Scenario
N.T., a 79-year-old woman, arrives at the emergency room with expressive aphasia, left facial droop, left sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0600, she stayed in bed, complaining of a mild headache over the right temple and feeling slightly weak. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure (BP) has been well controlled. N.T. is currently taking flecainide (Tambocor), hormone replacement therapy, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). The physician suspects
N.T. has experienced an acute cerebrovascular accident (CVA).
1. What role do diagnostic tests play in evaluating N.T. for a suspected CVA?
2. Explain how knowing the type of CVA is an important factor in planning care.
3. Which factor in N.T.'s history is the most likely contributor to her having experienced a CVA?
Case Study Progress
After a non-contrast CT scan, she is diagnosed with a thrombolytic CVA. The physician writes the orders shown in the chart.
Chart View
Physician's Orders
IV 0.9% NaCl at 75 mL/hr
Activase (tPA) per protocol
Stat CBC, PT/INR, CPK isoenzymes
Neurologic assessment every hour
Obtain patient weight
Vital signs every hour
Oxygen at 2 L per nasal cannula (NC)
NPO until swallowing evaluation
4. Outline a plan of care for implementing these orders.
5. Which interventions can you delegate to the nursing assistive personnel (NAP)? Select all that apply.
a. Obtaining N.T.'s weight
b. Assisting N.T. in repositioning every 2 hours
c. Initiating oxygen therapy by nasal cannula
d. Performing N.T.'s neurologic checks every hour
e. Obtaining a manual BP per protocol
6. What is the purpose of monitoring the CK isoenzyme levels?
6 Neurologic Disorders
7. Complete the National Institutes of Health Stroke Scale (NIHSS) scores for each of N.T.'s symptoms.
Symptom Score
Alert 0
Knows month and age 0
Able to follow commands 0
Extraocular movements (EOMs) intact 0
No visual loss 0
Partial left facial paralysis 2
Left leg no movement 4
Left arm no movement 4
No ataxia 0
Sensation intact 0
Moderate aphasia 1
Neglect of left side 1
8. Based on your scoring, what level of CVA did N.T. experience?
9. The instructions on the tPA vials read to reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. N.T. weighs 143 pounds. What is the
amount of the bolus dose, in both milligrams and milliliters, you will administer in the first minute? What is the amount of the remaining dose that you will need to administer?
10. Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply.
a. Currently on Coumadin with an INR of 2.4
b. Major surgery in the last 14 days
c. Systolic BP of 150
d. Platelet count of less than 100,000
e. Blood glucose of less than 50 mg/dL
f. History of myocardial infarction 1 year ago
g. Improving neurologic status
6 Neurologic Disorders
11. What are your responsibilities during the administration of Activase (tPA)?
12. If N.T.'s deficits are temporary, how long might it take before they completely reverse?
13. During the first 24 hours after receipt of Activase (tPA), the primary concern is controlling N.T.'s:
a. Cardiac rhythm
b. BP
c. Glucose level
d. Oxygen saturation
14. While assessing N.T., you note the following findings. Which one is unrelated to the CVA?
a. Headache
b. Lethargy
c. Lumbar pain
d. Blurred vision
15. Why was N.T. placed on clopidogrel (Plavix) post-CVA?
16. Because N.T. had a thrombolytic infusion, how many hours should you wait before beginning administration of any anticoagulant or antiplatelet medications?
17. Is there any benefit from continuing simvastatin (Zocor) after her CVA?
18. As you walk into the nurses' station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallow study and referral for a speech-language pathologist (SLP). Give the rationale for these orders.