B.W. is an 84 year old, 71 in, 76.4kg retired teacher who presented to the ED 8 days ago with clinical manifestations of cerebrovascular accident (CVA), including sever aphasia, that has begun two hours earlier. Following a stat CT scan, he was treated with IV alteplase and stabilized. Since being admitted to the nursing unit, he has started rehab and is preparing for transfer to a rehab facility in the community in which he lives. B.W. has a history of HTN, smoking (20+) years, quit 40 years ago, appendectomy 43 years ago, R hip replacement 5 years ago. He is a recent widower, having been married for 63 years. He lives alone. His children all live out of state. B.W. is a full code, Baptist, with allergies to ciprofloxacin and iodine.
Initial assessment- 0700 VS: T 98.2, BP 167/88, P 92 and regular, R 18 and unlabored. O2 sat 95% on RA. Occasional wincing with movement. Reports "stinging" pain 2-3/10 in R hip, A&Ox3-4. Slow speech. Follows most directions given time. Slight right facial droop, right upper and lower extremity weakness. Lungs are diminished in the bases, no cough present. Apical pulse 92 bpm. Abdomen is slightly distended with normal BS on the left and decreased BS in both upper and lower quadrants. Urine is clear and pale yellow. Experiences some difficulty with voiding. Dorsalis pedis pulses are 2+ bilaterally. Capillary refill <2 seconds. 20 g saline lock left forearm (LFA). Braden score is 20.
Treatments: VS q4hr including neuro checks, fall precautions, ambulate with assistance, NPO until swallow eval, PT, OT, I&O, bladder scan and straight cath PRN, knee high antiembolic stockings, SCDs, BMP, CBC, aPTT, PT/INR daily.
Medications: 1000mL D5W @125 mL/hr, heparin 5,000 units subcit q8 hr, metoprolol 100 mg PO bid, lisinopril 20 mg PO daily, milk of magnesia 30 mL PO PRN, acetaminophen 650 mg PO PRN.
1. Identify the two major types of CVA based on etiology.
2. What is the classification of alteplase? Which of the major two types of CVA is it used to treat? Since B.W. was treated with alteplase which type of CVA did he have?
3. From B.W. initial assessment findings, identify the side of the brain in which his CVA occurred.
4. List a minimum of 12 risk factors for CVA. Identify which are modifiable either through life changes or medication intervention.
5. What aspects of B.W.'s assessment can be delegated to UAP?