HESI Case Study; Older Adult with Stroke

***The non-contrast CT scan confirms the presence of an ischemic stroke. Based on that information, the initiation of recombinant tissue plasminogen activator (rtPA) can begin.

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Based on the client's weight of 254 pounds (115.21 kg), what is the total dose for the rtPA infusion? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

103.7 mg **Dimensional analysis method: x mg = 0.9 mg X 115.21 kg = 103.689 = 103.71 kg Ratio proportion method: x mg : 115.21 kg :: 0.9 mg : 1 kg x = 115.21 X 0.9 = 103.689 = 103.7 mg Formula method: D/H X Q 115.21 kg X 0.9 mg = 103.689 = 103.7 mg1 kg

**The client is triaged and he is immediately assigned to the acute side of the ED. An additional IV line with an 18 gauge angiocath is started with an intravenous infusion of sodium chloride 0.9% at 80 mL/hr. His weight is obtained and a 12-lead EKG is performed. Based on his presenting symptoms, the pharmacy is notified of the client's admission and the potential need for recombinant tissue plasminogen activator (rtPA).The ED healthcare provider (HCP) places the following prescriptions in the electronic medical record (EMR).ALL LABS stat CBC without differential Serum electrolytes Serum glucose BUN & creatinine CK & troponin Baseline ABG Type and cross; hold PTT, INR DIAGNOSTICS 12 lead ECG STAT CXR STAT Head CT scan without contrast STAT

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The remainder of the rtPA dose is to infuse over an hour. What is the rate that the nurse will set the pump in order to deliver the remaining dose? (Enter numerical value only. If rounding is necessary, round to the nearest whole number.

156 mL/hr Total dose in mL 173 mL - bolus of 17 mL = 156 mL to be infused in one hour156 mL/60 minutes = 156 mL/hour

Based on the client's weight, the total dose for the rtPA infusion is 103.7 mg. The pharmacy sends an IVPB of 250 mL NS containing 150 mg of rtPA. How many milliliters of this fluid would be the total dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

173 **Dimensional analysis method: x mL = 250 mL X 103.7 mg = 25,925 = 172.8 = 173 mL150 mg 150 Ratio proportion method: x mL : 103.7 mg :: 250 mL : 150 mg 150x = 25,925 = 172.8 = 173 mL150 150 Formula method: D/H X Q 103.7 mg X 250 mL = 25,925 = 172.8 = 173 mL150 mg 150

**Surgery is planned for the client. His spouse is confused and concerned about the procedure and asks the nurse for clarification of the surgeon's explanation. What is an accurate explanation of the surgical procedure that the nurse can provide to the family?

A tiny catheter will be inserted in the femoral artery and a retriever will enter the blocked artery to remove the clot. **This describes the MERCI (mechanical embolus removal in cerebral edema) procedure that is indicated for persons with ischemic stroke.

The nurse wants to determine if the client is ready to begin transfer from the bed to the chair. Which action indicates readiness?

The client corrects his own posture when sitting at the edge of the bed. **Autocorrecting posture is an indication of the balance that is needed for transfer.

**Safe and Effective Care: Management of CareDuring the 24 hours post-stroke onset, the client experiences cerebral edema with a resulting decreased level of consciousness and a temperature of 101.3° F (38.5° C). In addition to elevating the head of the bed and maintaining head alignment, what other measures are important to manage the increased intracranial pressure?

Administer mannitol as ordered. **These diuretic drugs decrease intracranial pressure.

**The client is experiencing constipation. Due to swallowing difficulties, he is ingesting approximately 1000 mL a day, but he is not eating fruits or vegetables. The nurse plans interventions to promote bowel motility and to relieve constipation. Which intervention is appropriate to include in the plan of care?

Administer prescribed stool softener daily. **Stool softeners, or a fiber products are appropriate.

**Safe and Effective Care: Care PlanningThe nurse develops a plan of care for the client. Priority is given to maintaining the airway. Which nursing concern best describes the nature of the client's respiratory problem?

Airway clearance is not effective. **Decreased level of consciousness, and impaired gag and swallow reflexes result in ineffective clearance of the airway.

**Due to loss of sensation, immobility, nutritional needs, and decreased circulation, the client is at risk for skin breakdown. The nurse develops a plan of care to prevent skin breakdown. The plan of care for the client to prevent skin breakdown should include which interventions? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Avoid massaging any areas of redness. **Prolonged redness (greater than 15 minutes) indicates tissue damage. Massage increases the damage. Apply heel protectors on the client's heels. **Heel protectors help take the pressure off the bony prominent surface of the heel. Place a pressure relieving mattress on the bed. **Control of pressure is the most important intervention for prevention of skin breakdown.

**The nurse explains to the spouse that the client's blood pressure is being monitored very closely because he received the infusion of rtPA. Additionally, other medication has been ordered to treat any increases in blood pressure. After an infusion of rtPA, what is the primary reason for keeping the blood pressure below 185/110?

Cerebral hemorrhage. **Clients receiving rtPA require careful monitoring for cerebral hemorrhage or other signs of bleeding. Give antihypertensive medications as prescribed when BP is greater than 180/105.

**Stroke is a major public health concern in this country. Because stroke causes major disability and death, it is critical to identify those at risk in order to implement prevention strategies by targeting modifiable risk factors. What risk factors in the client's history predispose him to stroke? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Male gender. **Stroke is more common in men than in women. However according to research articles more men may suffer strokes, but, more women die or have more of a debility compared to men if they experience a stroke. Heavy alcohol use. **There is a known association with heavy alcohol use and strokes. **History of Transient Ischemic Attack (TIA). Approximately 30% of individuals who experience a TIA have a stroke within 5 years. Sedentary lifestyle. **Sedentary lifestyle is associated with increased risk of a stroke. Obese and hypertensive. **Obesity is associated with hypertension, high blood glucose, and high lipid levels. All of these increase the risk of stroke if not controlled.

Within 10 minutes of being transported to the ED, the client begins to experience an episode of blindness in his right eye, loss of sensation in his right hand, and the inability to speak clearly. Which nursing action has highest priority?

Monitor blood pressure. **Clients who have a stroke may have significant hypertension. The AHA recommends antihypertensive therapy only if blood pressure is higher than 220/120 mm Hg because autoregulation of blood pressure at a higher level may help cerebral perfusion.

**Results of radiology imaging reconfirms that the client has suffered a left-sided ischemia stroke, which correlates with his presenting symptoms. The RN, PN, and unlicensed assistive personnel (UAP) are caring for the client during the acute phase while he is receiving an rtPA infusion. Which actions can the RN delegate to the UAP? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Obtain vital signs. **The UAP assists with activities of daily living (ADL), provided training has occurred. Assist with positioning. **The UAP assists with activities of daily living (ADL), provided training has occurred. Measure intake and output (I&O). **The UAP assists with activities of daily living (ADL), provided training has occurred.

Client outcomes are often related to the delivery of emergency care. Which nursing intervention is appropriate to implement in the emergency care of the client?

Remove dentures and implement seizure precautions. **Seizures occur in 5 to 7% of stroke patients in the first 24 hours.

**ADMISSION ORDERS Admit to Neuro ICU when bed available Maintain both IV access lines Notify HCP if not able to maintain ordered BP parameters with labetalol NPO Place on continuous cardiac monitoring Monitor temperature every 1 hour Monitor glucose levels every 2 hours via fingersticks Notify HCP for serum glucose >200 mg/dL Strict I & O Use of cooling blanket if needed to maintain temp < 100.4º F (38º C) Continuous pulse oximetry - maintain O2 saturation >95% Seizure precautions Compression stockings and pneumatic compression devices BP every 15 minutes x 2 hours after starting infusion; every 30 minutes x 6 hours; every 60 minutes x 24 hours after Monitor MAP and notify HCP < 60 MEDICATIONS rtPA 0.9mg/kg IV; 10% of total dose bolus over 20 minutes; remainder dose administered over 60 minutes Sodium chloride 0.9% @50 mL/hr Labetalol 10mg IVP Q 20 minutes PRN if SBP > 185 and DBP > 110 mmHg for 2 or more readings 5 to 10 minutes apart; up to 3 doses every 10 to 20 minutes Acetaminophen 600 mg suppositories PRN temp > 100.4° F (38° C) every 4 to 6 hrs Titrate oxygen supplementation to keep O2 saturation >95% Nicotine patch 21 mg every day DIAGNOSTIC Head MRI with and without contrast STAT Follow-up head CT scan with contrast STAT

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**Case Conclusion The client makes significant progress gaining independence. He is discharged home after a three month stay in the intermediate care facility. They secure the assistance of a home health aide to be with the client while the spouse is at work. The importance of adherence to antihypertensive medication and warning signs of a stroke are reviewed with the family. The client continues to progress and begins to find new ways to socialize with his friends. Previous Section

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**Health Promotion and Maintenance: Care in the Rehabilitation PhaseThe spouse is concerned about providing the care the client needs after he is discharged. The spouse asks for information about the effects of left sided stroke on cognitive function, so that they can plan to make necessary adaptations at home. A multidisciplinary team assesses the client's rehabilitation potential. The spouse expresses care concerns because of being the sole support for the client while working full time. Prior to the client's stroke the spouse found it increasingly difficult to care for him as his arthritis worsened. A particular concern is fall risk due to the added complication of the stroke, although the spouse wishes to have him return home after a period of rehabilitation in an intermediate care facility. The client is transferred to an intermediate care facility.

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**Safe and Effective Care: Care ManagementThe client returns to the ED. Time is of the essence in stroke management. The healthcare team immediately seeks to determine the time of the ischemic event. According to his spouse, the client woke up at 6:00 am and asked for assistance getting to the bathroom. At that time, there were no signs of speaking difficulties or paralysis. The spouse states that stroke signs were evident two hours later, when he was found on the floor. The time is now 9:20 am and the nurse recognizes that the rtPA can restore blood flow if administered within 3 to 4.5 hours following the ischemic event in clients with no recent bleeding events. The HCP adds the following orders to the electronic medical record (EMR).

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**The ED HCP utilizes a tool called the NIH Stroke Scale (NIHSS) created by the National Institute of Neurological Disorders and Stroke. This tool is used to measure the severity of a stroke. It is measured in baseline intervals: 2 hours, post-treatment of rtPA; 24 hours, onset of symptoms +/- 20 minutes; 7-10 days; 3 months; other. Scores that increase are usually indicative of more severe stroke that correlate with the size of the infraction seen on the cranium computerized tomography (CT scan) and magnetic resonance imaging (MRI). The points the client demonstrates fall into the different categories as seen in the following chart. POINTS SEVERITY 0= No stroke 1 to 4= Minor stroke 5 to 15= Moderate stroke 15 to 20= Moderate/severe stroke 21 to 42= Severe stroke The client's initial score in the ED prior to initiation of the rtPA is 20. In order for the ED HCP to begin the initiation of recombinant tissue plasminogen activator (rtPA), the presence of an ischemic stroke needs to be confirmed by a non-contrast CT scan.

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Meet the Client At approximately 8:00 am, the client's spouse finds him on the floor of his bedroom. The spouse calls 911 and states that the client has difficulty speaking and he is not able to get himself off the floor. When trying to roll him to his back, the right side of his body appears limp and weak. When the EMS team arrives, one performs an assessment while the other asks about the client's health history. The client is overweight, sedentary, smokes, drinks multiple alcoholic beverages every day, has arthritis, and has had hypertension and transcient ischemic attacks (TIA) for years. The paramedics perform a Cincinnati Pre-Hospital Stoke Scale Assessment. Based on the assessment findings, the paramedics call the Emergency Department (ED) to report a suspected stroke. En route to the hospital, an 18 gauge peripheral IV catheter is placed in the client's left arm. He is receiving 6 liters of oxygen via facemask and his O2 saturations remain above 95%.

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The client is to receive 10% of total dose bolus over 20 minutes. What hourly rate will the nurse set the pump to deliver this dose over a 20 minute period? (Enter numerical value only. During calculations, round to the tenth. If rounding is necessary at the end, round to the nearest whole number.)

52 mL/hr Dimensional analysis method: x mL = 103.7 mg X 0.1 X 60 minutes X 250 mL = 155,550 = 51.85 = 52 mL/hourhour 1 hour 20 min 1 hour 150 mg 3,000 Ratio proportion method: 10% of total dose = 103.7 mg X 0.1 = 10.37 mg 10.37 mg : x mL :: 150 mg : 250 mL 150 x = 2,592.5 = 17.3 mL 17.3 mL : 20 minutes :: x mL : 60 minutes 20 x = 1,038 =51.9 = 52 mL/hour150 150 20 20 Alternate method: D/H X Q 10% of total dose = 103.7 mg X 0.1 = 10.37 mg 10.37 mg X 250 mL =2,592.5 = 17.2 mL in 20 min 60 min X 17.283 mL = 1038 = 51.9 = 52 mL/hour150 mg 150 20 min 20

**A bed in the Neuro ICU is available and the client is transferred. The infusion of rtPA that was initiated in the ED has not completed infusing. Which medications if listed to be given, should the nurse question for at least 24 hours after completion of the infusion of rtPA? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Antithrombotic. **Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours post infusion due to increased risk of hemorrhaging. Acetylsalacylic acid. **Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours post infusion due to increased risk of hemorrhaging. Heparin. **Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours post infusion due to increased risk of hemorrhaging. Warfarin. **Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours post infusion due to increased risk of hemorrhaging. Enoxaparin. **Clients who have received fibrinolytic therapy for stroke should avoid any type of antiplatelet or antithrombotic for a period of at least 24 hours post infusion due to increased risk of hemorrhaging.

**The client is experiencing urinary incontinence. In the initial phase of care, an indwelling urinary catheter is placed. The nurse updates the plan of care for urinary management to reflect the rehabilitation needs of the client. Which intervention is most appropriate?

Apply an external catheter. **This is an appropriate measure for clients in the rehabilitation phase.

**The nurse is concerned about preventing joint contractures in the rehabilitation phase of the client's care. The nurse realizes that his right side, the weaker side, needs special attention when positioning. The nurse positions the client in bed. What are the correct positional interventions to support optimal musculoskeletal function?

Apply high topped tennis shoes on the client to prevent foot drop. **High topped shoes help to prevent foot drop. Use of foot boards is controversial as they may increase spasticity.

**The hospital where the client is admitted is ranked as a Primary Stroke Center certified hospital. Because of this quick access to the hospital, HCPs were able to implement stroke care guidelines to maximize his outcome. The HCP was able to retrieve the clot in his brain, which minimized residual effects of the stroke. His initial NIHSS score was 20 in the ED prior to the initiation implementation of the guidelines. His current score is now 10.The client exhibits a degree of dysphagia following his stroke and subsequent treatment. After he is stabilized a speech pathologist conducts a swallow evaluation and determines that he can begin oral feedings. The nurse prepares to give the client his first feeding. Which action is an appropriate intervention?

Determine if the client can swallow a small amount of crushed ice. **After elevating the bed 90° and assessing the gag reflex, swallowing ability is assessed with a small amount of crushed ice.

**Based on the client's confirmed diagnosis of ischemic stroke, the ED HCP orders a follow-up head CT scan with contrast and a head MRI with contrast STAT with an ED nurse in attendance. The nurse accompanies him to the radiology department as he is transported via stretcher. The nurse brings an emergency intubation tray in the event he requires intubation. The client is scheduled to have an open CT scan with contrast. What information should the nurse obtain prior to administering the intravenous contrast? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Does the client have an allergy to iodine, **The contrast that is used for CT scan procedures contains iodine. Does the client have a shellfish (crustacean) allergy. **Studies have shown to be a correlation between shellfish allergies and an allergic reaction to the contrast used in CT scan procedures.

The spouse asks the nurse why the client ate only half of his meal and only the food on the right side of the plate. What is the nurse's best response? Select all that apply

He can only see half of the plate, so we need to encourage him to turn his head to see it all. **Hemianopsia, or blindness in half of the visual field, results from damage to the optic tract or occipital lobe. Usually this deficit occurs as homonymous hemianopsia, in which there is blindness in the same side of both eyes The patient with this condition must turn his or her head to scan the complete range of vision. Otherwise, he or she does not see half of the visual field. For example, the patient eats only half of a meal because that is the only portion seen.

**Safe and Effective Care: Family CommunicationThe spouse notices that the client's blood pressure is 180/100 and questions the nurse about what treatment is being given to manage his high blood pressure. What is the best response for the nurse to provide to the client's spouse?

High blood pressure is common after a stroke. It is the body's way of assuring a sufficient blood flow to the brain. **The family should be reassured that BP is being carefully monitored. Medication will be given if the systolic pressure exceeds 185 mm Hg.

**Physiologic Integrity: AssessmentThe stroke team is called to the ED for the client. Based on his presenting symptoms, the nurse suspects that the client has suffered left-sided brain damage. What other observations would support this assessment? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Inability to understand speech and simple math questions. **Impaired comprehension of language and math are indicative of left-sided brain damage. Slow, cautious behavior and anxiety. **These behaviors, as well as depression, are indicative of left-sided brain damage. Slurred speech and aphasia. **Impaired speech and aphasia are indicative of left-sided brain damage. Right hemiplegia. **A right hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body) indicates a stroke involving the left cerebral hemisphere because the motor nerve fibers cross in the medulla before entering the spinal cord and periphery.

**Physiologic Care: PharmacotherapyIt is determined that the client is at risk for deep vein thrombosis (DVT) due to his immobility and loss of muscle tone. A low molecular weight heparin is ordered. The client receives enoxaparin subcutaneously as a preventive measure for DVT. While on this therapy, the nurse should monitor which lab reports?

International Normalization Ratio (INR). **Clients receiving enoxaparin should have routine monitoring of the INR.

After the CT scan is completed, the client is transported to the MRI scan. His spouse accompanies him and the nurse for the MRI. What information should the MRI technician obtain from the spouse prior to the procedure? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Is the client claustrophic or afraid of closed-in, small places. **Most MRIs are closed, requiring the client to be placed in a long, hollow cavity to conduct the exam. It is important for the technician to explain the procedure and prepare the client on what to expect from the MRI scan experience. Does the client have any metal piercings or metal implants. **The MRI is like a large magnet that uses magnetic field and radio waves to create an image of soft tissue and organs. Anything metal placed in the field while the machine is activated will be attracted to the magnetic field and could cause harm to the client. **Did the client serve in the military and does he have a history of shrapnel from a war injury. The MRI is like a large magnet that uses magnetic field and radio waves to create an image of soft tissue and organs. Anything metal placed in the field while the machine is activated will be attracted to the magnetic field and could cause harm to the client.

Which nursing observations are consistent with ischemic rather than hemorrhagic stroke? (Select all that apply. One, some, or all options may be correct.)

Often occurs during or after sleep. **This is in contrast to hemorrhagic stroke which often has an onset after activity. History of transient ischemic attack. **TIAs are considered a warning sign of ischemia stroke. Both TIA and stroke result from formation of a clot with vessel occlusion, but in stroke there is also infarction and cell death. No loss of consciousness in the first 24 hours. **Ischemic strokes are not associated with immediate loss of consciousness unless it is a brain stem stroke or is accompanied by seizures and increased intracranial pressure. About 50% of persons with hemorrhagic stroke exhibit decreased level of consciousness. Sudden onset with progression of symptoms over hours. **Sudden onset of symptoms is associated with ischemic stroke due to emboli. This occurrence is commonly associated with atrial fibrillation.

**Physiological/Psychosocial IntegrityThe client has been ambulating and sitting in a wheelchair. He is eating orally, but the nurse wishes to optimize his nutrition by encouraging a sufficient intake. The client has an intact gag reflex but his oral intake is suboptimal. Which strategy can be implemented to promote improved nutritional intake? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Position the client upright in a chair for meals. **A 90° sitting position is ideal for meals. This upright position also allows gravity to help swallow effectively. The client can be placed in high Fowler's, but it is preferable to have him sit in a chair if he is able. Encourage the client to make selections from his menu. **Allowing the client to select his menu choices may help increase his consumption. Offer six smaller meals instead of three large meals per day. **It may be easier for the client to handle smaller meals at first, then progress up to three larger meals each day. Ask his spouse for a list of the client's favorite healthy choice foods. **Including his spouse into his plan of care and assessing what foods he likes may help to make healthy choices of those foods and increase his appetite. Request that UAP open all containers and assist the client as needed. **The client may have difficulty opening containers due to hemiplegia, and the UAP can do this and assist the client in eating his meals as needed.

**On initial evaluation, the client has a diminished gag and swallow reflex and his level of consciousness is decreasing. The nurse prioritizes airway management in the emergency phase and expects to implement which airway interventions?

Prepare for intubation. **Intubation and mechanical ventilation will be necessary because altered gag and swallow reflexes, as well as declining level of consciousness make it difficult for the client to maintain an open airway.

**Safe and Effective Care: Management in the Rehabilitation PhaseAn important cardiovascular concern is prevention of deep vein thrombosis (DVT). The client is particularly at risk for development of a DVT in his weakened right lower extremity. He has no mobility in the right leg. The nurse delegates care assignments to the unlicensed assistive personnel (UAP) to foster client mobility. Which action by the UAP is a responsibility of the nurse that cannot be delegated to the UAP?

The UAP measures the calf and thigh, noting any swelling, warmth, or pain. **These actions describe assessment. Assessment is the role of the nurse and cannot be delegated

**Safe and Effective Care: Care ManagementThe client arrives to the ED via ambulance at approximately 8:40 am. The paramedics conduct an SBAR report to the ED medical staff. Based on the client's history, what is the most significant piece of information that warrants a more thorough investigation by the nurse?

The client sometimes forgets to take his antihypertensive medication. **The nurse needs to question the client to know when he last took his prescribed anti-hypertensive medications. Hypertension has a mechanical effect on the integrity of the blood vessels, leading to the weakened vessel wall and/or the formation of a thrombus which can cause a stroke to occur. The type of medication and the time he took the medication will have implications for the prescribed plan of care.

**Safe and Effective Care: Management in the Rehabilitation PhaseThe client's surgery is successful. The clot is removed and a stent is put in place to help maintain the vessel open. Following emergent care, he is now stabilized. As part of the rehabilitation phase of recovery, an in depth neurological assessment is high priority. In addition to a comprehensive physical assessment, the nurse recognizes the importance of guidelines of the National Institutes of Health Stroke Scale and continues assessing at the specified intervals. An orientee asks the neuro ICU nurse about the National Institutes of Health Stroke Scale. Which statement by the nurse is correct?

The scale evaluates impact of cerebral infarction on comprehensive neurological functioning. **In addition to level of consciousness, visual, language, and motor abilities are assessed.