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Stroke Case Study (45 min)

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Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”

Critical Thinking Check
Bloom's Taxonomy: Application

What nursing assessments should be completed at this time?

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You assess Mrs. Blossom to find she has a left sided facial droop, slurred speech, and is unable to hold her left arm up for more than 3 seconds.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What is/are your priority nursing action(s) at this time?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What may be occurring in Mrs. Blossom?

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You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.

 

Critical Thinking Check
Bloom's Taxonomy: Analysis

What are the possible interventions for Mrs. Blossom at this time?

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Critical Thinking Check
Bloom's Taxonomy: Comprehension

What are the contraindications for thrombolytics like tPA (alteplase)?

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You administer tPA per protocol, initiate q15min vital signs and neuro checks. You stay with the patient to continue to monitor her symptoms.

Critical Thinking Check
Bloom's Taxonomy: Comprehension

What are possible complications of tPA administration? What should you monitor for?

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After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What would you explain has happened to Mrs. Blossom physiologically?

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Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker,  with a follow up appointment in 1 week to see the neurologist.

Critical Thinking Check
Bloom's Taxonomy: Application

What education topics should be included in the discharge teaching for Mrs. Blossom and her family?

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