NURS7066 - Assessment One: Short Answer Questions related to a Case Study

Assessment One: Short Answer Questions related to a Case Study
The ISBAR Handover:
Introduction: Mrs Mary Fenech is a 78-year-old lady with no known allergies (NKA)
Situation: She arrived in the Emergency Department at 09:30 hrs with slurred speech and right sided weakness since 0530 hrs while at home.
Findings from the CT perfusion assessment using Mean Transit Time (MTT) and Time to Peak (TTP) images showed reduced blood flow in the left middle cerebral artery (MCA) vascular territory extending from the medial cerebellum to the deep white matter at the centrum semiovale above the lateral ventricle. A CT angiogram showed an acute left Internal Carotid Artery (ICA) occlusion. Thrombolysis with Alteplase was administered at 11:30hrs
Background: Atrial Fibrillation (AF), Hypertension (HTN), Type 2 Diabetes Mellitus (IDDM), No head trauma, no prior stroke within the previous 3 months.
Regular medications-
Atenolol 50mg daily, Aspirin 100mg daily, Lipitor 40mg daily, Magnesium 200mg daily, Amlodipine 5mg daily, Perindopril 5mg daily, NovoRAPID insulin
•− Airway: slight inspiratory stridor
•− Breathing: Respiratory rate 24, bilateral air entry, clear sounds. SpO2 90% on room air
•− Circulation: BP 149/69, irregular rate - 80 bpm
•− Disability: GCS 12 (E 4, V 3, M 5) Pupils equal and reacting to light (PEARL). Sluggish eye gaze. Temp 36.9
•− Exposure: x2 IVC in Right & Left cubital fossa
•− Fluid: IV Compound sodium lactate (Hartman’s) at 20 mL /hr TKVO
•− Glucose blood level: 9.5mmol/L
•− Weight approx. 86kg
Stroke Assessment:
F: Face- Right sided facial droop
A: Arms- Right sided weakness
S: Speech- Aphasia
T: Time of onset 0530hrs, Time of thrombolysis 1130hrs, time of ECR planned at 1300hrs, Door-to-Needle time 150 minutes, Symptom to needle time 390 minutes
Results: A diagnosis of left MCA stroke with totally occluded left Internal Carotid Artery (ICA)
Nursing Interventions:
•− Initiate Stroke Pathway
•− Keep in resuscitation bay (Triage category 2)
•− Connect to continuous cardiac monitoring
•− Record a 12 lead Electrocardiograph (ECG)
•− Initiate supplemental oxygen if SpO2 < 93%
•− Monitor airway patency
•− Record Glasgow Coma Scale hourly
•− Prepare for endovascular clot retrieval (ECR) to restore blood flow
•− Arrange for a Speech Pathology consult
•− Maintain head of the bed elevated to 30 degrees
•− Insert a nasogastric tube
•− Maintain nil by mouth
•− Collect requested pathology
•− Monitor for haematemesis, melaena and haematuria
•− Daily weight
Pathology tests:
•− Coagulation profile and cross match (PT, APTT, INR)
•− Full blood count (FBC)
•− Liver function tests (LFTs)
•− Electrolytes, urea, creatinine (EUCs)
•− Blood glucose level (BGL)
•− Alteplase (IV)
•− Heparin 5000iu (IV)
•− Labetalol
•− Insulin NovoRAPID (SC)
Short Answer Question Format:
•− Review the Learning Guide for Assessment Details p. 7-8.
•− Complete your answers for the questions in a Word document.
•− List each question number and then your answer.
•− All answers must relate to the Mrs Mary Fenech case study.
Question 1: (250 words)
Explain the underlying pathophysiology specifically related to the following clinical manifestations:
•Right sided facial droop with right sided weakness in upper and lower limbs
Question 2: (500 words)
•Select 1 Category only, from the 3 categories listed in the table below.
•Provide a rationale for each of the interventions listed for the category that you have selected.
•You must critically analyse the available evidence-based literature to support your rationale. Then, concisely explain your rationales in your own words and citing your evidence as in-text references to support your answers.
Category 1
Non-pharmacological interventions Category 2
Pharmacological interventions Category 3
Reperfusion interventions
• Continuous cardiac monitoring
•12- lead ECG 6th hourly
•Monitoring LOC
•Supplemental oxygen if SpO2<93%
•Monitor for haematemesis, melaena and haematuria•Heparin 5000iu IV
•NovoRAPID sub cut supplemental insulin.
•Pantoprazole IV•Thrombolysis with Alteplase IV
•Endovascular clot retrieval (ECR)
Question 3:
As the registered nurse caring for this patient, you will now prioritise 5 of the highest clinical priority related Nursing Interventions (indicated above). Then, list them in the order that you would attend to each one.
Question 4. (250 words)
Concisely, justify the rationale for each of the following nursing care strategies for Mrs Mary Fenech.
•Maintain Nil by Mouth
•Monitor for haematemesis, melaena and haematuria
•Insertion of a nasogastric tube
•Collaborating with the family
•Health care team collaborations

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