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Case Study: Mrs. T.

Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.
Case Study: Mrs. T.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. T., presented below.
Health History and Medical Information
Mrs. T., a 42-year-old female, has been living at home with her two high school age children, husband, and dog. She is a schoolteacher who works full-time teaching at the local grade school. She tries to be active by walking with her husband and dog for 20 minutes on the weekend but is starting to add weight as she gets older. She has no known allergies. She is a pack-a-day smoker and drinks three glasses of wine/per night after work. She tries to eat healthy but likes to eat out at fast food restaurants to avoid having to cook.
Medical history includes atrial fibrillation controlled with beta blocker, hypercholesterolemia, mild anemia related to heavy menses, and migraines. Current medications include:

Metoprolol 50mg daily
Pravastatin 40 mg at bedtime daily for cholesterol
Birth control pill Microgestin Fe in the AM
Amitriptyline 20 mg/daily for migraines
Case Scenario
You are the school nurse where Mrs. T. works. While at recess duty, another teacher runs up to you and reports that Mrs. T. is not acting like herself. When you approach, you see her sitting on a bench mumbling something to the kids gathered around her. She has dropped her cell phone on the ground, and her right arm appears limp. You try asking her questions and you notice the right side of her face is slacken, and she does not seem to be making sense when talking. You call an ambulance, and try to walk her back to your office, but she does not move well. You reassure her and try to determine if anything occurred prior to her loss of speech and movement. The other teachers say it came on suddenly, within the last 5 minutes. Mrs. T. shakes her head no to pain.
Objective Data – Completed by Ambulance Personal:
Temperature: 36.5 degrees C
BP 184/92, HR 101, RR 24, Pox 99%
Blood Glucose = 107
Positive FAST & VAN score, NIHSS = 12
Height: 62 inches; Weight 89 kg
Laboratory/Test Results – On Arrival to the Emergency Department (Initial Results)
WBC: 9.4 (1,000/uL)
INR – 0.7
CT Head is normal.
Negative pregnancy test
Cholesterol – 247, Triglycerides – 302

Critical Thinking Table
Clinical Manifestations
Describe the clinical manifestations present in Mrs. T., focusing on what is normal and abnormal and how this relates to her current condition.
Subjective
Objective
Primary and Secondary Diagnoses
Discuss the primary and secondary medical diagnoses that should be considered for Mrs. T., and why you chose this diagnosis.
Primary medical diagnosis and why you chose this diagnosis.
Secondary medical diagnosis and why you chose this diagnosis.
Formulate a nursing diagnosis from the medical diagnoses
Pathophysiological Changes
Explain the pathophysiological changes in Mrs. T.
What pathophysiological changes would you expect to be happening to Mrs. T.?
How will pathophysiological changes transition in the subacute phase after diagnosis and initial treatment?
Health Status Effect
Describe the effects Mrs. T.’s current health status may have on her.
Describe the physical, psychological, and emotional effects Mrs. T.’s current health status may have on her.
Discuss the impact it can have on her role in the family.
Treatments and Support
Discuss treatments and support that can be completed for Mrs. T.
Discuss the immediate treatments that can be completed for Mrs. T.
Describe the long-term support she may need to return to baseline activity level.
Explain how the interdisciplinary team is utilized to help her family support and cope with her diagnosis.

Sample Answer

Critical Thinking Table: Mrs. T.

| Component | Description
1. Clinical ManifestationsDescribe the clinical manifestations present in Mrs. T., focusing on what is normal and abnormal and how this relates to her current condition.

Subjective (Reported by patient or observers)	Objective (Measurable/Observable by healthcare professional)
Abnormal:	Abnormal:
* “Not acting like herself” (reported by another teacher)	* BP 184/92 (Hypertension): Significantly elevated, indicating a potential hypertensive crisis or existing uncontrolled hypertension, a major risk factor for stroke.
* Mumbling something to kids (incoherent speech)	* HR 101 (Tachycardia): Elevated heart rate, which can be related to stress, pain (though she denies pain), or an acute cardiovascular event.
* Dropped cell phone on the ground (loss of fine motor control/weakness)	* RR 24 (Tachypnea): Elevated respiratory rate, possibly indicating distress, anxiety, or altered neurological function.
* Does not seem to be making sense when talking (aphasia/dysphasia)	* Right arm appears limp (Right-sided weakness/hemiparesis): Classic focal neurological deficit consistent with a stroke on the left side of the brain.
* Right side of her face is slacken (Facial

Full Answer Section

Right side of her face is slacken (Facial droop/paralysis):** Another key sign of a neurological event, often indicating a stroke.
* Does not move well when trying to walk her back (Gait disturbance/ataxia, lower extremity weakness)	* Positive FAST score: F (Facial droop – right side slacken), A (Arm weakness – right arm limp), S (Speech difficulty – mumbling, not making sense), T (Time to call ambulance – sudden onset). This is a strong indicator of stroke.
* Sudden onset, within the last 5 minutes (acute neurological event)	* Positive VAN score: Visual (not specified), Aphasia (yes), Neglect (not specified). The positive aphasia component strongly suggests a left hemispheric stroke.
* Shakes head no to pain (absence of pain despite obvious distress, which can be normal for stroke).	* NIHSS = 12: A score of 12 indicates a moderate to severe stroke. This quantifies the neurological deficits observed.
	* Weight 89 kg; Height 62 inches: BMI is significantly elevated (BMI = 33.3 kg/m²), indicating obesity. Obesity is a significant risk factor for cardiovascular disease and stroke.
	* Cholesterol – 247, Triglycerides – 302: Both are elevated despite being on Pravastatin, indicating uncontrolled hyperlipidemia, a major risk factor for atherosclerosis and stroke.
Normal:	Normal:
* No known allergies	* Temperature: 36.5 degrees C: Normal body temperature.
* Denies pain	* Pox 99%: Oxygen saturation is normal.
* Blood Glucose = 107 mg/dL: This is within normal limits (or borderline elevated but not acutely hypoglycemic/hyperglycemic). This helps rule out a diabetic emergency as the primary cause of symptoms.
	* WBC: 9.4 (1,000/uL): Within normal limits, suggesting no acute infection as the primary cause of symptoms.
	* INR – 0.7: Within normal limits for someone not on anticoagulants (normal range usually 0.8-1.2). Mrs. T. is on a beta-blocker, not an anticoagulant. This is important as it rules out excessive bleeding as a primary cause if it were a hemorrhagic stroke or if she was on an anticoagulant.
	* CT Head is normal: This is a crucial finding. A normal CT scan initially, especially in an acute stroke scenario, often suggests an ischemic stroke rather than a hemorrhagic stroke. Hemorrhagic strokes usually show up immediately on CT. Ischemic strokes may not show up for several hours.
	* Negative pregnancy test: Rules out pregnancy-related complications or contraindications for certain treatments.

2. Primary and Secondary Diagnoses

Discuss the primary and secondary medical diagnoses that should be considered for Mrs. T., and why you chose this diagnosis.

Primary Medical Diagnosis and Why You Chose This Diagnosis	Secondary Medical Diagnosis and Why You Chose This Diagnosis	Formulate a Nursing Diagnosis from the Medical Diagnoses
Primary Medical Diagnosis: Acute Ischemic Stroke (Cerebrovascular Accident – CVA)	Secondary Medical Diagnosis 1: Atrial Fibrillation (AFib) with increased risk of cardioembolic stroke.	Nursing Diagnosis: Impaired Verbal Communication related to cerebral injury, as evidenced by mumbling, not making sense when talking, and positive VAN score (aphasia component).
Why: The sudden onset of focal neurological deficits (right-sided facial droop, right arm limp, aphasia/mumbling, gait disturbance) is highly indicative of a stroke. The positive FAST and NIHSS score of 12 strongly confirm a neurological event consistent with a stroke. The normal initial CT head scan is critical because it helps rule out an acute hemorrhagic stroke (which would show up immediately) and strongly suggests an ischemic stroke (which may not be visible on CT for several hours post-onset). Ischemic stroke is caused by a blockage in a blood vessel to the brain, which aligns with her risk factors. The rapid onset within 5 minutes is classic for a vascular event.	Why: Mrs. T. has a known history of atrial fibrillation, which is controlled with a beta-blocker. However, AFib is a major risk factor for cardioembolic stroke, where an irregular heartbeat can cause blood clots to form in the heart, which then travel to the brain and block blood flow. Despite being controlled with Metoprolol, AFib carries an inherent risk of clot formation if she is not also on an anticoagulant (her INR of 0.7 suggests she is not). This makes AFib a very likely underlying cause of her ischemic stroke.	Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular impairment, as evidenced by right arm limp, not moving well, and positive FAST (arm weakness) and NIHSS score of 12.
	Secondary Medical Diagnosis 2: Uncontrolled Hyperlipidemia / Dyslipidemia.	Nursing Diagnosis: Risk for Aspiration related to impaired facial muscle control (right facial droop) and potential difficulty swallowing secondary to stroke.
	Why: Mrs. T. has a history of hypercholesterolemia and is on Pravastatin, but her current cholesterol (247 mg/dL) and triglycerides (302 mg/dL) are significantly elevated. Uncontrolled hyperlipidemia contributes to atherosclerosis, the hardening and narrowing of arteries, which is a leading cause of ischemic stroke. This indicates poor management of a critical risk factor, potentially contributing to the current event.	Nursing Diagnosis: Ineffective Health Maintenance related to insufficient knowledge of lifestyle modifications for cardiovascular health, as evidenced by pack-a-day smoking, daily alcohol consumption, sedentary lifestyle, high BMI, and uncontrolled hyperlipidemia.
	Secondary Medical Diagnosis 3: Hypertension (Acute/Uncontrolled).
	Why: Her blood pressure on admission (184/92 mmHg) is significantly elevated. While it could be a transient elevation due to the acute stress of the stroke, her history of AFib and likely underlying cardiovascular risk factors suggest potential chronic hypertension. Hypertension is the leading modifiable risk factor for stroke, contributing to both ischemic and hemorrhagic types. Its acute elevation during the event is concerning.
	Other relevant pre-existing conditions: Mild anemia related to heavy menses (less directly linked to acute stroke but important for overall health), Migraines (while not directly causative of this type of stroke, certain types of migraines with aura are associated with increased stroke risk, though less likely to be the primary cause of her current symptoms).

3. Pathophysiological Changes

Explain the pathophysiological changes in Mrs. T.

What pathophysiological changes would you expect to be happening to Mrs. T.?	How will pathophysiological changes transition in the subacute phase after diagnosis and initial treatment?
Given the sudden onset of focal neurological deficits, the positive FAST/NIHSS, and a normal initial head CT, Mrs. T. is most likely experiencing an acute ischemic stroke. This involves:	In the subacute phase (days to weeks after the initial stroke), the pathophysiological focus shifts from acute cell death to recovery, repair, and adaptation.
1. Cerebral Ischemia: A sudden interruption of blood flow to a specific area of the brain due to a blockage (thrombus or embolus). In Mrs. T.’s case, given her AFib and high cholesterol, a cardioembolic stroke (clot from the heart) or an atherothrombotic stroke (clot forming on an atherosclerotic plaque in a brain artery) are highly probable.	1. Penumbra Resolution/Infarct Maturation: The ischemic penumbra, if successfully reperfused or if collateral circulation improves, may recover some function. The core ischemic tissue, however, will progress to irreversible neuronal death (infarction), leading to glial scarring and liquefactive necrosis as macrophages clear cellular debris.
2. Loss of Oxygen and Glucose Supply: Brain cells, deprived of blood flow, rapidly lose their supply of essential oxygen and glucose. Neurons are highly sensitive to this deprivation.	2. Inflammation and Edema Resolution: The initial inflammatory response and cytotoxic/vasogenic edema will gradually resolve. However, depending on the stroke size, some residual edema might persist.
3. Excitotoxicity: As brain cells become ischemic, they release excessive amounts of excitatory neurotransmitters (e.g., glutamate), which overstimulate surrounding neurons, leading to an influx of calcium ions. This sustained overstimulation is toxic to neurons, contributing to further cell death.	3. Neuroplasticity and Synaptic Remodeling: The brain begins to reorganize itself. Unaffected brain regions can take over functions previously performed by the damaged area. New synaptic connections are formed, and existing ones are strengthened or weakened, allowing for functional recovery. This process is crucial for rehabilitation.
4. Inflammatory Response: Ischemic injury triggers an inflammatory cascade. Microglia (resident immune cells of the brain) and other immune cells are activated, releasing cytokines and other inflammatory mediators. While initially protective, prolonged or excessive inflammation can extend the area of damage.	4. Angiogenesis: The formation of new blood vessels may occur in the peri-infarct region, attempting to improve blood flow to partially damaged areas.
5. Cellular Edema: Two types of edema can occur:	5. Axonal Sprouting and Remyelination: Surviving neurons may sprout new axons to form connections with other neurons, and some remyelination may occur, aiding in nerve signal transmission.
* Cytotoxic edema: Swelling of individual brain cells due to pump failure (Na+/K+ ATPase pump) as ATP supply diminishes, leading to intracellular fluid accumulation.	6. Long-term Risk Factor Management: If the initial cause was embolic or thrombotic, the focus will shift to strict long-term management of her AFib (likely with anticoagulants now), hyperlipidemia, and hypertension to prevent recurrent strokes. This involves continued pharmacological interventions and aggressive lifestyle modifications.
* Vasogenic edema: Breakdown of the blood-brain barrier, allowing fluid to leak from blood vessels into the extracellular space, increasing intracranial pressure.
6. Ischemic Penumbra: This is a crucial area of brain tissue surrounding the core ischemic infarct. Cells in the penumbra are ischemic but not yet irreversibly damaged. They are hypoperfused but potentially salvageable if blood flow is restored quickly. This is the target for acute stroke interventions like thrombolysis.
7. Neurological Deficits: The specific location of the brain damage determines the resulting neurological deficits. Her right-sided weakness, facial droop, and aphasia (difficulty with speech/understanding) strongly suggest an ischemic event in the left cerebral hemisphere, specifically affecting areas responsible for motor control of the right side of the body and language processing (e.g., Broca’s or Wernicke’s areas).

4. Health Status Effect

Describe the effects Mrs. T.’s current health status may have on her.

Describe the physical, psychological, and emotional effects Mrs. T.’s current health status may have on her.	Discuss the impact it can have on her role in the family.
Physical Effects:	Impact on Role in the Family:
* Motor Deficits: Persistent right-sided weakness (hemiparesis) or paralysis (hemiplegia), potentially affecting her ability to walk, use her right arm and hand for daily tasks (dressing, eating, writing, cooking). This could lead to a loss of independence.	Mrs. T.’s stroke will have a profound and immediate impact on her role within her family, transitioning from an active contributor to a potential recipient of significant care.
* Speech and Language Deficits (Aphasia): Difficulty expressing thoughts (expressive aphasia) or understanding spoken/written language (receptive aphasia), as evidenced by mumbling and not making sense. This will severely impact her ability to communicate with her family, friends, and colleagues.	1. Wife/Partner Role: Her ability to engage with her husband in activities like walking, sharing conversations, or participating in household decisions will be severely curtailed, at least initially. The husband may take on a primary caregiver role, leading to emotional strain, financial pressure, and changes in their marital dynamic. Intimacy may also be affected.
* Facial Droop: Affects eating (drooling, difficulty chewing), drinking, and emotional expression, potentially leading to social isolation.	2. Mother Role: Her role as a mother to her two high school-aged children will be significantly altered. She may be unable to provide care, help with homework, or participate in their school activities. The children may need to take on more household chores and emotional support for their mother, potentially impacting their own academic performance and social lives. They may experience fear, sadness, and resentment.

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