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Case Study 64Angela C. CobarUniversity of New HampshireI was assigned case study 64. This case pertained to stroke and TPA specifically. Within the time that I presented the case study and started to write this paper, my close friend’s father suffered a stroke. Although he had a hemorrhagic stroke, unlike in the study, it was interesting to piece together the information and symptoms. It is important to know classic symptoms of strokes because it is crucial to intervene in a short amount of time. According to the Center for Disease Control (2015), stroke is the fifth leading cause of death in the U.S. and the leading cause of long-term disability. My first semester at clinical, I was placed at a rehabilitation facility and most of the patients I was assigned there had suffered a stroke and were going through physical, speech, and occupational therapy to try and regain their baseline, pre-stroke. There are two different causes of stroke, my case study focused on an ischemic stroke so that is what I will be focusing on as well. An ischemic stroke is caused by a lack of blood flow to brain cells because of a thrombus in the brain vessels. The brain cells begin to die without oxygen and brain function is lost. With quick intervention, long-term damage can be prevented (Mayo Clinic Staff, 2016). One of the possible treatments includes alteplase (TPA). This is a thrombolytic medication that dissolves the clot and is also known as a miracle drug (Medscape, 2016). Although this medication has a lot of complications, the benefit many times out weighs the risks and the patient often makes a full recovery. My case study states the following: N.T. is a 79 yo woman who arrives at the ED with expressive aphasia, left facial droop, left sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 600, she stayed in bed, complaining of a mild headache over the right temple feeling slightly weak. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her PMH includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure has been well controlled. The medications she is on include: flecainide, hormone replacement therapy, calcium channel blocker, aspirin, simvastatin, lisinopril. The physician suspects N.T. has experienced an acute cerebrovascular accident (CVA). Diagnostics help evaluate what kind of stroke NT is having. It is crucial to know what type of CVA the patient is experiencing because the treatments are very different between the two types. If NT is given TPA and she is having a hemorrhagic stroke, then she could die within minutes of receiving the medication. A CT scan or MRI would be ordered to determine what kind of stroke NT is experiencing. The most likely cause of her stroke is her PMH of Afib. This causes her heart to beat at an irregular rhythm from which she could gather a clot in her heart, which gets shot out into her brain. Case study progress: After a CT she is diagnosed with a thrombolytic stroke. Her orders include, IV 0.9% NaCl at 75ml/hr., Activase (TPA) per protocol, Stat CBC, PT/INR, CPK isoenzymes, Neurologic Assessment every hour, Obtain pt. weight, VS every hour, O2 at 2L per NC, NPO until swallowing evaluation. A nurse should first hook the patient up to oxygen to support oxygenation since the clot is preventing blood flow, having as much oxygen as possible available is crucial. Then get IV access established and draw labs from site for stat PT/ INR, enzymes, and CBC, then hang IV NS. Obtain pt. weight for TPA administration. Give TPA per protocol, then neuro-exams q1hr. Make sure they are NPO until speech is able to do a full swallowing exam. Obtaining weight, assisting in repositions every 2 hrs., and obtaining manual BP can all be delegated to the LNA. Only a nurse can initiate oxygen and assess neuro status. Isoenzyme levels are used to measure damage of tissue. “This test is done if a CPK test shows that your total CPK level is elevated. CPK isoenzyme testing can help find the exact source of the damaged tissue… CPK-1 (also called CPK-BB) is found mostly in the brain and lungs; CPK-2 (also called CPK-MB) is found mostly in the heart; CPK-3 (also called CPK-MM) is found mostly in skeletal muscle” (Chen, 2015, para. 12). While completing the National Institutes of Health Stroke Scale (NIHSS) scores for each of N.T.'s symptoms, she scored a total of 14. Alert: 0; Knows month and age: 0; Able to follow commands: 0; Extraocular movements intact: 0; No visual loss:0; Partial left facial paralysis: 2; Left leg no movement: 4; Left arm no movement: 4; No ataxia: 0; Sensation intact: 0; Moderate aphasia: 2; Neglect of left side: 2 (Stroke Center, 2016). A score of 14 means she suffered a mild-moderate stroke (Rehab Measures, 2006). The provider gives you the following order for TPA. Instructions of TPA vial reads: Reconstitute with 50ml of sterile water to make a total of 50mg/50ml (1mg/ml). Hospital protocol is to infuse 0.9mg/kg over 60 minutes. Weight: 65kg. 10% of dose must be given as bolus over 1 minute. The nurse will administer 5.85 ml in the first minute. The nurse will administer 52.65 ml over the remaining 59 min. A nurse should not give TPA if the patient is currently on Coumadin with INR of 2.4, major surgery within 14 days, PLT count of less than 100,000, BG< 50 and an improving neuro status (Boston Medical Center, 2014). Nursing responsibilities include assessing for signs of bleeding, neuro exams, VS (Medscape, 2016). Case Study Progress: N.T. is admitted to the neuro unit. A second CT scan (18 hrs. later) reveals a small CVA in the right hemisphere. She is placed on Flecainide, Amlopidine, Clopidogrel, Aspirin, Simvastatin, Lisinopril. TPA takes 3-5 minutes to work and if her symptoms are temporary then the TPA will reverse them within a few minutes (Medscape, 2016). By the time her infusion is done and the full dose has been given, NT would ideally be relieved of her symptoms if the clot were fully deformed. With therapy and administration of TPA however, full recovery could take 6-12 months.The main concern when giving tPA is blood pressure monitoring because if it is too high a vessel could burst and with TPA there is no way for her to clot so the bleeding will not stop (Boston Medical Center, 2014).Lumbar pain is not expected with tPA administration and would indicate another problem or illness (Medscape, 2016).She is placed on an antiplatelet to prevent other thrombi from forming in the future and preventing another stroke or heart attack. NT must wait 24 hours before taking antiplatelet/ anticoagulant medications because of the administration of alteplase (Boston Medical Center, 2014). N.T should stay on her simvastatin to help with her hyperlipidemia, which may cause coronary artery disease, which leads to HTN and stroke. It is also believed that statins help stabilize the endothelial wall and prevent plaque rupture.She will need speech therapy consult for a swallow evaluation due to her risk of aspiration secondary to her stroke and dysphagia. Patient outcome states that she did make a full recovery of her symptoms thanks to the administration of tPA and quick response time. While looking at research however, most patients are not this lucky. Researching tPA, I found several interesting articles about the administration of thrombolytic therapy to treat ischemic strokes. As previously mentioned, there is a strict protocol for alteplase because there is such a high risk for complications. Several of the articles I found however, stated that although some patients may not meet the protocol, they should still be receiving medication. It is theorized that since the risk is so high for tPA, that physicians are hesitant to give this medication to prevent other complications from occurring. Lyerly, et al., (2014) states that less than 10% of patients receive this treatment. The researchers studied patients who had received tPA despite protocol for reasons such as: time of administration greater than three hours, blood pressure, elevated PT/ PTT, stroke within three months, and unclear time of onset, to see the risk to benefit aspect to breaking protocol. The researchers found that although one-third of the patients had received thrombolysis with protocol violations, the results were equal to those who had not broken protocol. This led them to conclude that there is a need for increased use of thrombolytic therapy in patients diagnosed with an ischemic stroke (Lyerly, et al. 2014).Although there may be a need to break protocol with tPA, there is only a certain window of time that it should be given be over the three hours it suggests. Jamary O. Filho and Owen B. Samuels (2016), state that although there is a benefit to extending the three-hour window, treatment beyond 4.5 hours may be more harmful to the patient than beneficial. It is concluded that, although there may be a similar outcome with administration of tPA after three hours, there is an increased mortality rate when tPA is given after 4.5 hours. These deaths occur around 90 days post stroke and therefore the benefit does not outweigh the risk with giving tPA after four and a half hours. Before alteplase can even be administered though, there are a series of steps that need to be completed. Since time is of the essence, their is a hospital protocol set in place for patients experiencing a stroke. At Boston Medical Center there protocol is as follows: door to alert of stroke team of 5 min., they must be assessing patient within 5 minutes of being paged, door to CT/MRI is within 25 minutes, CT/ MRI results read within 45 min along with EKG and chest X-ray, labs within 30 min, tPA administration decision within 10 minutes, totaling to 2 hours of door to treatment administration (Boston Medical Center, 2014). Although this seems like a lot of procedures in a short amount of time, there is a specified group of people who take care of stroke patients and respond rapidly and only to these calls. The “evidence suggests that patients with acute stroke have better outcomes when admitted to a hospital unit that is specialized for the care of patients with all types of acute stroke, including ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage (Filho, 2016, para. 6). Understandably not all hospitals can afford a specialized stroke team, but whenever possible this should become a priority because of the increased rate of survival in patients. This data also addresses the need for faster availability of neuroimaging and other diagnostic tests, which relates well into my next article about the future of strokes and MRIs. There is a push for faster and faster diagnostics for time sensitive illnesses such as stroke. Neal et al,. (2014) suggests, “A 6-minute multimodal MR protocol with good diagnostic quality is feasible for the evaluation of patients with acute ischemic stroke and can result in significant reduction in scan time rivaling that of the multimodal computed tomographic protocol” (para. 20). This technology would make the 25-45 minute process of an MRI possible within 10 minutes and lead to faster response times by the healthcare team resulting in better patient outcomes. Better patient outcomes are a result of teamwork, technology, and evidence based practice. If there is a specified team to treat these patients then they are the best equipped to make decisions and the fastest to respond. Evidence based practice involves literature reading for things such as tPA administration. Although it is not the protocol yet, patients can and should receive this high-risk medication because the benefits outweigh the risk, even if the requirements are not fully met. And finally, technology needs to advance as fast, if not faster, than we advance. A six-minute MRI reading would significantly improve outcomes by cutting down door to treatment times. The goal is and always should be patient health and with these steps, stroke can be better treated and maybe soon, it will not be the fifth leading cause of death in the U.S. ReferencesBoston Medical Center. (2014). Stroke and Cerebrovascular Center. for Disease Control. (2015, March 24). Stroke facts. , Micheal A. (2015, Jan. 9). CPZ Isoenzymes Test. Medline Plus. , Jamary O. MD, MS, PhD. (2016, Feb.). Initial Assessment and Management of Acute Stroke. UpToDate. Filho, Jamary O. MD, MS, PhD, Samuels, Owen B. MD. (2016, Feb. 11). Reperfusion Therapy for Acute Ischemic Stroke. UpToDate. Lyerly, M. J., Albright, K. C., Boehme, A. K., Bavarsad Shahripour, R., Houston, J. T., Rawal, P. V., & ... Alexandrov, A. V. (2014). Safety of Protocol Violations in Acute Stroke tPA Administration. Journal Of Stroke & Cerebrovascular Diseases. Mayo Clinic Staff. (2016, Jan. 20). Stroke. Mayo Clinic. . (2016). Alteplase. , K., Khan, R., Choudhary, G., Meshksar, A., Villablanca, P., Tay, J., & ... Kidwell, C. S. (2014). Six-minute Magnetic Resonance Imaging Protocol for Evaluation of Acute Ischemic Stroke: Pushing the Boundaries. Rehab Measures. (2006). National Institutes of Health Stroke Scale. Center. (2016). Stroke Assessment Scales (NIHSS). The Internet Stroke Center. ................
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