Assignment task:
J. R. is a 68-year-old Caucasian female. Five years ago, she had surgery (femoral-popliteal bypass) for arteriosclerosis obliterans of her lower extremities. She has a history of smoking ½ to 1 ppd of cigarettes for 50 years. She is mildly obese, weight 140 lbs., height 5' 2". Her adult weight at age 40 was 110 lbs. She has one highball or glass of wine a day. She has been on estrogen for 20 years. Family history: mother had adult-onset Type 2 diabetes and died of cancer at age 62; father died at age 35 from an industrial accident; first sister died of subarachnoid hemorrhage, age 65; second sister, age 60, hemiparetic as a result of CVA; two brothers died of cancer; one brother is hypertensive Type 2 diabetic; three younger sisters are alive and well.
J. R. developed a severe headache 24 hours ago that was not relieved by OTC analgesia. Several hours later, she experienced slurred speech and numbness of the fingers in her right hand, right side of her tongue, and lips. When the numbness and speech did not resolve after 4 hours, she asked her husband to take her to the hospital. She was admitted to the neurological intensive care unit. On admission, she still had a severe right-sided headache and was very anxious. She is oriented x 3 and able to follow commands. Vital signs: Oral temp 37 C, HR 90, Resp 16 non-labored, BP R upper extremity 230/110m L upper extremity 225/120, PERRL, LOC on GSC 15, speech clear, left upper extremity normal grip and no drift; right lower extremity, weaker grip than on left and arm drifts down without hitting bed; lower extremities, equal dorsiflexion and no drift bilaterally, however, client had difficulty performing right heel-shin test. Pin prick tests demonstrated normal sensation on left extremities and dullness on right extremities. Face, asymmetric smile, right facial weakness, cranial nerves all intact, bruit over left carotid, ophthalmoscopic exam, negative for papilledema and anisocoria; extraocular movements intact, no evidence of hemianopsia, negative for ptosis, ophthalmic artery pressure, decreased bilaterally. Reflexes were hyperreflexic on right; Babinski sign positive on right. Lumbar puncture yielded negative result for blood, total cell count, protein, and glucose were normal. EEG showed localized focal activity in the left hemisphere. Chest x-ray revealed a normal chest, no cardiomegaly. ECG was normal. Blood studies showed clotting profiles, CBC, electrolytes, and triglycerides all within normal levels, except for elevated blood glucose at 140 mg/dL. CT scan showed increased density on the left indicating an infarction. Digital angiogram revealed a narrowing of the carotid arteries bilaterally with greater involvement on the left. Evidence of ulcerated plaques in both arteries. Middle cerebral branches indicate narrowing and occlusion on the left.
Medications ordered for immediate IV administration: 250 mg ASA; clopidogrel 600 mg; labetalol 1-2 mg/min by continuous IV infusion; total dose of 300 mg has been used; lorazepam 0.05 mg/kg IM
1. Identify the risk factors that J. R. demonstrates to predispose her to a stroke.
2. Use the NIH stroke scale to assess this client and based on the results and other assessment findings, describe two nursing interventions you will need to implement.
3. Describe the purpose of each of the ordered medications.
4. Why is thrombolytic therapy not ordered by the provider?