Neurological assessment.
39163Case Study: Neuro TIA
Mrs. G., a 59 year old African-American woman with hypertension and hypercholesterolemia, is brought to the emergency department by her husband. He noticed that all of a sudden his wife had slurring of her speech, along with slight numbness on the right side of her face and in her right arm.
She has a history of tobacco use: she quit ten years ago but started smoking occasionally last year. Mr. G. also smokes about one pack per day. She has a positive family history of heart disease. She occasionally takes walks in the neighborhood with friends, but does not have a regular exercise regimen.
In the emergency department, Mrs. G. is alert and oriented. Her vital signs are temperature 98.2 F (36.7C), blood pressure 148/97, pulse 81, and respiratory rate 14. An electrocardiogram (EKG) monitor shows a normal sinus rhythm. Mrs. G. is still complaining of numbness in her face and right arm. At this time, her speech is clear. She is able to move all of her extremities and follow commands. Her pupils are round, equal, and reactive to light (4mm to 2 mm) and accommodation. There is no nystagmus noted. Her right hand grasp is only slightly weaker than her left. Mrs. G. does not have a headache and denies any nausea, vomiting, chest pain, diaphoresis, or visual complaints. She is not experiencing any significant weakness, has a steady gait, and is able to swallow without difficulty. Laboratory blood test results are as follows: white blood cell count (WBC) 8,000 cells/mm, hemoglobin (Hgb) 14 G/dL , hematocrit (Hct) 38, sodium (Na) 149 mEq/L, Potassium (K) 4.5 mEq/L, glucose 105 mg/dL, calcium (ca) 9.5 mg/dL, blood urea nitrogen (BUN) 15 mg/dL, and creatinine (creat) 0.8 mg/dL. Coagulation studies were within normal limits. A head computed tomography (CT) scan is done which shows no acute intracranial change and magnetic resonance imagery (MRI) is within normal limits. Mrs. G. is started on an intravenous heparin drip of 25,000 units in 500cc of D5W at 18 ml per hour (900 units per hour). Mrs. G. is admitted for a neurology evaluation, magnetic resonance angiography (MRA) of the brain, a fasting serum cholesterol, and blood pressure monitoring. Upon admission to the nursing unit, her symptoms have completely resolved.
Questions:
1. On admission to the nursing unit, despite resolution of her symptoms, what are your priorities for assessment of Mrs. G.? Specifically, what additional questions would you ask? And what would you include in your physical assessment of Mrs. G?
2. The neurologist’s consult report states, “At no time during the episode of numbness did the client ever develop any scotoma, amaurosis, ataxia, or diplopia.” Explain what these terms mean.
3. What are the clinical manifestations of TIA? How does a TIA differ from a stroke?
4. Identify Mrs. G.’s predisposing risk factors for a TIA and possible stroke. Which factors are modifiable and which are not?
5. What type of lifestyle modifications should the nurse discuss with Mrs. G. and her husband prior to discharge? List the topics you would include for health teaching.
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