Case Study: Mr. Maisy - Stroke and Nursing Interventions
1) A patient who does not open her eyes when you ask her to do so has an alteration of:
2) Which of these cranial nerves controls movements of the eyes?
- CN CNIX
- CN VII
- CN II
- CN III
3) Alterations in the autonomic cardiovascular functions can be present after damage to the:
- Brain stem
- Spinal cord
- Cerebral cortex
4) Spinal transection at the level of T4 will cause:
- Areflexia below the injury
5) An embolic stroke is caused by:
- A cerebral capillary that spasms and stops blood flow to a brain region
- A cerebral artery that bursts due to hypertension
- A ruptured atherosclerotic plaque in a cerebral artery that forms a blood clot
- A blood clot formed in the heart that travels to and blocks a cerebral artery
6) Which answer best describes cerebral perfusion pressure?
- The difference between the mean arterial pressure and intracranial pressure
- The difference between the mean arterial pressure and systolic blood pressure
- The difference between the intracranial pressure and systolic blood pressure
- The difference between the systolic and diastolic blood pressure
7) What are the clinical signs of Cushing’s Triad?
- Elevated BP, Pulse, and Pulse Pressure
- Increased Systolic BP, Bradycardia, and Wide Pulse Pressure
- Elevated BP, low Pulse Pressure, and Tachycardia
- Increased in Systolic BP, low Pulse Pressure, and Tachycardia
8) Which of the following is NOT an example of central stimulation?
- Sternal rub
- Supraorbital pressure
- Trapezius pinch
- Nail bed pressure
9) Recognition of early stroke symptoms is vital to improving patient outcomes, what does the
F.A.S.T acronym stand for?
- Fast, access to hospital care, speedy presentation and time to assess
- Facial nerve, accessory nerve, sensory responses and tone (motor responses)
- Face, articulation of speech, sensory, tone
- Face, arm, speech, time
10) If an individual presented with difficulty in finding the right word and putting words together to make meaning, they would be experiencing what type of dysphasia.
- Wernicke’s receptive dysphasia
- Broca’s expressive dysphasia
- Broca’s receptive dysphasia
- Wernicke’s expressive dysphasia
A 45 year-old male Mr Maisy was cooking in the kitchen when he collapsed onto the floor, shortly after vomiting. His daughter called an ambulance and was taken to the emergency room. Mr Maisy had a long history of elevated blood pressure, atrial fibrillation and type two diabetes, he was a smoker when he was younger and his father died of a stroke.
His admission observations were as following:
- Blood pressure: 160/80
- Pulse: 72 (irregular)
- Respirations: 22
- Temperature: 8oC
- Glasgow Coma Scale: 7 (eyes 1, verbal 2, motor, 4)
- Pupils equal and reacting
Mr Maisy was admitted and was found to have suffered a transient ischaemic attack affecting the brainstem. He slowly regained consciousness over the next 24 hour, kept in observation for another 48h, after which he was discharged.
Two weeks later Mr Maisy woke up, with the following signs and symptoms: Right sided arm and facial weakness and well as difficulty understanding what is being said to him. Mr Maisy is also unable to answer questions or obey commands, presenting with severe aphasia and his attempts at speech are nearly unintelligible. He has near total paralysis of the lower part of his face on the right side and his right arm is ataxic yet he is able to exert some effort against gravity. Mr Maisy has no sensory loss and normal motor function impairment of his leg.
His admission observations this time were:
- Blood pressure: 180/70
- Pulse: 96 (irregular)
- Respirations: 20
- Temperature: 6oC
- Glasgow Coma Scale: 11 (eyes 4, verbal 2, motor, 5)
1. Mr Maisy first suffered a transient ischaemic attack affecting his brainstem. Describe what a transient ischaemic attack is, and for the signs and symptoms that could be related to dysfunction of the brainstem, explain how they developed.
2. Based on Mr Maisy’s presenting symptoms while suffering the transient ischaemic attack, list and justify FIVE important nursing interventions that a registered nurse would implement for Mr Maisy besides medications.
Case Study: Miss Baily - Stoma Complications and Nursing Interventions
3. Outline FIVE possible risk factors for stroke that Mr Maisy has presented with and describe at least ONE nursing intervention for each risk factor
11) A patient with ulcerative colitis may have problems in the digestion of:
- Nothing, no digestion problems
12) An essential criterion in the diagnosis of metabolic syndrome in women is:
- BMI > 30kg/m2
- Waist circumference > 80cm
- TC/HDL> 4
- TG >2mmol/L
13) Steatorrhoea is most commonly a symptom of:
- Both cholelithiasis and pancreatitis
- Neither pancreatitis nor cholelithiasis
14) Prolonged vomiting may lead to:
- Perforation and peritonitis
- Hypovolaemic shock
- Electrolyte imbalance and alkalosis
- Electrolyte imbalance and dehydration
15) Stimulant laxatives such as castor oil are used to treat constipation because they:
- Increase the volume of non-absorbable liquid
- Increase the water content of the faeces
- Increase motility and secretion
- Alter the consistency of the faeces
16) When should Nutrition screening occur?
- On admission and then weekly during the patient’s episode of care
- At least monthly in slower stream facilities
- If the patient’s clinical condition
- All of the above
17) A patient presents with pale conjunctiva and blue sclerae; identify the possible nutritional deficiency.
- Iron deficiency
- Vitamin K deficiency
- Potassium deficiency
- Protein deficiency
18) A Body Mass Index of 32 is generally considered to be:
- Morbidly obese
19) Following the insertion of a nasogastric tube, what is the most reliable method to ensure it is in the correct position.
- Aspirate some gastric contents, inspecting it and checking the pH
- Aspirate some gastric contents, checking the pH
- X-ray (except when unavailable or contraindicated)
- Visual inspection of the length
20) Prior to the insertion of a nasogastric tube which of the following correctly describes the method for ascertaining the length of tube to be inserted
- Tip of the nose to the top tip of the ear to the xyphoid process
- Tip of the nose to the stomach
- Tip of the nose to ear lobe to stomach
- Tip of the nose to ear lobe to xyphoid process
Miss Baily is a 24 year-old admitted to hospital six weeks ago following a motor vehicle accident. She presents with a fluctuating level of consciousness and is requiring supplementary feeding via a nasogastric tube.
Yesterday Miss Baily began vomiting undigested nasogastric feed and on further review, it is noted that Miss Baily documentation indicates increasing restlessness suggesting pain, and that she has not had her bowels open for six days. Her observations were as following:
- Blood pressure: 130/60
- Pulse: 108
- Respirations: 26
- Temperature: 2oC
Two days later and despite medical interventions, Miss Baily’s symptoms have not improved and it was decided that she would require surgery. During surgery, a section of Miss Baily’s intestine was removed and an ileostomy was required. You will be caring for Miss baily 6 days post-surgery. When you arrive to meet Miss Bailey, you note that she is distressed, her observations are:
- Blood pressure: 105/55
- Pulse: 102
- Respirations: 28
- Temperature: 6oC
When you review her fluid balance chart, you note that the output of her ostomy has been 1.8 litres in the last 24 hours. Her fluid balance chart from yesterday notes that her stoma output was similar and her fluid balance was 3 litres negative.
4. Explain why Ms Baily vomited undigested nasogastric feed and was in pain. In your answer, explain the pathophysiological reasons and likely sequence of events leading to that presentation.
5. The output from Ms Baily’s ostomy has been 1.8L in the last two days. Explain whether this volume is normal or should have been a cause for concern for the nurses the day before.
6. Could the 1.8 litre output through the ostomy be related to Ms Baily’s drop in blood pressure? Briefly explain how.
7. Based on Miss Baily’s presenting symptoms outlined in part one, list and justify five important nursing interventions that a registered nurse would implement for Miss Baily’s besides medications based on her presentation and justify your answer.
8. List and describe five potential complications that could arise related to Miss Bailey’s stoma.
21) Long-term bed-ridden patients are at risk of osteoporosis because in these patients:
- the osteoblasts are not as efficient and there is less growth hormone
- the osteoclasts are no longer inhibited by oestrogen and destroy the bone more actively
- there is reduced weight-bearing stimulation of bone formation
- None of the above
22) During lower limb compartment syndrome, a cold foot is due to:
- Compression of a vessel
- Compression of an undamaged muscle
- Compression of the fascia
- Compression of a nerve
23) A patient with a femur that is separated from the tibia has a:
24) An example of congenital alteration of a joint is:
- Gouty arthritis
- Club foot
- Septic arthritis
25) The primary treatment for Myaesthaenia Gravis is:
- Nothing, it cannot be
26) When performing a neurovascular assessment of lower limb circulation, which two pulses in the require palpation?
- Dorsalis pedis and posterior tibialis
- Dorsalis pedis and popliteal
- Posterior tibialis and popliteal
- Popliteal and femoral
27) The surgical treatment for compartment syndrome is:
28) Capillary refill is an indication of:
- Oedema of the extremities
- Skin temperature
- Peripheral circulation
29) The main rationale for checking paraesthesia during a neurovascular assessment is to assess for:
- Decreased circulation
- Nerve compression or damage
- Malalignment of bones
30) Which of the following best summarises the non-modifiable and modifiable risk factors of osteoporosis?
- Female sex, age greater than 55, history of late menopause, high calcium intake, sedentary lifestyle, smoking, reduced vitamin D
- Female sex, age less than 55, history of early menopause, low calcium intake, sedentary lifestyle, smoking, reduced vitamin D
- Female sex, age greater than 55, history of early menopause, high calcium intake, sedentary lifestyle, smoking, increased vitamin D
- Female sex, age greater than 55, history of early menopause, low calcium intake, sedentary lifestyle, smoking, reduced vitamin D
Mrs Kelly Doug is a 57 year-old female who has fallen in the community whilst hanging out washing. On her arrival to hospital, she is complaining of upper arm pain and leg pain on the same side that she fell; x-rays confirm a humerus shaft fracture and osteoporotic changes in her femur. Mrs Doug was previously in good health despite leading a relatively sedentary lifestyle and having a 30-pack-day smoking history that spans years. The only medications that she takes are for her hypertension and hormone replacement therapy. Her observations are as follows:
- Blood pressure: 140/70
- Pulse: 88
- Respirations: 24
- Temperature: 8
- Pain Score: 6/10
Two weeks after her fall you will be caring for Mrs Doug, who has returned from surgery earlier in the day where she had her fracture realigned and a new plaster cast applied. Mrs Doug is asking for additional pain relief stating that she is experiencing considerable pain. Her observations are the following:
- Blood pressure: 130/60
- Pulse: 110
- Respirations: 26
- Temperature: 4
- Pain Score: 10/10 (despite only recently receiving pain relief)
9. Name and describe the condition affecting Ms Doug when you care for her after surgery. In your answer, explain the pathophysiological reasons and likely sequence of events leading to her experiencing considerable pain despite receiving pain relief.
10. Outline five possible risk factors for fractures that Mrs Doug has presented with and describe at least one nursing intervention for each risk factor.
11. Refer to the case of Mrs Doug and identify five aspects of a neurovascular assessment that would be vital to undertake, providing a rationale for each assessment.
Case Study: Mr. Maisy - Stroke and Nursing Interventions
1: B (consciousness)
2: D (CNIII)
3: B (spinal cord)
4: A (Paraplegia)
5 : D (A blood clot formed in the heart that travels to and blocks a cerebral artery)
6: A (The difference between the mean arterial pressure and intracranial pressure)
7: B (Increased Systolic BP, Bradycardia, and Wide Pulse Pressure)
8: D (Nail bed pressure)
9: D (Face, arm, speech, time)
10 : A (Wernicke’s receptive dysphasia)
1; A transient ischemic attack (TIA) is like a stroke and produces similar symptoms. However, it only lasts for about a few minutes and produces no permanent damage. These usually serve as warning situations of underlying deep rooted anomalies which need immediate medical attention. In TIA there is temporary blockage of blood supply to the brain resulting in a situation such as stroke. The plaguing of the arteries supplying blood to the brain with cholesterol containing fatty acids can contribute to the development of TIA. The TIA could be characterized by the presence of a number of condition such as –
- Numbness or weakness of the face, arms or legs
- Severe headache
- Loss of balance or coordination
The clot develops in the blood vessel supplying the brainstem cutting the normal flow of blood. A clot in the brainstem can impair several important functions of the body such as swallowing, breathing, speech, hearting and eye movements. It is also the centre for balance and coordination. Therefore, damage to the brainstem can be life threatening condition resulting drooping face in one direction, partial or transient loss of body movements etc. It can also lead to a condition known as locked in syndrome where the entire body excepting the eye muscles are paralysed. Here, the patient Mr. Maisy depicted unintelligible speech, weakness of face and right ataxic arm.
- Assessment of the decreased cerebral perfusion leading to loss of consciousness, this will help in discovering the extent of the neurological deficit and will determine and influence the interventions to follow.
- Assessing and monitoring neurological functions frequently and elevating HOB at nights. Assessment of the trends in the level of consciousness will help in discovering potential for increased ICP and will help in determining the extent and progression of damage. The elevation will aid in increasing the gravitational blood flow.
- Improving the consciousness of the patient to resist further cerebral perfusion, persistent cerebral perfusion will lead to facilitate the paralysis and enhance the possibility of whole body paralysis.
- Assisting in self care activities and changing lying position every two hours, this will prevent the extent of fatigue and will help in avoiding overexertion. it will help in preventing blood stasis and will therefore avoid the occurrence of pressure ulcer
- Provide comfort measure and non-pharmacological interventions for pain and assisting the patient in the measures. Activity intolerance and resultant pain is very common due to neurovascular impairments. The comforting measures will help in relieving the patient from the discomfort and pain.
- Elevated blood pressure: As the blood pressure of the patient had ranged between 160/80 to 180/70 in the facility, it is a very important risk factor for stroke. As an intervention, that will be needed to be administered antihypertensive medications such as calcium channel blockers and ACE inhibitors to reduce the blood pressure to ward off the risk of stroke in the future.
- Smoking: As prolonged smoking can damage the blood vessels and lead to arterial blockages it is a grave risk factor for stroke. The intervention for the patient will be to educate him on the consequences of smoking on his health, especially the cardiac healthy and the possibility of stroke.
- Type 2 diabetes: As having prolonged type two diabetes doubles the risk of stroke the patient will need to maintain a strict diet and will have to reduce body weight to avoid further risk of arteriosclerosis.
- Arterial fibrillation: Arterial fibrillation leads to frequent blood clot formation in the arteries enhancing the risk of stroke. The intervention will be educating the patient to do deep breathing exercises, blood circulation improving physiotherapy, and follow a strict low cholesterol diet.
- Genetic predisposition: As the patient had his father die of stroke, his chances of developing arterial diseases are very high. The intervention in this case will be to educate the patient the importance of regular checkups and using cardiac health resources like the stroke foundation.
11. C) Lipids
12. B) waist circumference > 80 cm
13. C) Pancreatitis
14.D) Electrolyte imbalance and dehydration
15 . C) increasing the motility and secretion
16.D) All of the above
17. A) iron deficiency
18. B) obese
19. C) X-Ray
20. A) tip of the nose to the top tip of the ear to the xyphoid process
4. In this context, the patient was found vomiting undigested content and was in pain. on further inspection the patient was suggested ileostomy. In ilesotomy an opening is made surgically in the abdominal wall. The surgeon passes the ileum through the opening and stitches it into place. The ileostomy needs to be performed in the patient’s case as she was suffering from improper colon function and unable to pass faeces. This could be further attributed to injuries or accidents that involve the intestines.
Case Study: Miss Baily - Stoma Complications and Nursing Interventions
5. Mrs. Baily had an output of ostomy equivalent to 1. 8 litres in the last two days. This should have been a serious cause of concern for the nurses attending the patient as the normal urine output should have been within the range of 4 -8 litres. The low urine input could be a signal that there is less s water absorption from the digestive content as the patient is unable to hold food within the ileum pouches.The patient depicted same stoma output since the last two days which signified that the body of the patient had become toxic due to the accumulation of the nitrogenous waste.
6. The less output though the ostomy could be related to drop in blood pressure, as the patient is not able to absorb sufficient water from the food through the intestinal wall , it results in situation of drop in the orthostatic pressure of the patient.
The plasma solute concentrations have been responsible for maintaining effective blood pressure. These are again absorbed in the blood through the food. However, since the ileum is unable to hold the food after the injury, the patient is unable to retain or absorb the required amount of nutrients affecting the orthostatic pressure.
7. Therefore, based upon the present conditions depicted by the patient a number of nursing interventions could be suggested for the patient such as
- Non-pharamacological pain management where the patient could be counselled with behavioural modifications to change her attitude towards her present health condition which could reduce the anxiety and the panic associated with pain and make the patient more resilient.
- Monitoring of the blood pressure of the patient on a regular basis which could help in monitoring the anomalies in the orthostatic pressure maintenance which is related to plasma solute concentration
- Assessment of the urine output in the patient along with faecal output which will help in understanding the normal body functioning of the patient
- The patient should not be made to remain in a lying down position as it may affect the normal bowel movement within the patient
- Monitoring the body temperature of the patient which will signify any other anomalies present within the body of the patient.
8. The number of complications that could arise to Miss Bailey’s stoma are:-
- necrosis due to tissue death or injury in the region
- The stoma complications could further result in a prolapsed stage by increasing the chances of bacterial and viral infections in the region manifold times
- It could lead to parastomal hernias , which are incisional hernias in the area of the abdominal musculature that was incised to bring the intestine though the abdominal wall to from the stoma
- It could lead to edema in the long run which often become the site of secondary infections
- Additioinally, the necrosis of the tissues in the adjacent areas adjacent to the colon may enhance the fungal and pathogen activity leading to the development of conditions such as urine continence within the patient.
21: A (there is reduced weight-bearing stimulation of bone formation)
22: C (Compression of the fascia)
23 : B (Dislocation)
24: B (Gouty arthritis)
25: A (Anticholinesterase)
26: A (Dorsalis pedis and posterior tibialis)
27: C (Fasciotomy)
28: D (Peripheral circulation)
29: D (Oedema)
30: D (Female sex, age greater than 55, history of early menopause, low calcium intake, sedentary lifestyle, smoking, reduced vitamin D levels)
9. As the patient has had a surgery previously and also had a fracture realignment done for the patient, the chances of the patient suffering from a compartment syndrome is very high. Along with that the pain score of the patient had been 10/10 and she had been slightly febrile and with extremely low blood pressure which can be due to circulatory resistance. Hence, it can be deduced that the post operative complications that the patient had been suffering from had been post surgical acute compartment syndrome
Despite the fact the patient had been given the pain medication, compartment syndrome can easily lead to acute pain. The most plausible pathophysiology of the patient acquiring the compartment syndrome is the acute pressure produced by the fracture realignment which must have led to fascial oedema. the increased pressure due to the fracture within a limited space can compromise the circulation and function of the tissues within, resulting in tissue ischaemia, necrosis and nerve damage, which in turn leads to acute limb compartment syndrome. Hence the patient had been feeling acute pain even after being administered pain medication due to her progressing compartment syndrome.
10. Age: As the over the age of 50 the risk of compartment syndrome and related complications are considerably higher. The age being 57 is a serious risk factor for the patient. The intervention will be to refer the patient to occupational therapist and physiotherapist for exercises port fascioctomy.
Gender: Females are at a greater risk of developing this condition, especially after a certain age and hence the patient will be further encouraged for regular check-ups as an intervention to avoid risk of further complications.
Smoking: As smoking enhances the risk of acute limb compartment syndrome to some extent as well, the intervention will be to educate and encourage the patient to cease smoking.
Sedentary lifestyle: The immobility is another great risk factor for gaining acute limb compartment syndrome. The intervention will be encourage her for mild exercises throughout the day
Fracture realignment: The realignment increased the chances of compartment syndrome due to fascial pressure. Intervention will be to assessment and medication administration.
11: Pallor: as it is a good indicator of extremity being perfuse this assessment will be performed first.
Pain: It is an indicator of impending compartment syndrome by its unique pain sensation, hence, it will be performed.
Palpation: dorsal and peripheral surfaces are very important sensation for parasthesia assessment for the compartment syndrome; hence, it will be performed next.
Radial nerve sensation parasthesia: radial, median and ulna nerve sensations will help in better assessment of compartment syndrome by the unique and quick diagnosis.
Pulse: as the pulse in the extremity will indicate whether the arterial bed is intact or not, it will be the final assessment for compartment syndrome.