Download Neurological Case Studies N4390 Group Name: Scenario #1 You

Neurological Case Studies
N4390
Group Name:_____________________________________
Scenario #1
You have been asked to see D.V., a 25-year-old man, in the neurology clinic. D.V.
has been referred by his internist, who suspects him of having symptoms of multiple
sclerosis (MS). D.V. has experienced increasing urinary frequency and urgency over
the past 2 months. Because his female partner was treated for a sexually transmitted
infection, D.V. also underwent treatment, but the symptoms did not resolve. D.V. has
also recently had two brief episodes of eye “fuzziness” associated with diplopia and
flashes of brightness. He has noticed ascending numbness and weakness of the right
arm with the inability to hold objects over the past few days. Now he reports rapid
progression of weakness in his legs.
1. MS is an inflammatory disorder of the nervous system causing scattered, patchy
demyelinization of the central nervous system (CNS). What does myelin do? What
is demyelinization?
2. MS is characterized by remissions and exacerbations. What happens to the
myelin during each of these phases?
3. Isn't D.V. too young to get MS? What is the etiology?
4. Outline the subjective and objective assessment data that you would gather
because a diagnosis of MS is suspected. Place a star next to the symptoms that D.V.
has.
5.What are four common diagnostic tests you can begin to teach D.V. about, and
what role will they play in determining whether D.V. has MS?
6. D.V. asks you, “If this turns out to be MS, what is the treatment?”
7. As part of your teaching plan, you want D.V. to be aware of situations or factors
that are known to exacerbate symptoms. List four.
Scenario #2
N.T., a 79-year-old woman, arrived at the emergency room with expressive
aphasia, left facial droop, left-sided hemiparesis, and what is presumed to be
symptoms of mild dysphagia. Her husband states that when she awoke that
morning at 0600, she complained of a mild headache over the right temple, was
fatigued, and felt slightly weak. Thinking that it was unusual for her to have
those complaints, he went to check on her and found that she was having trouble
saying words and had a slight left-sided facial droop. When he helped her up
from the bedside, he noticed weakness in her left hand and convinced her to
come to the emergency department. Her past medical history includes
paroxysmal atrial fibrillation, hypertension (HTN), hyperlipidemia, and a remote
history of deep vein thrombosis. A recent cardiac stress test was normal, and her
blood pressure has been well controlled. N.T. is currently taking flecainide
(Tambocor), hormone replacement therapy, amlodipine (Norvasc), aspirin,
simvastatin (Zocor), and lisinopril (Zestril). After a noncontrast CT scan, she is
diagnosed with a thrombolytic stroke. The physician writes the following orders:
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IV 0.9% NaCl at 75 mL/hr
Activase (tPA) per protocol
Stat CBC, PT/INR, CK isoenzymes
Neurologic assessment every hour (NIHSS)
Obtain patient weight
Vital signs every hour
Oxygen at 2 L per nasal cannula (NC)
Outline a plan of care for implementing these orders.
The instructions on the tPA vials read to reconstitute with 50 mL of sterile
water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is
to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus
over 1 minute. N.T. weighs 143 pounds.
1. What is the amount of the bolus dose, in both milligrams and
milliliters that you will administer in the first minute?
2. What is the amount of the remaining dose that you will need to
administer?
3. What are the three types of cerebrovascular accidents (CVAs)?
4. Why is a non-contrast CT scan ordered? Why would you want to also
get an EKG? (What role do each of these diagnostic tests play in
evaluating N.T. for a suspected CVA?
5. Explain why lowering high blood pressure is important for client’s
experiencing a stroke and what are the goals for lowering blood
pressure if TpA is an option for treatment.
6. Contraindications for beginning fibrinolytic therapy include: (Select
all that apply.)
a) Currently on Coumadin with an INR of 3.4
b) Major surgery in the last 14 days
c) Systolic BP of 150
d) Platelet count of less than 100,000
e) Blood glucose of less than 50mg/dL
f) History of myocardial infarction 1 month ago
g) Improving neurologic status
N.T. is admitted to the neurology unit. A second CT scan (18 hours later) reveals a
small CVA in the right hemisphere. She is placed on flecainide (Tambocor),
amlodipine (Norvasc), clopidogrel (Plavix), aspirin, simvastatin (Zocor), and
lisinopril (Zestril).
7. List the 1) drug type, 2) why you think the patient is taking the
medications, 3) function along with 4) important nursing
considerations for each of the above listed medications.
8. If N.T.'s deficits are temporary, how long might it take before they are
completely reversed?
9. How would you assist N.T. in learning how to use a cane with a leftsided weakness during the rehabilitation phase of CVA care? Explain
in detail how you will direct N.T. in ambulating with the cane.
10. During stroke rehabilitation, what are the priorities of care and
interventions to facilitate positive outcomes?