Question

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 mild headache over the right temple and feeling slightly weak. He went and get 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 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).

Question: 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 below:

Physician's orders: IV 0.9% NACI at 75 ml/hr; Activase (tPA) per protocol; Stat CBC, PT/INR, CPK isoenzymes; Neurologic assessment every hour; Obtain patiet weight; Vital signs every hour; Oxygen at 2 L per nasal cannula(NC); NPO until swallowing evaluation

Question: Outline a plan of care for implementing these orders

The instruction on 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 ver 1 minutes. N.T. weighs 143 pounds.

Question: What is the amount of the bolus dose, in both milligram and mililitres, you will administer in the first minute? What is the amount of the remaining dose that you will need to administer?

N.T is admitted to the neurology unit. A second CT scan (18 hours later reveal a small CVA in the right hemisphere. She is placed on flecainide (Tambocor), Amlodipine (Norvasc, clopidogrel (plavix), Aspirin , simvastatin ( Zocor) and Lisinopril (Zestril)

Question: If N.T"s deficits are temporary, how long might it take before completely reverse?

Question: Why was N.T placed on clopidogel (Plavix) post- CVA?

Is there any benefit from the continuing simvastatin (Zocor) after her CVA ?

Question: As you walk into the nurses' station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallowing study and refferal for speech -language pathologist.(SLP) GIve the rationale for these order?

Answer 1

Question:

The main contributing factor for cerebrovascular accident for N.T are high blood pressure and hyperlipidemia

Question:

Plan of care:

*Monitor vital signs every hour to manage ICP

*Assess weight of the patient to obtain the base line data

*Assess the neurological status every hour

*Sent the blood investigations such as CBC,PT/INR,CPK and isoenzymes

*Administer oxygen 2L through nasal cannula

*Start IV 0.9% NACL at 75ml/hr

*Administer Activase or tPA as per protocol

*Maintain the patient for NPO until the swallowing evaluation

Question:

Amount of bolus dose,ie 10% of the total dose,Here the total dose is 58mg

that means 10% of total dose is 6mg

here 1mg=1ml,therefore 6mg = 6ml,

Then we can say that amount of bolus dose in mg and ml is 6 will administer in the first minute

The remaining dose for tPA is 52 mg

Question:

If N.T's deficit are temporary with in the 3 hr we are initiating the treatment such as tPA to stop forming clots to improves the physical outcome with reducing permanent disability.Mostly the mild deficits usually recover between 6 months to 1 year

Question:

The C.T scan of N.T reveals a small CVA in the right hemisphere to prevent recurrent attack of stroke by py preventing platelet aggregation or further formation of clots she is placed on Plavix

Simvastin is a drug in the group of statins that stabilize the endothelial wall and prevent plaque ruptures

Question :

When N.T arrives at the emrgency room with mild dysphagia.The physician has ordered for a modified barium swallow study to diagnose the dysphagia and the Seech language pathologist role is to give recommendations for safer position while eating,type of food,its consistency and texture to prevent aspiration.