NRS 455 Case Study: Mrs. T.
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 before 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 | Abnormal subjective findings include loss of speech, comprehension, and skilled voluntary movement. She also has an altered mental status and is not in pain. |
| Objective | Significant abnormal objective findings include elevated blood pressure of 184/94, right-sided facial and arm weakness, an NIHSS score of 12 indicative of a moderate stroke, elevated triglyceride and cholesterol levels, and a BMI of 35.9. Significant normal findings include normal head CT, INR, blood sugars, and sPO2. |
| 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. | The primary diagnosis is a hemorrhagic stroke. A hemorrhagic stroke is an example of a central nervous system complication characterized by a rupture of cerebral vessels, resulting in intracerebral hemorrhage (Webb et al., 2022). The condition presents with a sudden onset headache, altered mental status, and neurologic deficits due to impaired cerebral blood flow. |
| Secondary medical diagnosis and why you chose this diagnosis. | Hypertension as she presents with an elevated blood pressure of 184/92 (Webb et al., 2022). |
| Formulate a nursing diagnosis from the medical diagnoses | Reduced cerebral perfusion due to ruptured blood vessels and intracerebral hemorrhage. |
| Pathophysiological Changes
Explain the pathophysiological changes in Mrs. T. |
|
| What pathophysiological changes would you expect to be happening to Mrs. T.? | Hypertension causes non-traumatic intracerebral hemorrhage due to the rupture of cerebral arteries, resulting in the formation of a hematoma. Due to interruptions in cerebral flow, the tissues beyond the rupture are prone to hypoxic injury, progressive neuronal injury, and edema (Montaño et al., 2021). In addition, bleeding may also occur in the subarachnoid space, and a hematoma forms there, which increases the risk of ICP, predisposing her to herniation and death. |
| How will pathophysiological changes transition in the subacute phase after diagnosis and initial treatment? | The subacute phase of the stroke is characterized by neuroplasticity and tissue remodeling, the main hallmarks of tissue healing. Hematoma formation causes an influx of macrophages that phagocytose the damaged neuronal tissue and extravasated blood (Magid-Bernstein et al., 2022). The macrophages release multiple cytokines that promote fibrosis in the affected area. The release of growth factors allows for new neuronal connections and neuroplasticity. The phase ends when the edema resolves and tissue reperfusion occurs. An infarct may also form in the area affected by the hypoxic injury. |
| 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. | Hemorrhagic strokes affect multiple brain regions, which may affect Mrs. T.’s physical, psychological, and emotional well-being. An episode of stroke causes limb weakness or paralysis, memory loss, loss of speech and language skills, and difficulties in making decisions. As a result, the symptoms impact Mrs. T.’s physical and cognitive abilities, thus affecting her ability to perform activities of daily living (Tiwari et al., 2021). Additionally, an episode may affect the function of the autonomic nervous system and involuntary muscles, resulting in an inability to control muscles of respiration, swallowing, bladder, and defection (Poomalai et al., 2023). Mrs. T. may also experience mental health challenges ranging from post-traumatic stress disorder, anxiety, dementia, neurocognitive disorders, and depression. |
| Discuss the impact it can have on her role in the family. | Strokes cause limitations in the physical ability to perform various activities, including teaching. Recovery of certain functions may vary depending on the extent of tissue damage and treatment offered following the acute episode. Mrs. T’s inability to teach may result in a loss of income, while limitations in the ability to perform activities of daily living necessitate a caregiver (Jírů-Hillmann et al., 2022). The caregiver is prone to experiencing burnout and mental health distress while providing care to Mrs. T. In addition, the diagnosis negatively impacts the family’s financial status due to medical and rehabilitation costs and loss of revenue (Montaño et al., 2021). The family may experience anxiety, post-traumatic stress disorder, depression, and uncertainties following the episode |
| 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. | Immediate antihypertensive therapy using intravenous labetalol or hydralazine is required to control Mrs. T’s blood to at least 140/90. She may require prophylactic anticonvulsants such phenobarbital prevent convulsions (Magid-Bernstein et al., 2022). Mannitol can also be used if cerebral edema occurs. If the hematoma enlarges or there are any symptoms of increased intracranial pressure, surgery can be done to decompress the intracranial structures. |
| Describe the long-term support she may need to return to baseline activity level. | Mrs. T. will be required to be started on maintenance oral antihypertensive medications, such as nifedipine or enalapril, to ensure long-term management of her hypertension. She may also need junior aspirin and atorvastatin to lower the incidence of an ischemic stroke or coronary artery disease. She also needs intensive physical and occupational therapy to help recover her motor skills and regain her ability to perform activities of daily living (Lip et al., 2022). In addition, she should be encouraged to make lifestyle changes, such as taking healthy diets rich in proteins and vegetables or low in starch and avoiding fast foods, wine, and cigarettes (Charchar et al., 2023). Her physical therapy should also allow her to perform exercises that may help in weight loss. |
| Explain how the interdisciplinary team is utilized to help her family support and cope with her diagnosis. | An interdisciplinary team is crucial in managing Mrs. T and her family during recovery. Mrs. T and the family require intensive psychotherapy to help them manage the psychological trauma following the acute stroke episode and the post-stroke psychological symptoms, such as depression and anxiety (Lip et al., 2022). As a result, psychologists and psychiatrists can be utilized. Additionally, they require occupational, physical, and speech therapists to help Mrs. T recover her physical and communication skills while the family learns important skills they may need for Mrs. T’s recovery. Social workers and rehabilitation nurses may be crucial in allowing the quick reintegration of Mrs. T. into the community and providing caregiving assistance to the family. |
References
Charchar, F. J., Prestes, P. R., Mills, C., Ching, S. M., Neupane, D., Marques, F. Z., Sharman, J. E., Vogt, L., Burrell, L. M., Korostovtseva, L., Zec, M., Patil, M., Schultz, M. G., Wallen, M. P., Renna, N. F., Shariful Islam, S. M., Hiremath, S., Gyeltshen, T., Chia, C., . . . Tomaszewski, M. (2023). Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. Journal of Hypertension, 42(1), 23. https://doi.org/10.1097/HJH.0000000000003563
Jírů-Hillmann, S., A Gabriel, K. M., Schuler, M., Wiedmann, S., Mühler, J., Dötter, K., Soda, H., Rascher, A., Benesch, S., Kraft, P., Pfau, M., Stenzel, J., Benghebrid, M., Schulte, K., Meinck, R., Volkmann, J., Haeusler, K. G., & Heuschmann, P. U. (2022). Experiences of family caregivers 3-months after stroke: Results of the prospective trans-regional network for stroke intervention with telemedicine registry (TRANSIT-Stroke). BMC Geriatrics, 22, 228. https://doi.org/10.1186/s12877-022-02919-6
Lip, G. Y., Lane, D. A., Lenarczyk, R., Boriani, G., Doehner, W., Benjamin, L. A., Fisher, M., Lowe, D., Sacco, R. L., Schnabel, R., Watkins, C., Ntaios, G., & Potpara, T. (2022). Integrated care for optimizing the management of stroke and associated heart disease: A position paper of the European Society of Cardiology Council on Stroke. European Heart Journal, 43(26), 2442. https://doi.org/10.1093/eurheartj/ehac245
Magid-Bernstein, J., Girard, R., Polster, S., Srinath, A., Romanos, S., Awad, I. A., & Sansing, L. H. (2022). Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circulation Research, 130(8), 1204. https://doi.org/10.1161/CIRCRESAHA.121.319949
Montaño, A., Hanley, D. F., & Hemphill, J. C., 3rd (2021). Hemorrhagic stroke. Handbook of Clinical Neurology, 176, 229–248. https://doi.org/10.1016/B978-0-444-64034-5.00019-5
Tiwari, S., Joshi, A., Rai, N., & Satpathy, P. (2021). Impact of Stroke on Quality of Life of Stroke Survivors and Their Caregivers: A Qualitative Study from India. Journal of Neurosciences in Rural Practice, 12(4), 680. https://doi.org/10.1055/s-0041-1735323
Webb, A. J., & Werring, D. J. (2022). New Insights into Cerebrovascular Pathophysiology and Hypertension. Stroke, 53(4), 1054. https://doi.org/10.1161/STROKEAHA.121.035850
Poomalai, G., Prabhakar, S., & Jagadesh, N. S. (2023). Functional Ability and Health Problems of Stroke Survivors: An Explorative Study. Cureus, 15(1), e33375. https://doi.org/10.7759/cureus.33375
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Assessment Description
Use the “Case Study: Mrs. T.” template to complete the assignment.
Case Study: Mrs. T. has indirect care experience requirements. The “NRS-455 – Case Studies: Indirect Care Experience Hours” form, found in the Topic 1 Resources, will be used to document the indirect care experience hours completed in the case study. As progress is made on the case study, update this form indicating the date(s) each section is completed. This form will be submitted in Topic 3.
You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competencies 2.3, 2.4, 2.5, and 2.9.
AttachmentsNRS-455-RS-T2-CaseStudyMrsT.docx
Case Study: Mrs. T. – Rubric
Rubric Criteria
Total 130 points
| Criterion | 1. Unsatisfactory | 2. Insufficient | 3. Approaching | 4. Acceptable | 5. Target |
|---|---|---|---|---|---|
| Clinical Manifestations of Mrs. T.
|
0 points
Subjective and objective clinical manifestations are not present. |
4.88 points
Subjective and objective clinical manifestations are incomplete or incorrect. |
5.14 points
Subjective and objective clinical manifestations are present but lack detail. |
5.79 points
Subjective and objective clinical manifestations are detailed. |
6.5 points
Subjective and objective clinical manifestations are thorough. |
| Primary Diagnosis
|
0 points
Primary medical diagnosis and rationale for this diagnosis are not present. |
19.5 points
Primary medical diagnosis and rationale for this diagnosis are incomplete or incorrect. |
20.54 points
Primary medical diagnosis and rationale for this diagnosis are present but lack detail. |
23.14 points
Primary medical diagnosis and rationale for this diagnosis are detailed. |
26 points
Primary medical diagnosis and rationale for this diagnosis are thorough. |
| Secondary Diagnosis
|
0 points
Secondary medical diagnosis and rationale for this diagnosis are not present. |
19.5 points
Secondary medical diagnosis and rationale for this diagnosis are incomplete or incorrect. |
20.54 points
Secondary medical diagnosis and rationale for this diagnosis are present but lack detail. |
23.14 points
Secondary medical diagnosis and rationale for this diagnosis are detailed. |
26 points
Secondary medical diagnosis and rationale for this diagnosis are thorough. |
| Nursing Diagnosis
|
0 points
Nursing diagnosis formulated from the medical diagnoses is not present. |
19.5 points
Nursing diagnosis formulated from the medical diagnoses is incomplete or incorrect. |
20.54 points
Nursing diagnosis formulated from the medical diagnoses is present but lacks detail. |
23.14 points
Nursing diagnosis formulated from the medical diagnoses is detailed. |
26 points
Nursing diagnosis formulated from the medical diagnoses is thorough. |
| Pathophysiological Changes
|
0 points
Description of the pathophysiological changes expected and how these will transition over the course of a week after diagnosis and initial treatment is not present. |
4.88 points
Description of the pathophysiological changes expected and how these will transition over the course of a week after diagnosis and initial treatment is incomplete or incorrect. |
5.14 points
Description of the pathophysiological changes expected and how these will transition over the course of a week after diagnosis and initial treatment is present but lacks detail. |
5.79 points
Description of the pathophysiological changes expected and how these will transition over the course of a week after diagnosis and initial treatment is detailed. |
6.5 points
Description of the pathophysiological changes expected and how these will transition over the course of a week after diagnosis and initial treatment is thorough. |
| Health Status Effect
|
0 points
Description of the physical, psychological, and emotional effects of the health status on the patient and the impact the health status has on the family and the ability of patient to work is not present. |
4.88 points
Description of the physical, psychological, and emotional effects of the health status on the patient and the impact the health status has on the family and the ability of patient to work is incomplete or incorrect. |
5.14 points
Description of the physical, psychological, and emotional effects of the health status on the patient and the impact the health status has on the family and the ability of patient to work is present but lacks detail. |
5.79 points
Description of the physical, psychological, and emotional effects of the health status on the patient and the impact the health status has on the family and the ability of patient to work is detailed. |
6.5 points
Description of the physical, psychological, and emotional effects of the health status on the patient and the impact the health status has on the family and the ability of patient to work is thorough. |
| Treatments and Support
|
0 points
Discussion of the immediate treatments and long-term support needed to return the patient to baseline activity level and an explanation of how to help the family support and cope with the diagnosis are not present. |
14.63 points
Discussion of the immediate treatments and long-term support needed to return the patient to baseline activity level and an explanation of how to help the family support and cope with the diagnosis are incomplete or incorrect. |
15.41 points
Discussion of the immediate treatments and long-term support needed to return the patient to baseline activity level and an explanation of how to help the family support and cope with the diagnosis are present but lack detail. |
17.36 points
Discussion of the immediate treatments and long-term support needed to return the patient to baseline activity level and an explanation of how to help the family support and cope with the diagnosis are detailed. |
19.5 points
Discussion of the immediate treatments and long-term support needed to return the patient to baseline activity level and explanation of how to help the family support and cope with the diagnosis are thorough. |
| Mechanics of Writing
Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc. |
0 points
Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout. |
5.85 points
Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent. |
6.16 points
Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted. |
6.94 points
Few mechanical errors are present. Suitable language choice and sentence structure are used. |
7.8 points
No mechanical errors are present. Appropriate language choice and sentence structure are used throughout. |
| Format/Documentation
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline. |
0 points
Appropriate format is not used. No documentation of sources is provided. |
3.9 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident. |
4.11 points
Appropriate format and documentation are used, although there are some obvious errors. |
4.63 points
Appropriate format and documentation are used with only minor errors. |
5.2 points
No errors in formatting or documentation are present. |
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