Assignment task:
Q1. Explain the underlying pathophysiology related to the clinical manifestations of Ischaemic Stroke.
Q2. Discuss the importance of reperfusion in the management of a patient presenting with an Ischaemic Stroke.
Q3. Identify evidence-based strategies when caring for a patient presenting with Ischaemic Stroke.
Q4. Justify and prioritise the nursing care related to the case study.
Q5. Promote shared decision-making processes collaborating with family and the health care team.
Case Study ISBAR Handover:
Introduction: Mrs Mary Fenech is a 78-year-old lady with no known allergies (NKA)
Situation: She arrived in the Emergency Department at 09:30 hrs with slurred speech and right sided weakness since 0530 hrs while at home.
Findings from the CT perfusion assessment using Mean Transit Time (MTT) and Time to Peak (TTP) images showed reduced blood flow in the left middle cerebral artery (MCA) vascular territory extending from the medial cerebellum to the deep white matter at the centrum semiovale above the lateral ventricle. A CT angiogram showed an acute left Internal Carotid Artery (ICA) occlusion. Thrombolysis with Alteplase was administered at 11:30hrs
Background: Atrial Fibrillation (AF), Hypertension (HTN), Type 2 Diabetes Mellitus (IDDM), No head trauma, no prior stroke within the previous 3 months
Regular medications-
Atenolol 50mg daily, Aspirin 100mg daily, Lipitor 40mg daily, Magnesium 200mg daily, Amlodipine 5mg daily, Perindopril 5mg daily, NovoRAPID insulin
Assessment:
- Airway: slight inspiratory stridor
- Breathing: Respiratory rate 24, bilateral air entry, clear sounds. SpO2 90% on room air
- Circulation: BP 149/69, irregular rate - 80 bpm
- Disability: GCS 12 (E 4, V 3, M 5) Pupils equal and reacting to light (PEARL). Sluggish eye gaze. Temp 36.9
- Exposure: x2 IVC in Right & Left cubital fossa
- Fluid: IV Compound sodium lactate (Hartman's) at 20 mL /hr TKVO
- Glucose blood level: 9.5mmol/L
- Weight approx. 86kg
Stroke Assessment:
F: Face- Right sided facial droop
A: Arms- Right sided weakness
S: Speech- Aphasia
T: Time of onset 0530hrs, Time of thrombolysis 1130hrs, time of ECR planned at 1300hrs, Door-to-Needle time 150 minutes, Symptom to needle time 390 minutes
Results: A diagnosis of left MCA stroke with totally occluded left Internal Carotid Artery (ICA)
Nursing Interventions:
- Initiate Stroke Pathway
- Keep in resuscitation bay (Triage category 2)
- Connect to continuous cardiac monitoring
- Record a 12 lead Electrocardiograph (ECG)
- Initiate supplemental oxygen if SpO2 < 93%
- Monitor airway patency
- Record Glasgow Coma Scale hourly
- Prepare for endovascular clot retrieval (ECR) to restore blood flow
- Arrange for a Speech Pathology consult
- Maintain head of the bed elevated to 30 degrees
- Insert a nasogastric tube
- Maintain nil by mouth
- Collect requested pathology
- Monitor for haematemesis, melaena and haematuria
Blood tests:
Coagulation profile and cross match (PT, APTT, INR), FBC, LFT, EUC,
Medications:
- Alteplase (IV)
- Heparin 5000iu (IV)
- Labetalol
- Insulin NovoRAPID (SC)