Neuro Case Study

To help you understand the role you play with CVA patients, follow along in this neuro case study that will have you on the edge of your seat (haha). Imagine it is 0645 on a beautiful Saturday and you receive report on the following fictitious patient:

What are you initial questions/concerns about this patient? What data do you want to focus on with your first head-to-toe assessment? What do you anticipate this patient needing based off this report? You fill out your report sheet, and it looks something like this:

You know you need more data, so you take a look through the chart. Namely, you want to see what his lab results are and want to check to see that the admitting MD ordered a lipid panel and HbA1c for this morning. No results yet, so it’s time to go see your patient…after all, he’s on q 30 min neuro checks until 10am. It’s going to be a busy morning!

Your initial assessment and AM rounds

0700: You head in to the room with the main goal of assessing Rick’s neurological status and BP. Because of his ETOH history, he’s at a higher risk for bleed than someone who doesn’t drink a case of beer a day. Speaking of this drinking habit…you want to confirm with the patient. If he really does drink that much, we’re going to have a problem in a day or two and we need to be prepared.

Your initial head-to-toe assessment reveals the following:

• NIHSS = 6…slowly improving!
• GCS 15
• Pt is able to hold left arm up for 10 seconds with only slight drift noted…improvement! Pt states he can use urinal independently now. Yay!
• Facial droop is minor; speech only mildly slurred.
• VSS on nicardipine gtt. BP from the cuff is 150/74.
• Occasional PVCs on the monitor, but he’s holding his BP so you’re not too worried.
• Lungs clear, normoactive bowel sounds.
• Abrasion to right knee looks clean (thanks to the ED nurses!), open to air.
• No complaints of pain, no complaints of headache, blurred vision or worsening numbness in any extremity.
• Both IVs patent
• Pt confirms he does drink a case of beer a day.
• Pt states he is tired from being up all night, but understands need for frequent assessments. States he will try to sleep in between.

0715: You sit down to chart your initial assessment and look through the labs and orders. Your AM labs don’t show anything of surprise and you notice the lipid panel AND the HbA1c were ordered. That new resident is on top of her game!

0730: Back in to wake Rick and conduct a neuro assessment No changes. Whew! You get those SCDs on and help Rick brush his teeth. You didn’t finish your initial charting yet, so you do that now. You hope to get it done before your 0800 neuro check.

Your morning continues in this vein until 0900. You’ve been conducting neuro exams every 30 minutes and you’re happy to see that Rick’s NIHSS is now 3…he scores points for slight drift in left arm, left leg and slight slurred speech. Looks like he’s going to have a pretty impressive recovery.

During this time you also note that your AM labs are in:

• Na 140; K 3.2; Mg 1.6; Ca 8.2; Ph 1.1; Cr .90; BUN 12
• WBC 8.5; Hgb 9.5; Hct 37%; PLT 130; INR 1.2
• Total cholesterol: 260; HDL 26; LDL 210
• HbA1C: 12 (woah!)

0900: Time for morning meds! Because Rick is still NPO pending his swallow evaluation, you don’t have many meds to give…a protonix IV, keppra (prophylactic for seizure) and that’s about it! You know he’s going to do awesome on his swallow eval, so you call Speech Therapy to see when they might be by. If you can get him on some PO antihypertensives, you can get this nicardipine gtt off and stop taking his BP every 15 minutes (ouch!). Your 0900 neuro exam goes off without a hitch. You notice more frequent ectopy on the monitor and attribute it to his low K and Mag levels. Otherwise, Rick is doing awesome…and wouldn’t you know it, his wife is a lovely person who knows you are an RN who went to school for years and years and not a glorified waitress, so she never once asks you to bring her a cup of coffee. 😉

1000: Time for a blood sugar check. If this one is also elevated, you’re going to need to talk to the MD about coverage. And yes it is…240. All that stress must be causing an SNS response. Your last q 30 neuro check is stable and you let Rick know you’ll be spacing them out to hourly. He grunts in response and goes back to sleep. You let Jan, his wife, know to alert you immediately if he complains of any worsening stroke symptoms or a headache.

1010: Time for rounds! You update the medical team on Rick’s condition and ask for the following:

• A banana bag (an IV infusion of vitamins and thiamine that we give to ETOH patients)
• PO blood pressure meds (pending your swallow eval)
• A statin (his cholesterol is super high)
• Diabetic educator (based off his super high HbA1c)
• ETOH protocol (includes anti-anxiety meds and librium to help control DTs)
• K and Mag replacement
• BS coverage with an aggressive sliding scale

Just then, the speech therapist comes in to conduct an evaluation of Rick’s ability to swallow. She lets you know that he “did great” and will be on a chopped diet with thin liquids. This means his food will be cut up small, but he can have liquids that are NOT thickened…which is good, because thickened liquids are really weird. You make sure to ask her what she thinks of his ability to swallow pills and she states that he should do fine with average-sized pills…larger ones may need to be halved. Woohoo! Rick is making progress!

Before the MD leaves to hang out in the lounge, you alert her that the pt passed his swallow eval and has a recommendation from Speech Therapy. She puts in the orders for a carb-control, cardiac/reduced sodium diet and you are good to go!

1100: Another neuro exam…funny how those hours fly by, isn’t it? All is well in Rick’s world and he is performing components of the exam without even being asked. Is this cheating? 🙂 You hang his banana bag, give him his PO meds and check the compatibility of Mag with nicardipine. You decide not to run anything concurrent with this potent calcium channel blocker and realize you need to start another PIV (those banana bags are not compatible with ANYTHING and you want to get the Mag going now). You nail the IV on your first try and start the magnesium replacement. Your K replacement is ordered PO, so you want to get him a little lunch first so it doesn’t upset his stomach. Besides, when Mag is optimized, it makes it easier for the body to “hang on” to its potassium…so getting that Mag in there is a good idea!

1200: You check Rick’s blood sugar, see that it’s still high (232) and provide insulin coverage. You bring him his lunch tray AND a big ol’ potassium pill that you’ve kindly cut in half. You watch as he safely swallows the pill and you notice his BP is vastly improved. You cut the nicardipine gtt down to 2.5 and anticipate it being off within the hour. Good job, you! Rick’s neuro status is stable and you think his speech might be even more improved.

1245: Jan comes rushing up to the nurse’s station saying, “He said he had a horrible headache and now I can’t get him to wakeup.” You hear a voice inside your head saying, “ooooooooohhhhh shoooooooooooot” Only you don’t say “shoot.” As you rush into his room questions run through your head:

• Did we overshoot his blood sugar control? Is this hypoglycemia?
• Did I turn the nicardipine down too much? Is he having a hypertensive bleed?
• Is he having a “hemorrhagic conversion” a common complication of stroke (especially after TPA)
• Is he able to protect his airway?
• How fast can we get to CT scan?

You grab a glucometer on your way in and ask one of your nurse pals to come in with you. You hand him the glucometer as you try to wake your pt. Your efforts are unsuccessful. You hear a gurgling in Rick’s throat and watch the monitor to see his O2 sat dropping to the mid 80s. We’ve got problems.

You immediately lower the head of the bed and ask your pal for the BVM (bag valve mask). You reposition the airway and notice slight improvement, but the sats still don’t climb above 90. You start bagging the patient and ask your nurse friend to call RT and the MD. Rick needs to be intubated STAT for airway protection and then you gotta go to CT.

As reinforcements enter the room,  you ask someone to finish the blood sugar (which never got done) and RT takes over bagging the pt. With manual ventilation, Rick’s sats come up to 98%, but he is still non-responsive. The blood sugar reads 140, so that’s not the problem. You run a BP and see it’s well within parameters.  Just then, the MD walks in as another RT shows up with the intubation try and a vent. Good teamwork, guys!

Doc Waters quickly assesses the situation, gets into place at the head of the bed and deftly intubates Rick as his wife cries in the corner. You notice your awesome charge nurse consoling her as she explains what is happening.

As CXR technician shows up to confirm endotracheal tube (ETT) placement. While they are setting up the machine, you quickly place an OGT tube so you can get confirmation of it at the same time as your ETT. They shoot the film and you then whisk Rick off to CT scan with your RT buddy at your side. Your heart sinks as you fear the worst has happened to your patient.

1315: CT scan shows Rick has now bled into his brain. It is one of the known risks of TPA and you are crushed that it has happened to your patient, especially one so young and who was doing so well. You let Doc Waters know of the results and page the neurologist on call as well.  When you speak to the neurologist, he tells you he’s consulted neurosurgery and ordered an MRI.

1400: You’ve spoken to the neurologist and received orders for tighter BP control (goal < 140) so you titrate the nicardipine gtt and also ask for an arterial line for closer monitoring. You get Rick settled after his emergent intubation, place a Foley catheter, update Jan and note that his neuro exam is awful…GCS is 3 (no eye opening, no verbal and decorticate posturing). The art line gets placed and MRI calls to tell you they’re ready for your patient. Off you go!

1530: You’re back from MRI and you call the neurosurgeon to let her know the results are available to view.

1545: Neurosurgeon calls you back to ask that you get an EVD kit ready for her. She’s on her way up to place a drain at the bedside. You look at the clock and realize you still have four more hours to go. It’s been a tough day. You find the cranial access kit (which includes a DRILL!) and get the EVD system set up.

1630: Your EVD is in place (thanks to a fast-acting neurosurgeon) and you notice that your intracranial pressure (ICP) is elevated. The neurosurgeon orders prophylactic Ancef (after all, she just performed a neurosurgical procedure!) mannitol q6 hours prn for elevated ICP as well as orders to keep the EVD at continuous drainage. Because you’ve recently reviewed the management of elevated ICP, you know that mannitol requires you to monitor your patient’s serum sodium and serum osmolality. You send a stat chemistry vial and do what you can to keep the ICP within parameters (decreased stimulation, positioning, sedation). With the sedation on board, you’re able to turn off your nicardipine gtt, but you want to keep a close eye and make sure that your CPP (cerebral perfusion pressure) is maintained above 70 (CPP = MAP – ICP). You may need levophed in order to keep CPP up while your patient is sedated. A stark contrast from how you started the day.

1700: You give your mannitol, clear your pumps and spend the next hour catching up on charting. You’re happy to see that the mannitol works quickly to reduce ICP and you make a mental note to keep an eye on urine output as you expect it to drastically increase due to the osmotic diuresis effect of this medication. You’ll want to keep a close eye on those electrolytes (especially K and Mag) Oh, speaking of K and Mag…did you remember to recheck those after you replaced them? You had a busy day and you had to prioritize…but better do that now, just to be safe! Chances are you can “add-on” the K and Mag test to the blood vial you sent earlier for the serum sodium. You spot Doc Waters and ask her to please review the x-ray for OGT placement so you can use it. She does and it’s fine…she writes an order to start Glucerna 1.2 at 20ml/hr.

1800: Your hourly neuro exam shows no changes as your EVD continues to drain drain drain. You do your end-of-shift charting, ensure your IV bags are not going to run dry during your NOC shift buddy’s first hour, replace suction tubing, tidy up the room, get Rick repositioned and start the tube feeding. Though Rick didn’t fare well, you did everything you could, followed protocol and kept the team updated. You can be proud of the work you did today. 

Your report sheet, after everything that happened, now looks like this:

You are now ready to give an awesome end-of-shift report. Now go home and sleep!

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