Ateneo de Zamboanga University

College of Nursing
RLE - Virtual Case (Wk. 4-6)
#2- Case Scenario: ACUTE ISCHEMIC STROKE
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At 10:00 AM. Patient B is an active woman, 70 years of age, who lost consciousness and collapsed at home.
She is a retired teacher, and living alone. Her daughter, Tricia 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. Tricia estimated that she
called EMS within 5 minutes after the collapse, and EMS responded within 10 minutes.
The EMS evaluated Patient B, drew blood for a glucose level, and determined that she may have had a stroke.
Immediately the team notified the nearest designated comprehensive stroke center that they would be arriving with
the patient within 15 minutes. Patient B's daughter accompanied her.
At 10:25 AM. On presentation in the emergency department, Patient B transferred to hospital stretcher and
immediately triaged. Because Patient B is still somewhat confused, her daughter Tricia 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 B had not called her primary care physician. Additional information provided by the daughter indicates that
Patient B has been treated for hypertension for 10 years but notes that she is often not compliant with her anti-
hypertensive medicine, a diuretic. The patient has never smoked, drinks occasionally, and is of normal weight (Ht. 5’ 6”;
Wt. 131 lbs.).
Patient B's vital signs taken: blood pressure is 150/95 mm Hg; RR -16 bpm; HR -98 BPM and refers to ER
physician. On initial physical examination, Patient B 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. Doctors order includes: request for CBC; Prothrombin time; serum electrolytes levels, cardiac
biomarkers, and renal function studies - ASAP; for CT Scan of the brain and Cerebral Angiography; pls. relay results
once available.
After one hour, all the results of laboratory tests were referred to the consultant neurologist specialist by the
ER primary physician, including a complete blood count, Prothrombin time, serum electrolyte levels, cardiac
biomarkers, and renal function studies, and shows all are within normal limits. However, CT scan 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 and there is no evidence of a subarachnoid hemorrhage.
The diagnosis is made 2 hours after Patient B's arrival in the emergency department. At 12:10 PM, seen and examined
by medical consultant neurologist-specialist with new orders: start with intravenous rt-PA (thrombolytic therapy) at a
dose of 0.9 mg/kg, and antiplatelet therapy is started at an initial dose of Aspirin 325 mg, 24 hours after thrombolytic
therapy, plain nss 1L 20 drops per minutes and a maintenance dose of 75 mg per day. Advised for admission at Neuro-
medical ward. May transfer to Neuro-medical ward after Patient B's condition stabilized.
At 5pm Dr. O (consultant neurologist), conducts his afternoon rounds. Patient B is again assessed with the
Neurologic Institute Health Stroke Scale (NIHSS), and the score is 12. The patient's cognitive and communication skills
are intact on evaluation, 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 B
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. Additional medication includes Atorvastatin 20 mg 1 tab.
Insert Foley catheter FR 16. Monitor Neuro Vital Signs (NVS). Daily. Dr. O ordered for referral to stroke rehabilitation,
and a multidisciplinary rehabilitation team is formed to assess Patient B’s rehabilitative needs. The team recommends
the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that includes daily
antiplatelet therapy.
The rehabilitation team discusses the results of the assessment with Patient B'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 B to be discharged to an inpatient stroke
unit, and a rehabilitation program is developed. The nurse on the team discusses the program with Patient B 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.
 After more than 2 weeks in the stroke rehabilitation unit, patient B gradually resumes the activity and ability to
functions independently with the score on NIHSS has improved to 5. The rehab physician inform the head nurse to
coordinate with the rehabilitation teams to provides discharge instructions for patient B to continue at home and
recommends some activity as a secondary preventives measures.

TASKS AND GUIDE QUESTIONS:

Head Nurse and Staff nurse Tasks:

1. Make an admitting nurses’ notes using the FDAR Charting?

- Charting notes should be reflected from: (3 shifting notes)
 Admission (ER) admitting notes
 Endorsement from ER --> Neuro-medical Unit
 Ward (endorsement ---> to the next shift (3-11 PM); ---> 11- 7 AM shift)

2. Transcribe all orders in the Doctors sheet, medication sheet, fluid sheet and other flow sheet. (May utilize
downloadable forms or forms given to you by previous CI duty.)

3. As an ER head Nurse what are your nursing responsibilities and duties in area of assignment? Also as staff
nurse know your duties and responsibilities.

4. What is the demographic profile of the patient?

5. Utilizing the nursing assessment present the case in an orderly manner (base from the scenario given):
a) What is the demographic profile of the patient?
b) What is the chief complaint of patient upon admission?
c) Patient history of present illness?
d) Patient past illness and medical history?
e) Social history?

6. Cluster the presented manifestations to subjective and objective signs.

7. What significant information contribute to clients’ present condition?
8. Identify medical/diagnostic/laboratory/surgical management that contribute to client’s care. Discuss what is the
implication to client’s present situation?

9. What preparation needed for Patient B who will undergo diagnostic test includes cerebral Angiogram and MRI.
(present during online synchronous session)

10. List down the drugs given to patient and conduct a drug study and give its significance to client care. (make a
medication card for each drug)

11. Identify top 3 priority problems base from the scenario given and Formulate a comprehensive NCP.
12. How do you monitor patient’s level of consciousness and compare with the NIHSS.

13. Identify what important health teachings to be included while the patient is confine in the rehabilitation unit?

14. Design a discharge teaching plan for Patient B with emphasis on (MODEL) Medications, Out-patient Follow up visit,
Diet, Exercises, Lifestyle modifications.
 ROLES NAMES
PCI:
- assign your student to make nurses notes
utilizing SOAPIE & ADPIE charting.  Cheska Sarabia
- Present NSO procedures related to the case:
CT scan, cerebral angiography.
-Talk with the head nurse and staff nurse
regarding the distribution of tasks/activities  Kilat, Kyla Marie G.
and guide questions.

Head Nurse:  Ruiz, Alliah C.

Staff Nurses:  Jawad, Ruhaina C (Neuro
1. Make an admitting nurses’ notes using the FDAR ward 7-3 pm)
Charting?
 Ladjamatli, Almena R. (3-11
- charting notes should be reflected from: (3 shifting
notes) pm)
a. Admission (ER) admitting notes  Taradji, Saima (11-7 am)
b. Endorsement from ER --> Neuro-medical Unit
c. Ward (endorsement ---> to the next shift (3-11
PM); ---> 11- 7 AM shift)

2. Transcribe all orders in the Doctors sheet,

medication sheet, fluid sheet and other flow sheet.
(May utilize downloadable forms or forms given to
you by previous CI duty.)

3. As an ER head Nurse what are your nursing

responsibilities and duties in area of
assignment? Also as staff nurse know your
duties and responsibilities.
Student Role:
4 & 5: Tahajid
6: Yu
7: Saalan
8: Santiago
Guide questions #
9: Ruiz and Yu
10: Abdurasad
11: Ong
12: Almena
13 & 14: Napii and Rodrigo