COLLEGE OF ST.
JOHN - ROXAS Member: Association of
LASSAI- Accredited Superschools (ALAS) Atila Balgos St.
Banica, Roxas City
NCM 116
Care Of The Clients With Problems In Nutrition, And Gastro-internal,
Metabolism And Endocrine, Perception And Coordination, Acute And Chronic
CASE STUDY IN MANAGEMENT OF PATIENTS WITH
CEREBROVASCULAR DISORDERS/NEUROLOGIC TRAUMA
Crisha Ann Bacuta BSN-3
College of St. John – Roxas
10/29/21
COLLEGE OF ST. JOHN - ROXAS
Member: Association of LASSAI-
Accredited Superschools (ALAS) Atila
Balgos St. Banica, Roxas City
NCM 116
Care of Clients With Problems in Nutrition, and Gastro-internal, Metabolism and
Endocrine, Perception and Coordination, Acute and Chronic
CASE STUDY
Management of Patients With Cerebrovascular Disorders
1. Penny Williams, a 74-year-old patient, is admitted to the telemetry unit with the diagnosis
of acute ischemic stroke. The patient is experiencing paroxysmal atrial fibrillation with a
controlled ventricular rate on the monitor. A CT of the head without contrast reveals no
evidence of hemorrhage. The transesophageal echocardiogram reveals moderate mitral
valve insufficiency and embolism as a primary cause of the stroke. The patient is on a
weight-based heparin protocol. The patient received digitalis to keep the ventricular rate
of the atrial fibrillation controlled. The patient has right-sided paralysis and global
aphasia. The patient has unilateral neglect of her right side and has right field
homonymous hemianopsia. Papilla edema is present bilaterally. The patient is drooling
from the right side of her mouth and coughs periodically. The patient was found by her
daughter when she got home from work. The daughter stated her mother was normal
before she left for work, and 10 hours later the mother exhibited the symptoms described
above. The time of onset for the stroke could not be safely determined so no interventions
could be used to treat the stroke.
a. What principles of nursing management should the nurse provide the patient during the
acute stage of the ischemic stroke based on the assessment findings from the case
study? Place the assessment findings that are supported by the nursing principle(s) in
parenthesis.
The nursing management in acute ischemic strokes includes:
Ongoing or frequent monitory of all systems including vital signs and
neurological assessment using glasgow coma scale ( GCS)
Monitor for potential complications: includes musculoskeletal problems,
swallowing difficulties, respiratory problems, and signs and symptoms of
increased intracranial pressure (IICP) and meningeal irritation.
Focus on patients' functions such as: self care ability, coping and needs to
facilitate rehabilitation.
Proper airway management
Check respiratory rate and oxygen saturation and give oxygen if saturation is
below 95 %
Check For peripheral perfusion, pulse, and blood pressure and treat
abnormalities with fluid replacement, anti-arrhythmias and inotropic drugs if
appropriate.
Hydration if signs of dehydration gives fluid parenterally or by NGT
Control glucose and temperature.
Dysphagia screening.
Acute treatment of thrombolytic and endovascular intervention.
Treatment of acute neurologic complication
Rapid triage to appropriate safe care.
COLLEGE OF ST. JOHN - ROXAS
Member: Association of LASSAI-
Accredited Superschools (ALAS) Atila
Balgos St. Banica, Roxas City
Management of Patients With Neurologic Trauma
1. Melvin Strong, a 19-year-old patient, presents to the emergency department after being
ejected from an automobile. He has a backboard with a cervical collar in place. The EMT
stated that when he saw the patient, the patient was unconscious but quickly gained
consciousness and was oriented ×3, talking, and able to move all four extremities. Within 5
minutes, the patient became unable to be aroused, opened his eyes only to painful stimuli,
made incomprehensible sounds, and withdrew from pain. The vital signs are: temperature,
100°F; blood pressure, 180/50 mm Hg; heart rate, 50 bpm; and respiratory rate, 14
breaths/min. The left antecubital IV site has NS at 125 mL/hr. The EMT stated that the
patient complained of a severe headache and had an episode of projectile vomiting before
the neurologic decline. The patient’s breath smells like alcohol. When the patient arrived,
the nurse noted that the patient’s pupils were unequal---the right pupil was larger than the
left pupil---but both pupils reacted to light accommodation. (Learning Objectives 1 and 2)
a. What do the assessment findings suggest?
The symptoms suggest a traumatic brain injury and, more specifically, an epidural
haemorrhage and the increased intracranial pressure from the arterial bleed causes the quick
changes in the neurologic status.
On arrival to the emergency within five minutes patient became:
unable to be aroused
opened his eyes on painful stimuli only E3
made incomprehensible sound V5
withdraw from pain M4
Vital signs were :
Temperature - 100°F
Blood pressure - 180/50mmhg
Heart rate - 50bpm
Respiratory rate - 14 breaths per min
His GCS was E3V5M4
b. What signs and symptoms does the patient exhibit related to increased intracranial
pressure?
The signs and symptoms does the patient exhibit related to increased intracranial pressure are
the following including:
Changes in LOC
Pupillary changes
Widening pulse pressure
Headache
Vomiting.
Projectile vomiting
Severe headache
Altered level of consciousness: coma state as reflected by the
Glasgow Coma Scale (GCS) of 8
Cushing triad of bradyapnea, bradycardia,and hypertension.
c. What medical and surgical treatment does the nurse anticipate for the patient?
Medical and surgical treatment that should be provided to the patient are the following:
evacuation of mass lesion
maintain euvolemia
hyperosmolar therapy.
ventriculostomy to drain CSF and lumbar drain .
maintaining 30 degree of bed
maintaining normocarbia
normothermia
sedation and analgesics
seizure management and prophylaxis
barbiturates and mild /moderate hypothermia for refractory intracranial hypertension.
Medical treatment: fresh frozen plasma, vitamin K, hemodialysis, , oral activated
charcoal, prothrombin complex concentrates, recombinant activated factor VII
Surgical treatment: craniotomy, stent or coil placement.
CT scan without contrast to locate the bleed and then the patient will be taken to the
operating room quickly to evacuate and stop the hemorrhage and decrease the
increasing intracranial pressure
Draw labs stat as ordered: CBC, coagulation profile, renal/metabolic
profile, type and cross, ETOH level
d. What Glasgow Coma Scale (GCS) did the patient have initially at the scene of the
accident? What GCS did the patient have when he began deteriorating neurologically?
Glasgow Coma Scale for this patient when he was brought to the emergency is less than 8 and
then after 5 min it was 12 ( E3V5M4 .)
E 3- open his eyes on painful stimuli
V5 - incomprehensive sounds
M4- withdraws pain
e. What nursing interventions should the nurse provide?
The nursing interventions that should the nurse provide to the patient are the following:
Optimizing cerebral tissue perfusion by implementing aneurysm precautions
Relieving anxiety
Monitoring and managing potential complications which are vasospasm, seizure,
hydrocephalus, rebleeding, hyponatremia.
Promoting home and community base care by educating patient about self-care,
continuing care.
Maintain a patent airway
Monitor for further changes in the neurologic status and cranial
nerve deficits, vital signs, and GCS
Institute measures to decrease intracranial pressure.
