ASSE

SSME
OF TH NT
8 RLE E
NCMB 41
WEEK 01 C R IT
ICAL
LY IL
L
GR OU
P 01
 GROUP 01
BSN - 4 - A - 2S
ANTONIO, JACKIE P.
CATEQUISTA, ALEXANDRA
CORRAL, GRIELL F.
DE LA GRACIA, ROMANE DARBY D.
DE LIMA, BIANCA MARIE L.
GENILO, AARON JOHN V.
JOCSON, DENESE NICOLE LEE
OLIVA, MICHAEL CARINO
TABIGUE, JOHN MANUEL G.
 TABLE OF CONTENTS

● CASE SCENARIO
● INTRODUCTION
● FOUR STAGES OF THE ASSESSMENT FRAMEWORK OF
CRITICALLY ILL PATIENT
● CRITICAL CARE CLIENT CLASSIFICATION OF LOLA NIDORA
● NURSING CARE PLAN
 CASE SCENARIO
“Lola Nidora”
A 65-year-old woman from Marikina City, Lola Nidora, who had a laparoscopic cholecystectomy
3 days prior, was last seen and described by her husband as “normal” at 10pm, right before sleeping.

According to her husband, Lola Nidora awake at 2AM nudging him when he discovered her
face in a state of panic and was mumbling words difficult to understand. “She seemed to have trouble
speaking and moving her right side of the body,” the husband stated. As such, he dialed 161 immediately.

She was brought by EMS to the ED at 2:15 am. The initial CT scan shows an occlusion of the left
MCA stem. The nurse noted Lola Nidora’s ineligibility for Alteplase IV tPA and her NIHSS was 19. The CT
angiogram confirmed occlusion of the left MCA. As such, Lola Nidora was taken emergently to the
neuroendovascular unit. She was planned to undergo Mechanical thrombectomy with a stent retriever and
suction aspiration with TICI (Thrombolysis in Cerebral Infarction) revascularization.
 MIDDLE CEREBRAL ARTERY (MCA) STROKE

Middle cerebral artery is the largest branch and the second terminal branch of
internal carotid artery. Furthermore, the temporal lobe, frontal lobe, and parietal
lobe of the brain, which control movement and sensation in the trunk, limbs, and
face, receive oxygenated blood from the MCA, according to Moawad (2021).
 According to Slater (2021), the Middle cerebral artery (MCA) stroke
describes the sudden onset of focal neurologic deficit resulting from brain
infarction or ischemia in the territory supplied by the MCA. A MCA stroke may be
hemorrhagic (resulting from a brain bleed) or ischemic (caused by a blockage).

Modifiable risk factors, includes:

hypertension, smoking, obesity, alcohol consumption, and diet all contribute to
both ischemic and hemorrhagic stroke.
 FOUR STAGES OF
ASSESSMENT FRAMEWORK
OF A CRITICALLY-ILL
PATIENT
PRE-ARRIVAL ASSESSMENT

Lola Nidora was brought by EMS to the ED at 2:15 am

Age: 65 years old

Gender: Female
Chief Complaint: “She seemed to have trouble speaking and moving her right side of the
body,” the husband stated.
Diagnosis: Occlusion of the left Middle Cerebral Artery (MCA) stem
Pertinent History: Laparoscopic Cholecystectomy 3 days prior
Physiologic Status: “Her face is in a state of panic and was mumbling words difficult to
understand”
Invasive devices, Equipment: Not Indicated
Status of Laboratory or Diagnostic Tests: Not Indicated
ADMISSION QUICK CHECK

Airway: Not Indicated

Breathing: Not Indicated
Circulation, Cerebral Perfusion, Chief Complaint: Disoriented
Drugs & Diagnostic Tests: CT angiogram confirmed occlusion of the left MCA
Equipment: Not Indicated
General appearance of the client:
➢ Her face is in a state of panic and was mumbling words difficult to understand.
➢ She seemed to have trouble speaking and moving her right side of the body.
COMPREHENSIVE ADMISSION ASSESSMENT
Past Medical History
- Had a Laparoscopic cholecystectomy 3 days prior
(TBA)
- Removal of the gallbladder through a small
incision through the umbilicus
- Is it major however a common procedure
surgery performed
Psychosocial Assessment
“She seemed to have trouble speaking and moving her right side
of the body,” as stated by the husband
Social History
- Age: 65 years old
- Gender: Female
- Marital Status: Married
- Primary Family Member/s: Husband
Spirituality
Not indicated but assessment for this part usually contains Faith
/ spiritual preference and healing practices of the patient.
● What is your faith or spiritual preferences?
● What practices help you heal or deal with them?
● Would you like to see a chaplain, priest, or other
spiritual guides?
 COMPREHENSIVE ADMISSION ASSESSMENT

Physical Assessment

- Initial CT scan shows an occlusion of the left

MCA stem
- The CT angiogram confirmed occlusion of
the left MCA
 COMPREHENSIVE ADMISSION ASSESSMENT

Physical Assessment

NIH Stroke Scale of 19

NIH Stroke Scale is a diagnostic method which assesses the severity of a stroke, it provides the measure of stroke-
related neurologic deficit
The scale contains 11 elements which are then evaluated with a score ranging from 0 to 4. The higher a number is
scored on an element, the more impaired the specific function is.

1. Level of consciousness
2. Best gaze
3. Visual
4. Facial palsy
5. Motor arm
6. Motor leg
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction and inattention
COMPREHENSIVE ADMISSION ASSESSMENT
COMPREHENSIVE ADMISSION ASSESSMENT
COMPREHENSIVE ADMISSION ASSESSMENT

Lola Nidora’s NIHSS was 19

 COMPREHENSIVE ADMISSION ASSESSMENT
Physical Assessment

Ineligibility for Alteplase IV tPA - possibly due to Lola Nidora’s Laparoscopic cholecystectomy 3 days prior

Contraindications Cautions

- Hypersensitivity to alteplase - Recent (within 10 days) major surgery or GI

- Active internal bleeding bleeding - Lola Nidora had a Laparoscopic
- AV malformation or aneurysm cholecystectomy 3 days prior
- Bleeding diathesis CVA - OB delivery
- Intracranial neoplasm - Organ biopsy
- Intracranial or intraspinal surgery or trauma - Recent trauma or CPR,
- Recent (within past 2 months), severe uncontrolled - Left heart thrombus
hypertension - Endocarditis
- Suspected aortic dissection - Severe hepatic disease
- Pregnancy
- Elderly
- Cerebrovascular disease
- Diabetic retinopathy
- Thrombophlebitis
- Occluded AV cannula at infected site
COMPREHENSIVE ADMISSION ASSESSMENT

General communication “She seemed to have trouble speaking and moving her right side of the body,” as
stated by the husband

Coping Styles Not indicated

Anxiety and Stress The husband discovered Lola Nidora’s face in a state of panic and was mumbling
words difficult to understand

Family Needs Case scenario only mentioned the husband as family of Lola Nidora

Unit Orientation Lola Nidora was planned to undergo Mechanical thrombectomy with stent
retriever and suction aspiration with TICI (Thrombolysis in Cerebral Infarction)
revascularization.

Referrals Not indicated

ONGOING ASSESSMENT
Nervous NIHSS score is 19

To assess:
● Neurological - NIHSS assessment
● Neurovascular status - 5P’s

Cardiovascular Disoriented

Respiratory Not indicated

Renal Not indicated

Gastrointestinal Not indicated

ONGOING ASSESSMENT
Endocrine, hematologic, Not indicated
and immunologic To assess:
● Assess for access site of Mechanical Thrombectomy for possible complications such as:
○ Retroperitoneal hemorrhage
○ Pseudoaneurysm
○ Arterial occlusion neuropathy
○ Infection

Integumentary Not indicated

To assess:
● Assess for skin integrity / pressure injury (groin site and distal extremities)

Pain/discomfort Not indicated

Psychosocial The husband discovered that Lola Nidora’s face is in a state of panic and mumbling words that was difficult to
understand.
SBAR Communication Tool
Situation Identification
- Name: Lola Nidora
- Age: 65 years old
- Gender: Female
- Marital Status: Married
- Primary Family Member/s: Husband
Problem
Lola Nidora awoke at 2AM having trouble in speaking and moving her right side of the body.

Background - Lola Nidora had a laparoscopic cholecystectomy 3 days prior

Assessment - Ineligibility for Alteplase IV tPA and her NIHSS was 19.
- The CT angiogram confirmed occlusion of the left MCA.

Recommendations Lola Nidora was taken emergently to the neuroendovascular unit, was planned to undergo Mechanical
thrombectomy with stent retriever and suction aspiration with TICI (Thrombolysis in Cerebral Infarction)
revascularization.
 CLIENT
CLASSIFICATION
CRITICAL CARE CLIENT CLASSIFICATION OF
LOLA NIDORA

LEVEL 0 - Normal ward care

LEVEL 1 - At risk of deteriorating
LEVEL 2 - Needs more observation or intervention
LEVEL 3 - Multisystem failure
 CRITICAL CARE CLIENT CLASSIFICATION OF
LOLA NIDORA
LEVEL 2 - NEEDS MORE OBSERVATION OR INTERVENTION

Based on the given scenario, Lola nidora had a laparoscopic cholecystectomy

however, According to her husband, Lola Nidora awoke at 2AM and observed that “She
seemed to have trouble speaking and moving her right side of the body,”. Moreover, She
was planned to undergo Mechanical thrombectomy with a stent retriever and suction
aspiration with TICI (Thrombolysis in Cerebral Infarction) revascularization.
So, it is considered as level 2 critical client classification.
 Mechanical Thrombectomy
According to Nuvance Health (n.d.), It is an endovascular technique for removing blood clots from
the brain after an ischemic stroke.

If mechanical thrombectomy is right for you, here’s how it works:

1. An endovascular specialist makes a small incision in your groin or wrist.
2. Using real-time X-ray-guided imaging, we thread a catheter through an artery that leads to your neck and
brain.
3. Once we reach the clot, specialists insert a device (stent retriever) into the catheter and advance it past the
blood clot.
4. The device expands to stretch the walls of the artery and grab the clot.
5. We then pull the stent retriever with the clot back through the artery and out through the incision.

Nuvance Health (n.d.)

 TICI (Thrombolysis in Cerebral Infarction)

According to Babi & Hacking (2017), grading system was described in 2003 by Higashida et
al. It is also stated that, 1 as a tool for determining the response of thrombolytic therapy for
ischemic stroke. Moreover, In neurointerventional radiology it is commonly used for patients post
endovascular revascularization. Like most therapy response grading systems, it predicts prognosis.

Classifications:
NURSING CARE
PLAN
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Ineffective cerebral SHORT TERM INDEPENDENT INDEPENDENT C

Lola Nidora was mumbling tissue perfusion related Determine the causes of a possible To choose effective interventions
Within 1 hour of nursing
words,difficult to understand, have to decrease oxygen interventions, the patient will rise in intracranial pressure and a
trouble speaking and moving her right reduction in cerebral perfusion.
side of the body as stated by her
supply to the left middle be able to:
husband cerebral artery as
- Demonstrate gradual stable
evidenced by CT scan of Regularly assess and record Determine the location, degree, and
OBJECTIVE DATA: vital signs and no increase of neurological condition, then compare progression or resolution of CNS
the patient, CT ICP it to previous result injury by assessing LOC patterns and
CT scan shows occlusion of the left angiogram, NIHSS of - Display no further the risk for rising ICP.
MCA STEM
19, mumbling words, deterioration of deficits
This will indicate whether the
CT scan angiogram confirmed trouble in speaking and Evaluate and keep track of the patient's condition is deteriorating or
occlusion of the left MCA LONG TERM patient's vital signs and O2 improving.
moving right side of the
saturation.
Patient NIHSS of 19 body Within 1 week of nursing To assess whether the brainstem is
interventions, the patient will Evaluate pupils,noting size, shape, intact, pupillary responses are
be able to: equality and light reactivity. helpful.

- Demonstrate enhanced
cerebral tissue perfusion as
evidenced by improve speech
and motor function
- Display normal neurological
status
- Demonstrate behavior and
lifestyle changes to improve
circulation
Put the client in the semi-fowler
position.
Maintain bed rest, provide quiet
environment ,limit visitors, and plan
activities for the patient.
Encourage the patient to refrain from
holding their breath and straining at
their stools.
This promote cerebral perfusion and
helps reduce pressure.
ICP can rise with ongoing
stimulation. The patient may become
stressed out due to constant activity
and lack of sleep.
This will further limit the blood
supply to the brain.
 INTERVENTION RATIONALE

INDEPENDENT INDEPENDENT

Provide soft diet for the patient and maintain fluid balance Soft foods allows the patient to swallow food easily

Perform passive ROM exercise Exercise prevents venous stasis and further circulatory problems

Encourage the patient to do relaxation techniques such as using listening to music,reading and meditation To decrease oxygen demands

Monitor input and output.

To keep track on the patient's ability to urinate and their fluid balance.

DEPENDENT
DEPENDENT
Administer supplemental oxygen as indicated
To prevent hypoxia

Prepare the patient for mechanical thrombectomy as per ordered

To improve cerebral perfusion and reduce neurological problems

COLLABORATIVE
COLLABORATIVE
Refer the patient to Speech and Language therapist
To aid in educating the patient of alternative swallowing procedures, to enhance communication and speech

Refer the patient to Physical therapist To improve balance and mobility

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

RISK FACTOR/S: SHORT TERM INDEPENDENT INDEPENDENT SHORT TERM

Risk for
Review patient’s ability to swallow, Nutritional interventions, including Within 1 hr of nursing intervention, the
Neuromuscular impairment Within 1 hour of nursing
(CT scan shows occlusion of the left impaired intervention, the patient will be able noting extent of paralysis, clarity of choice of feeding route, are patient was able to:

MCA stem.) to: speech, facial and tongue determined by these factors.
swallowing involvement, ability to protect
airway and episodes of coughing or
- Demonstrate feeding methods
appropriate to individual situation, with
- Demonstrate feeding methods
related to choking; presence of adventitious aspiration prevented.
appropriate to individual situation, breath sounds and amount and
with aspiration prevented character of oral secretions. Weigh _GOAL MET
neuromuscular periodically, as indicated. _PARTIALLY MET
_NOT MET

impairment LONG TERM Have suction equipment available at

After 1 week of nursing intervention,
the patient will be able to:
- Pass food and fluid from mouth to
stomach safely.
bedside, especially during early
feeding efforts.
Schedule activities and medications
to provide a minimum of 30 minutes
of rest before eating.
Assist client with head control or
support, and position based on
specific dysfunction.
Timely intervention may limit
LONG TERM
amount and untoward effect of
aspiration After 1 week of nursing intervention, the
patient was able to:
- Pass food and fluid from mouth to
Promotes optimal muscle function stomach safely.
and helps to limit fatigue
_GOAL MET
_PARTIALLY MET
Counteracts hyperextension, aiding _NOT MET
in prevention of aspiration and
enhancing ability to swallow.
Optimal positioning can facilitate
intake and reduce risk of aspiration
—head back for decreased posterior
propulsion of tongue, head turned to
weak side for unilateral pharyngeal
paralysis, and lying down on either
side for reduced pharyngeal
contraction.
 INTERVENTION RATIONALE

Provide pleasant environment free of distractions, such as TV. Promotes relaxation and allows client to focus on task of eating and swallowing.

Place client in upright position during and after feeding, as appropriate. Uses gravity to facilitate swallowing and reduces risk of aspiration.

Provide oral care based on individual need prior to meal. Clients with dry mouth require a moisturizing agent, such as artificial saliva or alcohol-free mouthwash, before and after
eating; clients with excess saliva will benefit from use of a drying agent, such as lemon or glycerin swabs, before meal and
a moisturizing agent afterward

Season food with herbs, spices, and lemon juice according to client’s preference, within dietary restrictions. Serve foods at Increases salivation, improving bolus formation and swallowing effort. Lukewarm temperatures are less likely to stimulate
customary temperature and water always chilled salivation, so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow.

Aids in sensory retraining and promotes muscular control.

Stimulate lips to close or manually open mouth by light pressure on lips or under chin, if needed.
Place food of appropriate consistency in mouth
Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing
intake. Food consistency is determined by individual deficit. For example: Clients with decreased range of tongue motion
require thick liquids initially, progressing to thin liquids, whereas clients with delayed pharyngeal swallow will handle
thick liquids and thicker foods better.
Note: Pureed food is not recommended because client may not be able to recognize what is being eaten. Most milk
products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.

Can improve tongue movement and control necessary for swallowing and inhibits tongue protrusion

Touch parts of the cheek with tongue blade weak tongue Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in client’s
terminating meal early
Feed slowly, allowing 30 to 45 minutes for meals.
Prevents client from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after client
has finished eating solids.
Offer solid foods and liquids at different times
Although use may strengthen facial and swallowing muscles, if client lacks tight lip closure to accommodate straw or if
liquid is deposited too far back in mouth, risk of aspiration may be increased
Limit or avoid use of drinking straw for liquids
Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing and intake

Helps client manage oral secretions and reduces risk of regurgitation

Encourage SO to bring favorite food

Maintain upright position for 45 to 60 minutes after eating

 INTERVENTION RATIONALE

Maintain accurate intake and output (I&O); record calorie count If swallowing efforts are not sufficient to meet fluid and nutrition needs, alternative methods of feeding must be pursued

This will help in giving balance nutrition and to determine if the patient’s body is responding well in the prescribed
Monitor and record the body weight of the patient nutrition

COLLABORATIVE
COLLABORATIVE
To provide additional advise on what food should the patient eat in order to optimise and improve health.
Refer the patient to a Nutritionist as needed only.
 REFERENCES:
❖ Mechanical thrombectomy. Mechanical Thrombectomy | Stroke | Nuvance Health. (n.d.). Retrieved
August 30, 2022, from https://www.nuvancehealth.org/services-and-treatments/neurology-and-
neurosurgery/stroke-services/mechanical-thrombectomy
❖ Hacking, C., Babu, V. Thrombolysis in cerebral infarction (TICI) scale. Reference article,
Radiopaedia.org. (accessed on 30 Aug 2022) https://doi.org/10.53347/rID-39569
❖ Moawad, H. (2021, October 18). Could you recognize the symptoms of a middle cerebral artery
stroke? Retrieved from https://www.verywellhealth.com/middle-cerebral-artery-stroke-3146460
❖ Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's pocket guide: Diagnoses,
prioritized interventions and rationales.
 REFERENCES:
❖ Bs, R. K. J., RPh, & Ccrn, H. K. R. B. (2020). Saunders Nursing Drug Handbook 2021, 1e (1st ed.).
Saunders.
❖ Burns, S., & Delgado, S. (2018). AACN Essentials of Critical Care Nursing, Fourth Edition (4th ed.).
McGraw Hill / Medical.
❖ Cnrn, R. P. J. H. L., & PhD Rn, K. C. H. (2017). Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing (Brunner and Suddarth’s Textbook of Medical-Surgical) (14th ed.). LWW.
❖ Is Laparoscopic Cholecystectomy Major Surgery? (2020, March 27). MedicineNet.
https://www.medicinenet.com/is_laparoscopic_cholecystectomy_major_surgery/article.htm
❖ Slater, D. (2021, Aug 9). Middle cerebral artery stroke: Overview, rehabilitation setting selection and
indications, best practices. Retrieved from https://emedicine.medscape.com/article/323120-overview
THANK YOU!!