stroke case study for nursing students

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When you’re performing research as part of your job or for a school assignment, you’ll probably come across case studies that help you to learn more about the topic at hand. But what is a case study and why are they helpful? Read on to learn all about case studies.

Deep Dive into a Topic

At face value, a case study is a deep dive into a topic. Case studies can be found in many fields, particularly across the social sciences and medicine. When you conduct a case study, you create a body of research based on an inquiry and related data from analysis of a group, individual or controlled research environment.

As a researcher, you can benefit from the analysis of case studies similar to inquiries you’re currently studying. Researchers often rely on case studies to answer questions that basic information and standard diagnostics cannot address.

Study a Pattern

One of the main objectives of a case study is to find a pattern that answers whatever the initial inquiry seeks to find. This might be a question about why college students are prone to certain eating habits or what mental health problems afflict house fire survivors. The researcher then collects data, either through observation or data research, and starts connecting the dots to find underlying behaviors or impacts of the sample group’s behavior.

Gather Evidence

During the study period, the researcher gathers evidence to back the observed patterns and future claims that’ll be derived from the data. Since case studies are usually presented in the professional environment, it’s not enough to simply have a theory and observational notes to back up a claim. Instead, the researcher must provide evidence to support the body of study and the resulting conclusions.

Present Findings

As the study progresses, the researcher develops a solid case to present to peers or a governing body. Case study presentation is important because it legitimizes the body of research and opens the findings to a broader analysis that may end up drawing a conclusion that’s more true to the data than what one or two researchers might establish. The presentation might be formal or casual, depending on the case study itself.

Draw Conclusions

Once the body of research is established, it’s time to draw conclusions from the case study. As with all social sciences studies, conclusions from one researcher shouldn’t necessarily be taken as gospel, but they’re helpful for advancing the body of knowledge in a given field. For that purpose, they’re an invaluable way of gathering new material and presenting ideas that others in the field can learn from and expand upon.

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Amani Baidwan, Kendyl Egizi and Alysha Payne

Darrell Jackson, 81 year old male, came to the Emergency Department at Los Robles Hospital by ambulance after he collapsed in a coffee shop. Upon arrival he presented with left sided weakness, facial drooping, and aphasia. He was diagnosed with an ischemic stroke, right humerus head fracture, and right wrist fracture. The priority of care upon initial presentation to the Emergency Department included a CT scan, frequent monitoring of vital signs, starting a peripheral IV, drawing labs, assessing blood glucose, and an EKG. The nurse in the Emergency Department continuously monitored Mr. Jackson’s neurological status, changes in level of consciousness and signs and symptoms of complications.

After much discussion with the family, consent was given for tissue plasminogen activator (tPA). After tPA was given, Mr. Jackson converted to a hemorrhagic stroke, which is one of many risks associated with administration of tPA. He was His computed tomographic scans (CT) revealed intraparenchymal hematoma in both cerebral hemispheres and a large hemorrhage in the left parietal lobe. In the Intensive care Unit, Mr. Jackson was on a ventilator, had a RASS score of -5 and was only responsive to noxious stimuli. Priority in plan of care included airway management and a CPAP trial to begin weaning protocols. The CPAP trial failed, and a tracheostomy was placed. Mr.Jackson was then transferred to the Progressive Care Unit to continue treatment where the NG tube was removed and a PEG tube was inserted. Mr. Jackson has no known allergies and has a history of hypertension, dementia, Parkinson’s disease, stroke, diabetes, GERD, BPH, hypophosphatemia and anemia.

Collaborative interventions are necessary from all healthcare providers, such as physicians, nurses, physical therapy, occupational therapy, speech therapy, case management and social work, to adequate;y care for Mr. Jackson. Case management has been working closely with the family to provide necessary resources to continue care for Mr. Jackson after discharge from the hospital. Mr. Jackson was discharged home with home health after 3 weeks in the hospital. His condition prior to discharge was as follows: A/O x 3 with mild cognitive deficits, speech impairment and left sided weakness.

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Stroke case study

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Stroke is the leading cause of disability in the United States. As advanced practice nurses, we anticipate caring for those impacted by strokes in many healthcare settings including emergency rooms, acute care, rehab settings, extended care facilities, and in primary care. Early diagnosis and treatment are imperative in the treatment of a stroke in order to minimize permanent deficits so it is important for advanced practice nurses to be proficient in recognizing clinical manifestations of a stroke. There are also many modifiable risk factors for strokes so advanced practice nurses need to be able to educate patients and families on potential lifestyle changes that can decrease stroke risk.

Ischemic Stroke: A Case Study

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This presents an analysis of a case of Ischemic stroke in terms of possible etiology, pathophysiology, drug analysis and nursing care

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Ischemic Stroke

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Patient M is an active woman, 70 years of age, who lost consciousness and collapsed at home. Her daughter, who was visiting her at the time, did not witness the collapse but found her mother on the floor, awake, confused, and slightly short of breath. The daughter estimated that she called EMS within 5 minutes after the collapse, and EMS responded within 10 minutes. EMS evaluated Patient M, drew blood for a glucose level, and determined that she may have had a stroke. They notified the nearest designated comprehensive stroke center that they would be arriving with the patient within 15 minutes. Patient M's daughter accompanied her.

The triage and transportation of an individual with suspected stroke should be similar to that for an individual with serious trauma, and treatment is recommended within 3 hours after the onset of stroke. Because of the limited time available for assessment and diagnosis before optimal treatment, the EMS dispatcher should notify EMS personnel immediately and coordinate transport of the individual to the closest emergency facility, preferably one that is a designated primary (or comprehensive) stroke care center.

On presentation in the emergency department, Patient M is immediately triaged. Because Patient M is still somewhat confused, her daughter is asked to provide information on the patient's history. The daughter reports that her mother had had an episode of sudden-onset numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The episode lasted only 5 minutes, and Patient M had not called her primary care physician. Additional information provided by the daughter indicates that Patient M has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive medicine, a diuretic. The patient has never smoked, drinks occasionally, and is of normal weight.

Patient M has two significant risk factors for stroke; one is a long history of hypertension. More than two-thirds of individuals older than 65 years of age are hypertensive, and it is important for individuals with hypertension to have regular blood pressure screening and to maintain a blood pressure of less than 140/90 mm Hg. Antihypertension therapy has been found to reduce the incidence of stroke by 30% to 40%. Patient M's noncompliance with her antihypertension medicine likely includes her among the 65% of known hypertensive individuals in whom blood pressure is not controlled.

Patient M's previous episode of numbness, confusion, and slurred speech appears to be evidence of a TIA, another substantial risk factor for stroke. Research has shown that approximately 5% of patients will have an ischemic stroke within 7 days after a TIA. In addition, the risk of stroke within 7 days is doubled for patients with TIAs who did not seek treatment. As is the case for many individuals who have a TIA, Patient M did not seek medical attention because the clinical symptoms resolved quickly. However, research findings indicate that urgent treatment should be provided for TIAs, as early treatment for TIA and minor stroke has been shown to reduce the risk of early recurrent stroke by 80%.

On physical examination, Patient M's blood pressure is 150/95 mm Hg. She has pain in her left arm and a slight headache. There are slight carotid bruits on the right. She is assessed with use of the NIHSS and found to have left hemiparesis and left visual/spatial neglect. The results of laboratory tests, including a complete blood count, prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal function studies, are all within normal limits. CT of the brain indicates a thrombus in a branch of the right internal carotid artery, with approximately 50% occlusion due to atherosclerosis. There is an area of infarction in the right anterior hemisphere. There is no evidence of a subarachnoid hemorrhage. The diagnosis is made 2 hours after Patient M's arrival in the emergency department. She is treated with intravenous rt-PA at a dose of 0.9 mg/kg, and aspirin antiplatelet therapy is started at an initial dose of 325 mg, 24 hours after thrombolytic therapy, and a maintenance dose of 75 mg per day.

Many of the patient's symptoms, including her loss of consciousness, shortness of breath, pain, and headache, are nontraditional symptoms of stroke. Studies have demonstrated that nontraditional symptoms are more prevalent among women, often leading to a delay in the evaluation for stroke. EMS personnel and clinicians should be aware of the potential for nontraditional symptoms in women and carry out a diagnostic evaluation addressing a suspicion of stroke.

Patient M is eligible for thrombolytic therapy with rt-PA according to evidence-based guidelines developed by the AHA/ASA: her blood pressure is lower than 185/110 mm Hg, the onset of symptoms is less than 3 hours prior to the start of treatment, and the laboratory values are within normal limits. Antiplatelet therapy with aspirin 325 mg daily (versus anticoagulant therapy with warfarin) is recommended for treatment of patients with stroke or TIA due to intracranial atherosclerosis with 50% to 99% occlusion. Antiplatelet therapy is not recommended as an adjunctive therapy within 24 hours of thrombolytic therapy.

When Patient M's condition is stabilized, her primary care physician and consultant neurologist provide a referral for stroke rehabilitation, and a multidisciplinary rehabilitation team is formed to assess her rehabilitative needs, recommend the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that includes daily antiplatelet therapy. Patient M is again assessed with the NIHSS, and the score is 12. The patient's cognitive and communication skills are intact on evaluation with the FIM, with the exception of the previously documented left visual/spatial neglect. The assessment also includes evaluation of the patient's risk for complications. Because of her spatial neglect, she is screened with the Berg Balance Scale and the Stops Walking When Talking test. The score on the Berg Balance Scale is 43, and Patient M does stop walking to engage in conversation. Psychosocial assessment includes screening with the Center for Epidemiologic Studies Depression (CES-D) Scale, as well as review of the medical history and conversations with the patient and her children; no signs of depression are present.

Patient M's score of 12 on the NIHSS falls within the range (6 to 15) that indicates she is likely to benefit from rehabilitation. Evaluating a stroke survivor's risk of complications is an important component of the overall assessment, and among the most common complications are falls, deep vein thrombosis, pressure ulcers, swallowing dysfunction, bladder and bowel dysfunction, and depressive symptoms. In assessing the risk of complications, the Berg Balance Scale appears to be the most appropriate screen for patients who are likely to fall, and a score of less than 45 is associated with a likelihood of falling. The risk of a fall is also increased when a patient stops walking to talk, as Patient M did, during the Stops Talking When Walking test.

Screening for signs of depression is also essential, as depression affects approximately 33% of stroke survivors. Signs of depression are subtle and may be vague. Several screening tools are available, but there is no universally accepted tool for use in the post-stroke setting. The CES-D was chosen in this case because it is easy to administer, is useful in older individuals, and has been found to be effective for screening in the stroke population, except for individuals who have aphasia. The diagnosis of depression in stroke survivors should be based on sources in addition to a formal screening tool, such as a medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.

The rehabilitation team discusses the results of the assessment with Patient M's daughter and son, both of whom live about 45 minutes away from the patient. Together, the team and the family members explore options to determine the best approach to rehabilitation. A decision is made for Patient M to be discharged to an inpatient stroke unit, and a rehabilitation program is developed. The nurse on the team discusses the program with Patient M and her children and explains the course of rehabilitation and the expectations. Rehabilitation will focus on an exercise program consisting of aerobic exercise, strength training, stretching, and coordination and balance activities.

Early initiation of rehabilitation is a particularly strong predictor of improved outcome, and rehabilitation in a stroke unit has been associated with improved quality of life, survival, and functional status at 5 years compared with a general healthcare facility. No studies have demonstrated the superiority of one rehabilitation setting over another, and the inpatient setting was chosen primarily to ensure consistent care, given how far away Patient M's children live, and the limited support she otherwise has for healthcare needs. Decisions about the setting and program for rehabilitation should be shared with family members, and family and other caregivers should be provided with educational resources about the rehabilitation process.

The exercise program developed for Patient M is designed to help her regain the ability to independently carry out activities of daily living safely and to regain a functional level of ambulation. The benefits of an exercise program include increasing fitness, strength, and flexibility; improving function; preventing injuries and falls; and reducing the risk of recurrent stroke.

Patient M gradually resumes the ability to function independently, and after more than 2 weeks in the stroke rehabilitation unit, the score on the NIHSS has improved to 5. Before she is discharged to her home, the rehabilitation team provides instructions for exercises to continue at home and recommends moderate physical activity as a secondary prevention measure. The team also educates Patient M about the importance of maintaining a normal blood pressure through use of her antihypertension medication and lifestyle modifications. At a follow-up visit with her primary care clinician at 3 months, Patient M's blood pressure is 135/80 mm Hg, and she reports that she has been compliant with her antihypertension medicine and antiplatelet therapy and is functioning well at home.

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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...

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Gale Document Number: GALE|A470159883

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Nurse Case Study: Failure to timely diagnose and treat stroke.

Failure to timely diagnose and treat stroke – partial paralysis of arm, aphasia, mild cognitive impairment and foot drop – $4 million settlement.

The plaintiff, age 52, went to the emergency department of the hospital in March 2005. He had experienced transient episodes of blurred vision and also had a numb right hand. He was examined by a doctor and nurse “A”. The plaintiff’s symptoms quickly resolved and a CT scan did not reveal abnormalities. The doctor diagnosed a transient ischemic attack and contacted the plaintiff’s treating physician. The plaintiff’s treating physician arranged transfer to the hospital’s telemetric monitoring area and requested neurological evaluation. Before the transfer occurred, the doctor and nurse “A” reassessed the plaintiff and detected no neurological abnormalities. About twenty minutes later the plaintiff was examined by another nurse, “B”, who noted slurred speech, confusion and weakness on the right side. The symptoms were reported to the emergency department and Nurse “B” was told that these symptoms had not been present in the examinations by the doctor and nurse “A”. Nurse “B” then contacted the doctor who then requested an immediate neurological consultation by a neurologist. The neurologist examined the plaintiff over an hour later. The neurologist considered the use of tPA, but the plaintiff had been at the hospital for over six hours at that time and the neurologist determined that the three-hour time for administration of tPA had passed. Further observation was recommended. The plaintiff’s symptoms worsened. By the next day it was determined that the plaintiff had suffered a full stroke. The plaintiff was transferred to another hospital and was hospitalized for several weeks. He achieved significant recovery, but continued to have partial paralysis of his right arm, aphasia, mild impairment of cognitive functions, and foot drop of the right foot. He requires a cane, but can independently perform most of his everyday activities. The plaintiff alleged negligence in the failure to timely diagnose and treat the stroke. The plaintiff claimed that the stroke was caused by a clot which traveled to the brain and could have been treated with tPA. The defendants claimed that tPA would not have provided any benefit to the plaintiff. Additionally, the neurologist claimed that Nurse “B” could not accurately determine the time of the onset of the symptoms and that the first two examinations by the doctor had been concluded more than four hours earlier. Nurse “B”, however, claimed that she reported to the neurologist that the symptoms had begun less than three hours prior to the examination. The doctor claimed that her order for an immediate neurological evaluation was all she was required to do. The defendants also claimed that the stroke was due to circulatory obstruction caused by a dissection of the left internal carotid artery, which was confirmed by angiography. A $4 million settlement was reached at the end of the plaintiff’s presentation of evidence at trial. With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 800-298-6288.

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PBL
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The plaintiff's symptoms quickly resolved and a CT scan did not reveal abnormalities. The doctor diagnosed a transient ischemic attack and contacted the