Learning Objectives
By the end of this section, you will be able to:
- Examine the clinical decisions based on patient needs in the case study
- Recognize steps in application of patient care in the case study
- Identify patient care outcomes in the case study
Unfolding Case Study
Nursing Care of a Patient Who Fell
Part 1
Mrs. Jackson, a 68-year-old female patient, presents to the emergency department after experiencing a fall at home. Her daughter witnessed the fall and brought Mrs. Jackson to the hospital saying, “My mom has been acting really confused after falling. I’m scared she might have a concussion.”
| Past Medical History | Medical History: Hypertension, atrial fibrillation, type 2 diabetes. Family History: Married for 45 years, 3 grown children. Mother deceased from Alzheimer’s. Father alive, with hypertension and prostate cancer, currently undergoing treatment. Social History: Former ½ pack/day smoker, quit 15 years ago. Allergies: No known drug allergies Current Medications:
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| Assessment | Time: 1200 General Survey: Patient appears anxious and confused. She is repeatedly asking, “Where am I? Why am I here?” Neurological: Alert and oriented x1, slurred speech, decreased sensation on right side of body. HEENT: Slight right facial droop. Respiratory: Clear lung sounds, normal breathing pattern. Cardiovascular: Rapid, thready pulse, capillary refill <2 seconds, warm extremities. Abdominal: Bowel sounds normoactive in all 4 quadrants, no tenderness. Musculoskeletal: muscle strength of right upper and right lower extremities, 2/5; left upper and lower extremities, 5/5 Integumentary: Skin pale but dry and intact. |
| Nursing Notes | Time: 1210 During assessment, signs/symptoms of stroke were noted. Code stroke paged overhead at 1208. Per protocol, patient transported for STAT CT scan. History obtained from daughter, who reports the time the patient was last seen normal was 1045. |
| Flow Chart | Time: 1215 pm Blood pressure: 148/79 mmHg Heart rate: 112 beats/minute Respiratory rate: 29 breaths/minute Temperature: 99.6 °F (37.5°C) Oxygen saturation: 92% on room air Pain: 4/10 Weight/BSA: 144lbs |
| Provider’s Orders | Time: 1230 STAT CT scan STAT labs including point-of-care glucose, CBC, BMP, INR, PTT, HA1C, 12-lead ECG NPO order (swallow screen prior to any PO) Admit to neuro floor for observation Q15 minute neuro checks x 4 hours, then Q 1 hour Continuous telemetry monitoring Fasting lipid panel at 0600 tomorrow MRI with contrast |
| Test Results | Time: 1240 Noncontrast CT scan confirms acute ischemic infarction involving the left middle cerebral artery, no evidence of hemorrhage. Glucose 125 mg/dL INR 2.3 |
| Nursing Notes | Time: 1245 Patient is within the time-appropriate time window for tPA, but history of anticoagulant use and INR >2 is a contraindication, per stroke protocol. Q15 minute neuro checks being completed. 12-lead ECG shows atrial fibrillation, provider notified. Patient made NPO and family updated on plan of care. |
Part 2
Mrs. Jackson has been on the neuro unit for two days and is now showing a slight improvement in symptoms. The family has requested to meet with the unit’s social worker to discuss rehabilitation options.
| Assessment | Time: 0800 General Survey: Patient is calm and pleasant. States, “I feel ready to go home.” Neurological: Alert and oriented x4, some intermittent slurred speech. Sensation improved. HEENT: Slight right facial droop. Respiratory: Clear lung sounds, normal breathing pattern. Cardiovascular: Strong pulse, normal sinus rhythm on the monitor, capillary refill <2 seconds, warm extremities. Abdominal: Bowel sounds normoactive in all 4 quadrants, no tenderness. Musculoskeletal: 4/5 muscle strength of right arm and right leg, left arm and left leg 5/5 Integumentary: Skin pale but dry and intact. |
| Flow Chart | Time: 0830 am Blood pressure: 138/82 mmHg Heart rate: 98 beats/minute Respiratory rate: 22 breaths/minute Temperature: 99.6 °F (37.5°C) Oxygen saturation: 98% on room air Pain: 2/10 |
| Provider’s Orders | Time: 0900 Start clopidogrel, loading dose of 300 mg today, 75 mg daily starting tomorrow, to take for 90 days Physical therapy consult Occupational therapy consult Bedside swallow study before PO (including meds), advance diet as tolerated Social work to coordinate discharge to home vs. rehab facility per PT/OT recommendations |
| Nursing Notes | Time: 1400 Bedside swallow study completed; patient passed. Clopidogrel loading dose administered, patient and family educated regarding the need to adhere to medication as prescribed to prevent future strokes. Patient and family expressed understanding. Physical and occupational therapy to evaluate patient this afternoon. Discharge planning to home vs. rehab facility in process with social work. Family has been updated on plan of care and all questions and concerns have been addressed. |
Clinical Decisions Based on Patient Needs
As soon as the patient arrived at the emergency room, the nurse began the process of critically thinking about what needed to be done. The nurse assessed the patient’s situation and then recognized, analyzed, and prioritized the patient’s needs. Once the needs were prioritized, the nurse made clinical decisions about the care to provide, then developed and refined the planned nursing interventions. Each of these actions by the nurse is discussed in more detail in the following sections.
Assessment of Patient Situation
The nurse began assessing the patient as soon as they arrived at the hospital. The nurse was informed that the patient fell at home and was brought to the emergency department by her daughter, who is concerned that the patient may have a concussion. The nurse immediately performed a general survey, looking for cues that would be indicative of a concussion or injury from the fall. During the general survey, the nurse noticed that the patient appeared anxious and confused. The nurse hypothesized that the confusion could be related to head injury from the fall, but that there may be more going on, and further assessment was indicated. The nurse performed a quick head-to-toe assessment and recognized the following relevant cues:
- Alert and oriented only to self
- Slurred speech
- Slight right facial droop
- Rapid, thready pulse
- Decreased muscle strength in right side extremities
- Decreased sensation to right side of body
The nurse recognized that the patient’s symptoms were consistent with a cerebrovascular accident (stroke) from using the FAST assessment and immediately activated a code stroke, recognizing the importance of initiating interventions in a timely manner. Additionally, the nurse recognized other important cues from the patient’s medical history that increased the probability of a stroke: hypertension, atrial fibrillation, and type 2 diabetes. The nurse also took note of the patient’s current medications, because that information often provides more context for a patient’s situation. In this case, the patient was actively taking two antihypertensive medications, an antidiabetic medication, an anticoagulant, and a daily aspirin.
Recognize, Analyze, and Prioritize Patient Needs
After recognizing symptoms of stroke and alerting the stroke team, the nurse also quickly initiated patient transport to the imaging department for a STAT head CT to determine if the patient was actually experiencing a stroke, and to identify, if necessary, the type of stroke (e.g., ischemic, hemorrhagic). The nurse also recognized the importance of asking the patient’s daughter when the patient was “last seen normal,” as the patient must be in the allotted time window from the onset of symptoms to receive tissue plasminogen factor (tPA), a clot-busting medication that is used to treat ischemic stroke. The nurse then performed important diagnostic tests per the provider’s order, including a point-of-care glucose, CBC, BMP, INR, PTT, HA1C, and 12-lead ECG.
Develop and Refine Interventions
Based on the provider’s orders, the nurse performed a 12-lead ECG and found the patient’s cardiac rhythm to be atrial fibrillation on the monitor. The nurse recognized that this cardiac rhythm is often a risk factor for stroke and hypothesized that it may have been a contributing factor to the patient’s presenting symptoms.
Other nursing interventions included performing frequent neurological checks, frequent vital sign checks, analyzing lab and test results, and initiating NPO orders. The nurse recognized the importance of performing frequent neurological checks, because these checks provide tangible measurements of the subtle changes that may indicate the patient’s status is worsening. While analyzing lab and test results, the nurse recognized that the CT report showed findings that were consistent with an ischemic stroke on the left side of the brain. These findings are consistent with the patient’s right-sided symptoms, as symptoms of a stroke are often exhibited on the opposite side of the body in relation to their location in the brain. The nurse also recognized that the patient’s blood glucose was slightly elevated, consistent with the patient’s diabetes, but was likely not the cause of the patient’s symptoms. Typically, hypoglycemia can mimic symptoms of stroke, not hyperglycemia. Lastly, the nurse initiated an NPO order for the patient because strokes increase the risk of dysphagia. At this point, the nurse should anticipate that the patient will require a bedside swallow screen and possibly future consultation with a speech language pathologist to determine their ability to swallow food, liquids, and medications before the NPO status will be changed.
Application of Nursing Care
Application of nursing care in the case study included the interventions mentioned in the previous section, as well as educating the patient and family about the plan of care. Experiencing a stroke can be stressful for both the patient and family members, so the nurse can help ease some anxiety by keeping everyone informed about what is happening. In this case, it was important for the nurse to let the patient’s family members know that the patient had experienced a stroke, but that typical treatment (tPA) was contraindicated because of the patient’s elevated INR value. The nurse should explain this in simple terms, avoiding complex medical jargon to ensure understanding. For example, the nurse might say, “We would typically give a medication that would dissolve the clot that is causing the stroke, but that medication carries a large risk of bleeding. Because the patient is on a blood thinner medication, she is already at an increased risk of bleeding, so if we gave this medication, it could cause her to experience bleeding in the brain, which is life-threatening. Instead, we are going to watch her closely to make sure her symptoms don’t get worse and do all we can to improve them.”
Incorporated Factors Affecting Patient Care
Caring for a patient who is having a stroke involves a lot of physical nursing tasks and skills, but it is also important to recognize the need to provide emotional support to the patient and their family members. Experiencing a stroke can cause a lot of anxiety, especially in this case, as the patient was unable to receive standard pharmacological treatment because of contraindications. The nurse should remain available to the patient and the family to discuss concerns and answer questions about the plan of care. It is important for the nurse to ask what kind of support or resources would help them cope with the diagnosis and, if possible, provide them. After being in the hospital for a few days and experiencing an improvement in symptoms, the nurse in the case study connected the patient and family to a social worker to help them transition from the hospital to home or to a rehabilitation facility.
Revising the Plan of Care
Even though the patient was not actively receiving treatment for the stroke, the nurse was still closely monitoring and assessing for subtle changes in health status that would indicate the need for a revised plan of care. Specifically, the nurse monitored the patient’s vital signs and neurological status, looking for improvement or worsening of symptoms. As the patient progressed through the hospital stay, the plan of care required revision to account for discharge and possible rehabilitation.
Evaluate Outcomes
After performing interventions, the nurse evaluated outcomes by reassessing the patient’s vital signs and neurological status. The patient’s vital signs remained stable, and the neurological status improved. Also, the nurse must evaluate the patient and family’s understanding of provided education. The nurse can do this by using the “teach back” strategy, which asks the learner to repeat the information in their own words to verify the message was received.
Evaluate Nursing Actions
In this case study, the nurse initially evaluated the patient’s neurological status every 15 minutes, looking for worsening or improving of symptoms. Because the patient was unable to receive tPA, the nurse did not administer a specific treatment for the stroke, but closely monitored the patient’s neurological status. This is an action that can be evaluated. For example, if the nurse notices that the patient’s neurological status is worsening, they might hypothesize that the stroke has expanded or the patient may be experiencing a hemorrhagic transformation and would relay this information to the provider to determine the next course of action, which may involve a surgical intervention. Thankfully, in the case study, the patient’s symptoms showed improvement a few days after the onset of the stroke, and the nurse began facilitating physical, occupational, and speech therapies to help the patient restore function and work toward discharge home. Additionally, the nurse facilitated communication between the patient and family and the social worker to initiate the process of leaving the hospital, either to home or to an appropriate rehabilitation facility for the patient to continue her journey of healing.
Another important way that the nurse monitored outcomes was ensuring patient and family understanding of the education provided. Specifically, the nurse provided information about the importance of taking the clopidogrel as prescribed to decrease the risk of subsequent strokes. To evaluate the patient and family’s understanding, the nurse should consider asking them to “teach back” the information. This process helps the nurse feel confident that they understand the significance of adhering to the medication.
Revised Plan of Care
The nursing interventions were successful, as indicated by the improvement in the patient’s neurological symptoms. If the symptoms had not improved, the nurse would have revised the plan of care to treat the patient’s condition more effectively. This may have included alerting the provider about the lack of improvement in the patient’s condition and/or requesting alternative treatment options, as available. The nurse was continually assessing the patient’s condition, monitoring for signs of worsening or improvement to use as a guide for revising the plan of care as necessary. This continuous assessment occurs until the patient is discharged.