You are to complete all of the critical thinking questions for each stage and embed typed answers into this document.
STAGE 1:
William Edwards 64 year old African American male
admit: 02/01/2021 Height: 72in Weight: 120 kg Allergies: NKDA

Chief Complaint- presented to the emergency department accompanied by his wife via EMS for c/o severe headache, right sided weakness, facial drooping, slurred speech, and nausea. The client developed status epilepticus (seizure activity) in route to the hospital which resolved with two doses of Ativan. His initial BP was 220/109 (146).
Past Medical History- HTN, CAD, obesity, hyperlipidemia, atherosclerosis, trans-ischemic attacks with documented non-compliance with medical plan of care.
Home Medications: Metoprolol 50 mg PO daily
Famotidine 20mg PO daily
Atorvastatin 20mg PO daily
ASA 81 mg PO daily

Past Surgical History- R carotid endarterectomy 2018
Past Social History- 1 PPD current cigarette smoker, no ETOH or illicit drug use.
History of Current Illness-
02/01/2021- On arrival to the ED, Mr. Edwards was placed on 2L NC, O2 Sats of 96% with anxiety, c/o HA, with marked R sided weakness. His current B/P is 220/109 (146). Onset of symptoms was 1.5 hours prior to arrival. He was loaded with 1200mg Dilantin IVPGBK.
Assessment:
Pain: 6/10 Headache- pounding all over.
Neuro: Asleep, easily arousable, Ox4, follows simple commands. GCS 14. PERRLA 3mm brisk. Upper/lower motor strength is unequal with L strong & R weak. Gross motor intact, fine motor NOT intact on R side (upper & lower) with good coordinated effort noted on L side. Slurred speech; drooling, tongue midline, no numbness/tingling or seizure like activity noted; evaluated as 7 on the NIH stroke scale.
Cardiac: S1 & S2 auscultated no extra sounds. Continuous ECG monitoring. Rhythm: sinus tachycardia HR 112. Peripheral pulses 2+/3+. Trace non-pitting peripheral edema in bilaterally lower extremities. BP remains 220/109 (146).
Respiratory: RR 22 even and unlabored, BBS- CTA but diminished in the bases. O2 sat 94% on 2L NC.
Gastrointestinal (GI): abdomen obese, soft, with NO tenderness, guarding, masses or pulsations noted. BS- active x 4 quads. Nausea present without vomiting. Diet: NPO. Last BM 2 days prior to arrival.
Genitourinary (GU): has not yet voided. Urinal at bedside.
Musculoskeletal (MS): High fall risk; Seizure precautions in place. Activity observed- bedrest.
Integumentary: Skin is dark brown, warm, dry and intact. Temp 98.5 orally. PIV- R FA 20g CDI with 0.9% sodium chloride infusing at 50 mL/hour.

Critical thinking exercises

1. What is the pathophysiology of a trans-ischemic attack vs thrombotic ischemic stroke?
2. List possible signs and symptoms of an acute ischemic stroke?
3. For stage 1, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why?
4. What priority medications would you expect to be ordered for this patient and why?
5. What priority lab/diagnostic tests would you expect to be ordered for this patient and what results would you anticipate being abnormal and why?
6. What patient and family teaching is important? Be specific.

STAGE 2: Mr. Edwards is sent for a CT scan of his head and then admitted to the ICU with the following orders:
Neurology consult for suspected ischemic stroke
Neuro Assessment q1h
Vital Signs q15 min
Activity: Bedrest
Diet: NPO
Place central line and get Chest X-Ray for placement.
NS at 50ml/hr
Labs: CBC, PTT/PT, INR, Chemistry, Lipid & Liver Panels, Troponin
Diagnostics: 12Lead EKG, Repeat Non-contrast Head CT in am
O2 at 2 1iters/min per NC—titrate for SpO2>91%
Labetalol 5 mg IV-Push PRN Q 10 min SBP > 180 mmHg
After SBP maintained under 180, administered t-PA per protocol

Lab & Diagnostic Results:
CBC: WBC- 8 RBC- 4.5 Hgb- 14 Hct- 42 Plt- 130
Coags: PT 13.0 PTT 32.0 INR 1.0
Chemistry Panel: Na 136 K 3.9 Cl 100 Ca 9.0 Mg 1.2 Phos 3.8 Glu 158 BUN 18 Creat 1.0
Total Protein 5.8 Albumin 3 GFR >60 Serum Osmo 305
Lipid panel: HDL 30 LDL 140 Total cholesterol 250 Triglycerides 300
Liver Panel: AST 20 ALT 24 Total Bili 1.0 Alk Phos 50
Cardiac: Troponin 0.01
12 lead ECG- Sinus Tachycardia
Chest X-Ray: All lung fields clear with mild atelectasis in the bases. Central line noted in R SCV.
CT head without contrast- diffuse cerebral edema noted, no evidence of intracranial bleeding or other abnormalities.
Critical thinking exercises

1. What is your rationale for each of the admitting orders? List out each order and explain why you think they are ordered for this patient.
2. What is your rationale for EACH of the abnormal physical assessment parameters in stage 1, the abnormal laboratory and diagnostic tests from stage 2? List each abnormal result out by section (physical exam, lab results, diagnostic tests) and provide abnormal result and explain rationale for why you believe they are abnormal.
3. tPA administration
   a. What are contraindications for administering tPA?
   b. What are the risks when giving tPA?
   c. How do you monitor for these?
   d. How is tPA administered? Be specific
4. What patient and family teaching is important in this stage? Be specific.

STAGE 3: Day 1 post t-PA administration. Mr. Edwards BP remained elevated during the night despite the labetalol and is currently 185/100(128). No S&S of bleeding noted. His HA is now at a 2/10 “tension”, still with R sided weakness, facial drooping, and slurred speech. Enteral tube in his R nare is CDI and running Glucerna at 10ml/hr. He is voiding via urinal with assistance, averaging 120ml/hr clear yellow urine. Triple lumen central line in R SCV CDI. No other changes noted from initial assessment.

The following orders were written by the Intensivist:
Speech therapy consult for swallow study; if fails place enteral feeding tube and get a KUB for placement; Start Glucerna 10ml/hr if client fails swallow study.
Repeat Head CT without contrast.
Carotid Doppler study.
Consult PT for assessment and treatment plan.
Obtain Dilantin Level
Nipride 0.5-8 mcg/kg/min continuous IV infusion: Titrate by 0.5 mcg/kg/min every 10min to maintain a SBP < 180
Mannitol 12.5gm IVPGBK Q12hrs
Dilantin 100mg IV push Q8 hrs
Lipitor 80mg PO Daily
Lovenox 40mg Sub Daily

Lab/Diagnostic results:
Drug Levels: Total Dilantin level 7.8 (normal range 10-20).
Carotid Doppler- R common 40% and L common 80% occluded.
Swallow Study: failed.
Abdominal x-ray(KUB)- DHT tip noted in duodenum just past pyloric sphincter.
CT scan Head: mild to moderate increase of cerebral edema noted on prior scan, no evidence of intracranial bleeding or other abnormalities.

Critical thinking exercises

1. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient.
2. What is your rationale for EACH of the abnormal lab/diagnostic results in Stage 3? List each out and explain rationale for why you believe they are abnormal.
3. For stage 3, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why?
4. The Dilantin level needs called to the provider. Write the SBAR report you would give.
5. After reporting the Dilantin level to the provider, what orders do you anticipate receiving and why?
6. What patient and family teaching is important? Be specific.
   STAGE 4: Day 2 post t-PA administration. Mr. Edwards BP is stable at 160/90 (113) on the Nipride drip currently running at 6mcg/kg/min. No S&S of bleeding noted. His neurological status has declined. He is lethargic and arouses only to painful stimuli with a blank stare, slight purposeful movement (localizes to the painful stimuli) and is nonverbal. Pupils: PERRL 3mm and sluggish. He has generalized non-pitting edema to all extremities. His abdomen is slightly distended and Glucerna is now running at 40ml/hr. He has not voided since last evening. No other changes noted from prior assessments.

The following orders were written by the Intensivist:
Stat repeat Head CT without contrast.
Stat Serum Osmolality
Increase Dilantin 100mg IV push Q6 hrs
Stat Bladder Scan

Lab/Diagnostic results:
Serum Osmolality: 316.
CT scan Head: substantial increase of cerebral edema noted from prior scan, new 3mm left to right midline shift with narrowing of the ventricles noted.

Critical thinking exercises

1. Calculate this patient’s GCS score and provide your priority nursing interventions and rationale for them.
2. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient.
3. What is your rationale for EACH of the abnormal lab/diagnostic results in stage 3? List each out and explain rationale for why you believe they are abnormal.
4. For stage 4, from different body systems, what are your 3 priority nursing concerns with supporting evidence for this patient and why?
5. The lab/diagnostic results from stage 4 needs called to the provider. Write the SBAR you would give.
6. After reporting the lab/diagnostic test results, what orders do you anticipate receiving and why?
7. What patient and family teaching is important? Be specific.
   STAGE 5: Neurosurgery was consulted and an External Ventriculostomy Drain (EVD) with Intracranial Pressure (ICP) Monitoring had been inserted. There is no change in neurological status. Bladder Scan showed 700ml.

The following orders were written by the Neurosurgeon:
Level EVD to EAC open to drain at 13cm H2O and call if output <10ml or > 30ml per hour
Q1 hr ICP/CPP measurements and call if ICP >20 or CPP <70 Repeat Head CT without contrast in am. Repeat Dilantin level in am Place Foley catheter with strict I/Os and call if output < 60ml or > 300 ml per hour
Start Docusate Sodium 150mg PO/Gastric Daily

Critical thinking exercises

1. What is your rationale for each of the above orders? List out each order and explain why you think they are ordered for this patient.
2. What are your nursing responsibilities when caring for a patient with an EVD/ICP?
3. What are the complications associated with an EVD?
4. List the nursing interventions that can be implemented to decrease ICP?
5. What patient and family teaching is important? Be specific.
   Mr. Edwards became more alert over the coming days, his stroke symptoms improved and the EVD was removed. On day 14 of his hospital stay he was successfully transferred to a neuro rehab center for further management and care.
   Final critical thinking exercise
6. How would the plan of care have change for a patient having a hemorrhagic stroke?
7. What is Cushing’s triad? Why is important to know how to assess for this?
8. What additional information would you like to have seen covered in this evolving case study?
9. As you watched this case unfold, how did it make you feel?

Provide a list of references utilized to complete this assignment.