in some degree of permanent neurological damage. The two major categories of stroke are ischaemic (lack of blood and hence oxygen to an area of the brain) and haemorrhagic (bleeding from a burst or leaking blood vessel in the brain) stroke. Ischaemic strokes can be broadly subdivided into thrombotic and embolic strokes. Narrowing is commonly the result of atherosclerosis – the occurrence of fatty plaques lining the blood vessels. As the plaques grow in size, the blood vessel becomes narrowed and the blood flow to the area beyond is reduced. Damaged areas of an atherosclerotic plaque can cause a blood clot to form, which blocks the blood vessel – a thrombotic stroke. Sudden onset of the right sideded weakness is explained by the emboli that formed as a reult of A-fib that was present. This caused a complete disruption of blood flow to the affected area of the brain ( left hemisphere). The severity can be mitigated by restoring perfusion and blood flow to this area of the brain. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV Will need to give IV meds to control BP and agitation, IV established patient. Lower BP/ Control BP 12 lead EKG stat Has telemtry ryhtmn change of a-fib. Need to confirm 12 k lead EKG. a-fib confirmed. Labetalol 10-20 mg IV prn every 15 minutes to keep SBP 160-180 Beta blocker to keep SBP pressure down Lower BP CT head stat To know what type of stroke John has. Idchemic Stroke outcome Cardiac monitor continuous Constant monitoring of cardiac rythmn due to stroke Get heart rate below 100 NPO To reduce choking No aspiration Alteplase IV dose per pharmacy (if CT negative for bleed) Breakdown clot blocking blood flow No adverse reactions, or hemorrage PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1.Establish peripheral IV 2.Labetalol 10-20 mg IV prn every 15" to keep SBP 160-180 3.CT head stat 4.Cardiac monitor continuous 5. Alteplase IV (if CT negative for bleed) CT Scan Establish peripheral IV Alteplase IV Labetalol Cardiac Monitor Rule out type of stroke To adminster medication - circulation intervation Needs to be admistered ASAP to restore blood flow to brain to reduce BP To monitor for cardiac dysrythmia Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Labetolol 20 mg IV push (5 mg/mL vial) Blocks stimulation of beta 1 Decrease BP and heart rate IV Push: Volume every 15 sec? Check BP and heart rate teach patient to change positions very slowly. Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Amount to Safely Administer: Nursing Assessment/Considerations: Alteplase 0.9 mg/kg IV over 60 minutes not to exceed 90 mg Converts plasmogen to plasmin which breaksdown clot Weight: 113.6 kg Amount to administer: look for allergic reaction check for bleeding asses vital signs asses on neurological assesment GU bleeding Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) John is having a circulation issue. Ineffective tissue prefusion as well as sensory-perceptual alterations. Effecting auditory, visual, tactile, and kinstethic as related to his tissue injury. 4. What interventions will you initiate based on this priority? Nursing Priority: Nursing Interventions: Rationale: Expected Outcome: Will expedite transfer for head CT–make sure they are aware and obtain ASAP! Perform frequent neuro checks–-usually every 15– 30" in the acute phase or per MD orders to trend \ any changes Frequent monitoring of BP -- at least every 15minutes Continuous monitoring of cardiac rhythm. Afib can readily accelerate into the 130–150s. Anticipate this possibility and ensure that primary care provider has prn to reduce rate if needed Seizure pads on side rail I 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? Neurologic 6. What is the worst possible/most likely complication to anticipate? Coma and seizures are the worst possible outcomes 7. What nursing assessments will identify this complication EARLY if it develops? Slurred speech and unconsciousness. 8. What nursing interventions will you initiate if this complication develops? contact primary care provider or send for help 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? He may need spiritual support and knowledge and education on his condition. 10. How can the nurse address these psychosocial needs? A nurse can give emotional and spiritual support.Being present and available . Giving more knowledge on the patients care moving forward. Evaluation: 1 Hour Later…Alteplase has just completed and the following clinical data is collected: Current VS: Most Recent: T: 99.0 F/37.2 C (oral) T: 99.2 F/37.3 C (oral) P: 74 (regular) P: 118 (irregular) R: 16 (regular) R: 20 (regular) BP: 178/86 BP: 198/94 O2 sat: 96% room air O2 sat: 99% room air