Scenario
Mr. Dover, a 63-year-old man with hypertension, high cholesterol, diet-controlled Type II diabetes, and a 20-pack-year smoking history, arrives at the emergency department after experiencing chest palpitations and lightheadedness. Cardiac monitoring reveals new-onset atrial fibrillation with a rapid ventricular rate of 180 bpm. He receives IV diltiazem and is started on a continuous infusion, which lowers his heart rate to 90–100 bpm, though he remains in atrial fibrillation.
After admission to the telemetry unit, he suddenly develops left-sided gaze deviation, facial droop, slurred speech, and flaccid weakness, representing an acute neurological change. A Code Stroke is initiated. A STAT non-contrast head CT shows no hemorrhage, raising suspicion for an ischemic stroke. With his wife’s consent, alteplase (tPA) is ordered at 0.9 mg/kg, with 10% given as a bolus and the remainder infused over 60 minutes. Before treatment, his vital signs were stable.
Precipitating Factors Contributing to the Ischemic Cerebrovascular Accident
The ischemic Cerebrovascular Accident (CVA) or stroke that struck Mr. Dover was most likely brought on by several contributing circumstances. His type II diabetes mellitus, hypertension, and hypercholesterolemia put him at a higher risk of having a stroke. Furthermore, his smoking habit increased this risk because tobacco use is known to encourage the formation of clots. His newly developed atrial fibrillation, which is characterized by an erratic and rapid heartbeat, may also have contributed to the creation of a clot that reached the brain and culminated in an ischemic stroke.
Inclusion and Exclusion Criteria for Alteplase (tPA) Administration
A diagnosis of ischemic stroke resulting in demonstrable neurological deficit, symptoms present for less than 4.5 hours, and patient age of 18 or older are the inclusion criteria for the administration of tPA. Evidence of cerebral bleeding, seizures at the outset of a stroke, and active internal bleeding are the first three exclusion criteria. Bleeding dysplasia, severe uncontrolled hypertension, and a history of cerebral hemorrhage accompany them.
The next ones are recent surgery or trauma, as well as any symptoms within the last three months that could have pointed to a subarachnoid hemorrhage, a stroke, or a significant head injury. Major surgery or serious trauma during the past 14 days constitutes the last exclusion criterion. Giving tPA was appropriate, given Mr. Dover’s recent onset of symptoms and the CT scan’s lack of bleeding evidence.
Priority Nursing Diagnosis with Supporting Rationale
Impaired verbal communication related to neurological disability, as evidenced by garbled and incomprehensible speech, is the nursing diagnosis for Mr. Dover. Mr. Dover’s failure to respond to straightforward inquiries and his obvious shift in speech style, which point to neurological abnormalities most likely caused by an ischemic stroke, support this diagnosis.
SMART Nursing Outcome for the Identified Diagnosis
A more specific SMART nursing outcome objective would be: within 7 days of initiating the care plan, Mr. Dover will exhibit progressive development in verbal communication. This goal can be reached given Mr. Dover’s current health and the intention to provide stroke-specific therapy.
Evidence-Based Safety-Focused Nursing Interventions for Acute Ischemic Stroke
The first nursing intervention is to prevent aspiration in the case of vomiting, ensuring that the patient is lying on his side. Second, given the motor deficits brought on by stroke, the establishment of a fall prevention protocol, which includes the use of bed alarms, is required to reduce the risk of damage. Third, it is crucial to regularly monitor Mr. Dover’s vital signs to promptly identify any tPA-related side effects or signs of a deteriorating neurological condition. Finally, providing Mr. Dover with straightforward, clear directions is crucial because it encourages the patient’s comprehension and cooperation, reducing frustration and increasing overall safety.
Interprofessional Team Members and Their Roles in Achieving Positive Patient Outcomes
An interprofessional team is an integral aspect of Mr. Dover’s care. A speech-language pathologist will evaluate Mr. Dover’s speech and swallowing abilities and help him improve them by providing tips for safe eating and drinking. This may greatly improve his ability to communicate while lowering his aspiration risk. Mr. Dover will benefit from a physical therapist’s assistance in regaining his strength and mobility, which will improve his overall function and reduce the risk of complications associated with immobility.
Finally, an occupational therapist will collaborate closely with Mr. Dover to retrain him in daily activities, as “stroke education at discharge” is among the most recommended measures to promote independence and ensure safety (Ormseth et al., 2017, p. 100). His recovery from an acute ischemic stroke will be greatly aided by this collaborative approach with numerous healthcare providers, and he will receive a thorough care plan that is tailored to his individual requirements.
Reference
Ormseth, C. H., Sheth, K. N., Saver, J. L., Fonarow, G. C., &Schwamm, L. H. (2017). The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke and Vascular Neurology, 2(2), 94–105.