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Ischemic stroke--a case study describing standards of care.

Mr. L., 70-year-old male, presented to the emergency department (ED) via ambulance, accompanied by his brother. Mr. L.'s brother stated that they were eating breakfast together when Mr. L. began to speak incoherently and slur his speech. Mr. L.'s brother explained that the sudden change in his brother prompted him to call 911 immediately. He also noted the time of the incident coincided with the beginning of the television program they were watching.

Mr. L. was verbal, but unable to answer accurately any questions. His speech was slurred, and responses to questions were inappropriate. Mr. L. was unable to verbalize medical history; however, his brother stated that Mr. L. takes "pressure pills" and also a "water pill." Mr. L. was not wearing any medical alert devices.

Mr. L's vital signs were: temperature 99 degrees Fahrenheit (F), pulse 118 beats per minute (BPM), respirations were rapid and shallow at 26 per minute, blood pressure measured 188/116 millimeters of mercury (mmHg), pulse oximeter reading was 88% on room air. An accurate weight of 74.5 kilograms was obtained using the bed scale. Mr. L. had pronounced left-sided facial drooping as well as ptosis of the left eye and significant weakness in his left arm and leg.

Before arrival in the ED, paramedics inserted an 18gauge intravenous (IV) catheter. They also performed a capillary blood glucose in route, which resulted as 100 milligrams per deciliter (mg/dL). Upon arriving in the emergency department, the triage nurse placed Mr. L. on 2 liters per minute (LPM) of oxygen via nasal cannula (N/C) and utilized The National Institutes of Health Stroke Scale (NIHSS) to assess Mr. L. The NIHSS is a standard tool to determine the severity of the stroke and identify a variety of treatment options based on neurological presentation of deficits (National Institutes of Health, 2003). The original NIHSS tool served a 15- item scale; however, four items on the scale were removed to create an 11-item scale. The 11-item scale (see Table I) serves as an effective and efficient assessment measure for utilization by a broad range of practitioners. In addition, increased reliability and validity scores resulted from the use of the 11-item scale as compared to the 15-item scale (Hinkle, 2014). Each category of the 11-item scale was assessed. The resulting NIHSS score was 17.

Using the NIHSS score as a guide, it was determined that the patient had a stroke with moderate to severe impact. Cardiac enzymes were drawn. Within eight minutes of Mr. L's arrival, the nurse completed an electrocardiogram (ECG) and placed a cardiac monitor. The ECG showed sinus tachycardia. The attending provider then ordered a computed tomography (CT) of the head. Mr. L. was transported to CT scan by the nursing supervisor and transporter. After the CT scan, Mr. L. was then transported back to exam room five in the ED, where the nurse continued her assessment. According to the electronic medical record, the patient had a past medical history of Stage II hypertension (HTN), gastroesophageal reflux disease, and lung cancer with metastasis to the spine. He recently finished chemotherapy and radiation treatments. Past surgical history included an appendectomy forty years ago and intraspinal surgery one week ago for removal of lesions. Current medications included esomeprazole 40 mg daily, lisinopril 40 mg daily, hydrochlorothiazide 50 mg daily, and acetaminophenoxycodone 5 mg/325 mg every 6 hours as needed for pain.

The ED physician reported that the results of the CT showed an infarct of the middle cerebral artery (MCA). Active hemorrhage was excluded. Mr. L. was then evaluated for the administration of alteplase (tPA). Due to his recent intraspinal surgery, tPA was contraindicated. Cardiac enzymes were negative. The nurse continued to measure the blood pressure, which did not necessitate intervention at the time. Blood pressure measurements necessitating intervention in this case are systolic > 220 mmHG or mean arterial pressure (MAP) of [greater than or equal to] 130 mmHg (Lewis, Dirksen, Heitkemper, & Bucher, 2013). The nurse inserted a Foley catheter to prevent urinary retention per the orders. Mr. L. was then admitted to the medical-surgical unit with remote telemetry monitoring.

Clinical Decisions

Based on the clinical presentation and CT of the head, acute ischemic stroke versus hemorrhagic stroke was suspected. Mr. L. had no recent history of head trauma, and his coagulation studies were within normal limits. Ruling out hemorrhagic stroke is an integral step in the clinical decision pathway for the care of ischemic stroke. Hemorrhagic stroke occurs when there is a bleed in the brain that compresses the surrounding brain tissue (American Heart Association/American Stroke Association, 2016). Ischemic stroke occurs when there is a disruption in blood flow to the brain due to thrombi or emboli. First line treatment in ischemic stroke is the administration of tPA, a fibrinolytic used to potentially dissolve the clot, thereby restoring blood flow to the affected brain tissue. Once a hemorrhagic stroke is ruled out, medical staff must assess the appropriateness of fibrinolytic therapy through the use of a fibrinolytic checklist. In this case, Mr. L. was unable to undergo tPA administration due to his recent spinal surgery; therefore, he received 300 mg of aspirin (ASA) rectally. ASA is the drug of choice for patients with ischemic stroke who are not candidates for fibrinolytic therapy (ACLS Training Center, 2016; Vallerand & Sanoski, 2014). Remote telemetry is indicated for a minimum of the first 24 hours after recognition of stroke to identify a cardiac arrhythmia that may contribute to the risk of ischemic stroke of a cardiogenic nature.

Upon admission to the medical-surgical unit, Mr. L. received oxygen at 2-4 LPM via N/C with instructions to titrate to keep oxygen saturation greater than or equal to 92%. Ischemic stroke patients often present with hypoxia. Hypoxia has been associated with poor outcomes following acute ischemic stroke (jauch et al" 2013). Labs were drawn including a comprehensive metabolic panel (CMP), complete blood count (CBC) with differential, prothrombin time/partial thromboplastin time (PT/PTT), international normalized ratio (INR), and lipid profile.

The attending ordered a neurology consult in addition to consults for physical therapy (PT) and occupational therapy (OT). Mr. L. remained NPO pending the results of a swallowing study and speech pathology consult to assess for dysphagia. Mr. L. underwent a carotid ultrasound (U/S) to evaluate the patency of the common carotid arteries. Plaques forming in the lumen of the carotid arteries may rupture, leading to emboli that travel to the smaller vessels of the brain, leading to a cerebral vascular event (McCance & Huether, 2014).The patient also underwent Doppler U/S of the bilateral lower extremities to assess for superficial and deep vein thrombosis (DVT) (Lewis et al" 2013). While hospitalized, Mr. L. received 40 mg of subcutaneous enoxaparin sodium daily to prevent DVT and pulmonary embolism (PE). Both DVT and PE are potential complications of immobility associated with stroke (American Association of Neuroscience Nurses [AANN], 2008).The attending provider ordered fluid replacement with IV normal saline solution (NSS) at a rate of 125 mL/hour. Fluid balance should be positive for at least the first 24 hours following acute stroke as dehydration is associated with a less favorable outcome after a cerebral vascular thrombotic event (AANN, 2008).

Immediate Interventions

Upon receiving the patient, the medical-surgical nurse completed an assessment, monitored vital signs and neurological checks every four hours, and completed the NIHSS daily. Vital signs were: temperature 99 degrees F, pulse 130 BPM, respirations 20 per minute, and blood pressure 158/86 mmHg; Glasgow Coma Scale (GCS) was 15, and the NIHSS score was 17. The health care provider allows the patient with an acute ischemic stroke to be slightly hypertensive, systolic blood pressure from 140 to 160 mmHg, to promote cerebral tissue perfusion. Mr. L. maintained bed rest with the head of the bed (HOB) elevated between 25 and 30 degrees to prevent a decreased blood flow to the brain (Ignatavicius & Workman, 2015).

Mr. L's nurse received the results of the previously ordered lab tests.The CBC showed a slight normocytic, normochromic anemia with a hemoglobin of 10.1 g/dL. These results likely reflected an anemia of chronic disease and could be attributed to Mr. L.'s metastatic cancer. The attending ordered a repeat CBC in 8 hours to trend results and rule out occult blood loss.The CMP was remarkable for a serum potassium of 5.3 mmol/L, alkaline phosphatase of 591 IU/L, and estimated glomerular filtration rate of 72 mL/min. Glucose was within normal limits (WNL) at 98 mg/dL. NSS remained as the maintenance IV fluid as there was no need for potassium or glucose replacement. Elevated alkaline phosphatase is a common finding in metastatic cancer patients due to bone destruction. Mr. L.'s glomerular filtration rate classified him as having stage two chronic kidney disease (Leeuwen, Poelhuis-Leth, & Bladh, 2013). The PT/PTT and INR were WNL for the patient. Finally, Mr. L.'s lipid profile showed a total cholesterol of 241 mg/dL with an HDL of 35 mg/dL, triglycerides of 120 mg/dL, and calculated LDL of 182 mg/dL. According to the American College of Cardiology and the American Heart Association (Stone et al., 2013), these results made Mr. L. a candidate for moderate to high-intensity statin therapy. Once Mr. L. resumes oral medications, atorvastatin 40 mg daily will be added.

Ongoing Interventions

Mr. L.'s vital signs were stable 24 hours post admission to the medical-surgical unit: temperature 98.8 degrees F, pulse 88 BPM, respirations 20 per minute, and blood pressure 150/78 mmHg. Remote telemetry monitoring indicated that Mr. L. remained in normal sinus rhythm with no cardiac arrhythmias. Mr. L.'s remote telemetry monitor was discontinued. Neurological checks continued every four hours, revealing Mr. L. was alert and oriented to person, place, time, and event with a GCS score of 15. Mr. L. recognized that he was hospitalized due to stroke. He responded to commands as well as yes and no questions. His speech remained slurred, but appropriate. Significant weakness remained on the left side. The NIHSS score was 11. Results of the carotid U/S showed 60% narrowing of the left carotid artery and 40% narrowing of the right carotid artery. These findings were consistent with the patient's presentation of an ischemic stroke. Upon discharge, the patient will need to meet with a vascular surgeon for possible treatment. The Doppler U/S was negative for any SVTs or DVTs. Repeat lab work showed Mr. L. now had a potassium level of 4.5 mmol/L and a hemoglobin of 10.0 g/dl. The previously elevated potassium level was likely related to dehydration, and the stable hemoglobin ruled out any bleeding concerns (Leeuwen et al., 2013).

Following the results of the swallowing study, Mr. L. was advanced to crushed medications with apple sauce. Mr. L.'s daily home medications were resumed as well as metoprolol tartrate 25 mg daily, atorvastatin 40 mg daily, and chewable ASA 325 mg daily. Mr. L. was scheduled for a swallowing evaluation of a mechanical soft diet and honey-thickened liquids. Mr. L's diet orders were determined pending this observation. Nursing staff assisted Mr. L. with meals and carefully monitored his intake and output. The Foley catheter and IV fluids were discontinued. Nursing staff assisted Mr. L. with the bedside urinal while calculating urine output every shift.

Oxygen therapy was titrated downward to maintain at least 92% oxygen saturation. Mr. L. remained on 2 LPM of oxygen via N/C with regular pulse oximetry spot checks, showing his oxygen saturation to be between 92-94%. The nurse assisted Mr. L. with incentive spirometry every hour during his bed rest to enhance pulmonary function.

PT's initial assessment recommended range of motion exercises. Mr. L. completed physical therapy exercises daily with a trained physical therapist. Mr. L. participated in active range of motion on his right side to maintain strength and ability. Passive range of motion was completed on his left side at the bedside with assistance every shift. An assessment by OT was completed, and the therapist began working with Mr. L. to resume autonomy in activities of daily living.

A social service consult was completed to help transition Mr. L. to a rehabilitation facility and eventual home planning. The attending physician also made a courtesy consult for Mr. L's oncologist.

Summary

Four days post admission, Mr. L. was discharged to a local rehabilitation facility on his previous home medications with the addition of enoxaparin sodium and warfarin sodium. The patient remained on enoxaparin sodium until his INR was within the therapeutic range of 2.0 to 3.0 (Leeuwen et al., 2013). Before transfer to the rehabilitation facility, Mr. L.'s neurologist, oncologist, and social worker met with Mr. L. and his brother to discuss Mr. L's prognosis. Because only the left side of Mr. L's body was impacted by the stroke, there was a good chance that Mr. L. would gain some function back in his left arm and leg, and his speech and swallowing abilities would likely continue to improve (American Heart Association/American Stroke Association, 2016; Lewis et al., 2013). PT, OT, speech therapy, and palliative care services continued to help Mr. L. regain the highest level of function possible. In this case, aggressive treatment was not pursued due to Mr. L's terminal cancer diagnosis. Due to quick recognition of stroke symptoms by his brother, Mr. L. had a good prognosis to continue his life with the highest quality of function.

References

ACLS Training Center. (2016, September 22). ACLS suspected stroke algorithm. Retrieved September 26, 2016, from https://www.acls.net/acls-suspected-stroke-algorithm.htm

American Association of Neuroscience Nurses (AANN). (2008). Guide to the care of the hospitalized patient with ischemic stroke (2nd ed.). Glenview, IL: Author.

American Heart Association/American Stroke Association. (2016). Types of stroke. Retrieved September 26,2016, from www.strokeassociation.org

Hinkle, J.L. (2014). Reliability and validity of the National Institutes of Health Stroke Scale for neuroscience nurses. Stroke, 45(3), e32-e34.

Ignatavicius, D.D., & Workman, M.L. (2015). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). St. Louis, MO: Elsevier Saunders.

Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J., Demaerschalk, B.,... Yonas, H. (2013). Early management of acute ischemic stroke. Stroke, 44, 870-947. doi: 10.1161/STR.0b013e318284056a

Leeuwen. A., Poelhuis-Leth, Q, & Bladh, M.L. (2013). Davis's comprehensive handbook of laboratory diagnostic tests with nursing implications (5th ed.). Philadelphia: F.A. Davis Company.

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2013). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). St. Louis, MO: Elsevier Mosby.

Massaro, L.M. (2012). Managing acute stroke and preventing secondary stroke. ADVANCE for NPs & PAs, 3(6), 16-22.

McCance, K., & Huether, S. (2014). Pathophysiology:The biological basis for disease in adults and children (7th ed.). St. Louis, MO: Elsevier Mosby.

National Institutes of Health (NIH). (2003). National Institutes of Health Stroke Scale (NIHSS). Retrieved from http://www.ninds.nih.gov/doctors/nih_stroke_scale.pdf

Stone, N.J., Robinson, J., Lichtenstein, A.H., Bairey Merz, C.N., Blum, C.B., Eckel, R.H., ...Wilson, PW.F. (2013). ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129, SI-S45.

Vallerand, A.H., & Sanoski, C.A. (2014). Davis's drug guide for nurses (14th ed.). Philadelphia: FA Davis Company

Michael M. Evans, PhD, MSEd, RN.ACNS, CMSRN, CNE, is Assistant Chief Academic Officer and Instructor of Nursing, Penn State University Worthington Scranton Campus, Dunmore, PA. He is a member of the MedSurg Matters! Editorial Committee.

Melissa B. Miner, MSN, RN, CNE, is Senior Instructor and Campus Coordinator for Nursing, Penn State Fayette,The Eberly Campus, Lemont Furnace, PA.

Gina Harrison, ASN, RN, is an RN - BS Student, Penn State University Worthington Scranton Campus, Dunmore, PA, and a Health Related Technology Instructor, West Side Career and Technology Center, Kingston, PA.

Justina M. Ferguson, MSN, RN, is an Instructor of Nursing and DNP Student, Penn State University Worthington Scranton Campus, Dunmore, PA, and a Nursing Supervisor, Moses Taylor Hospital, Scranton, PA.

Allison Miller, BSN, RN, is a Staff Nurse, Moses Taylor Hospital, Scranton, PA.

Allyson Favuzza, MSN, CRNP, FNP-C, is a DNP Student, Penn State University, Jonas Nurse Leaders Scholar, 2016-2018 Cohort, Family Nurse Practitioner/Director of Youth Services/CRNR The Wright Center for Primary Care, Scranton, PA.
Table 1.
Condensed National Institutes of Health Stroke
Scale (NIHSS)

NIHSS Item                           Scoring

1 a. Level of Consciousness (LOC)    0-3

1 b. LOC Questions                   0-2

Ic. LOC Commands                     0-2

2. Best Gaze                         0-2

3. Visual                            0-3

4. Facial Palsy                      0-3

5. Motor Arm and Leg                 0-4

a. Right Arm                         *9 Amputation, joint fusion;

b. Left Arm                          explain:

6. Motor Arm and Leg                 0-4

a. Left Leg                          *9 Amputation, joint fusion;
b. Right Leg                         explain:

                                     0-2
                                     Measure for right arm, left arm,
7. Limb Ataxia                       right leg, left leg
                                     *9 Amputation, joint fusion;
                                     explain:

8. Sensory                           0-2

9. Best Language                     0-3
                                     0-2
10. Dysarthria                       *9 Intubated or other physical
                                     barrier; explain:

11. Extinction and Inattention       0-2
(formerly Neglect)

Source: Adapted from NIH, 2003.
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Author:Evans, Michael M.; Miner, Melissa B.; Harrison, Gina; Ferguson, Justina M.; Miller, Allison; Favuzza
Publication:MedSurg Nursing
Date:Sep 1, 2016
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