Wagner_6e_SR_CRCheck_ch17_CE.docx

CHAPTER 17 </P></ANS></ANSSET></MCQSET> Clinical Reasoning Checkpoint Answers Mrs. H. A., a 45-year-old female, is admitted to your unit with mental status changes. She came into the emergency department with complaints of having the “worst headache of her life.” She rated her pain a 10 on a scale of 1 (no pain) to 10 (worst pain ever). She also reports the following symptoms: nausea, vomiting, photophobia, and increasing drowsiness. Her medical history consists of migraine headaches that she experiences monthly. She reports that this headache is much worse than her usual migraine headache. She takes a calcium channel blocker for hypertension, which she developed six years ago. She is a smoker (1½ packs per day for 20 years) and she is obese. Currently she continues to complain of headache (10/10). You perform a physical examination and note that she has nuchal rigidity and a lopsided smile that gives her face an asymmetrical appearance most notable on the right side. Her vital signs are normal other than her BP, which is hypertensive at 165/90. Other than her headache, she is neurologically intact. She continues to experience nausea and vomiting along with her headache. The health care providers suspect a stroke. 1. What diagnostic test is indicated for this patient? Answer: A CT scan without contrast and an cerebral angiogram. These tests will reveal an intracranial bleed (CT scan) and the cerebral vessel that is involved (angiogram), which could be causing her symptoms. Clinical update: Her CT scan reveals diffuse subarachnoid blood and enlarged ventricles. 2. What pathophysiology underlies this stroke? Answer: This patient has suffered a hemorrhagic stroke due to a subarachnoid hemorrhage from a ruptured aneurysm. Blood has collected and is filling the subarachnoid space and is causing hydrocephalus and impaired CSF absorption resulting in enlarged ventricles. She is at risk during the first 24 hours for extending her stroke from rebleeding. This could be fatal if not prevented and treated. 3. What should be the priorities of her care? Answer: Measures to promote and maintain cerebral perfusion pressure, control BP and pain, and optimize oxygenation will prevent secondary injury to brain tissue. Her care priorities are: Frequent neurological assessments. Management of oxygenation. It is important to provide her with supplemental oxygen therapy to keep her SaO2 at greater than 92%. Controlling intracranial pressure. A ventriculostomy may be needed to drain excess cerebral spinal fluid as well as to monitor intracranial pressure. Systemic blood pressure control. Initiation of calcium channel blocker therapy to reduce the risk of her developing vasospasm and control her BP. Other anti-hypertensive medications may be needed to control the BP. It is important to avoid sudden fluctuations in her BP so that cerebral perfusion pressure is maintained. Control of her pain. Use of opioids for pain is recommended. Monitor for and control seizure activity. She should be monitored closely for seizure activity and treated appropriately with medications such as Phenytoin or Fosphenytoin to prevent or control seizures. IV Lorazepam (Ativan), a benzodiazepine, may be indicated to stop acute seizure activity. Phenytoin may be given as a loading dose via a central line as a prophylaxis measure to prevent seizure occurrence, but it is important to prevent hypotension. Fosphenytoin is an alternative anti-seizure medication, and is actually preferred in patients without a central line because it is less irritating to tissues and is better tolerated, causing less hypotension. 4. In three days’ time, what will she be at increased risk of developing? Answer: Cerebral vasospasm. The exact reason why vasospasm occurs is not understood at this time, but is thought to be a result of complex pathophysiologic events caused by blood extravasated into the subarachnoid space and the injured vessel.