Risk Factors Predisposing J. R. to a Stroke

QUESTION

J. R. is a 68-year-old Caucasian female. Five years ago, she had surgery (femoral-popliteal bypass) for arteriosclerosis obliterans of her lower extremities. She has a history of smoking ½ to 1 ppd of cigarettes for 50 years. She is mildly obese, weight 140 lbs., height 5′ 2″. Her adult weight at age 40 was 110 lbs. She has one highball or glass of wine a day. She has been on estrogen for 20 years. Family history: mother had adult-onset Type 2 diabetes and died of cancer at age 62; father died at age 35 from an industrial accident; first sister died of subarachnoid hemorrhage, age 65; second sister, age 60, hemiparetic as a result of CVA; two brothers died of cancer; one brother is hypertensive Type 2 diabetic; three younger sisters are alive and well.

J. R. developed a severe headache 24 hours ago that was not relieved by OTC analgesia. Several hours later, she experienced slurred speech and numbness of the fingers in her right hand, right side of her tongue, and lips. When the numbness and speech did not resolve after 4 hours, she asked her husband to take her to the hospital. She was admitted to the neurological intensive care unit. On admission, she still had a severe right-sided headache and was very anxious. She is oriented x 3 and able to follow commands. Vital signs: Oral temp 37 C, HR 90, Resp 16 non-labored, BP R upper extremity 230/110m L upper extremity 225/120, PERRL, LOC on GSC 15, speech clear, left upper extremity normal grip and no drift; right lower extremity, weaker grip than on left and arm drifts down without hitting bed; lower extremities, equal dorsiflexion and no drift bilaterally, however, client had difficulty performing right heel-shin test. Pin prick tests demonstrated normal sensation on left extremities and dullness on right extremities. Face, asymmetric smile, right facial weakness, cranial nerves all intact, bruit over left carotid, ophthalmoscopic exam, negative for papilledema and anisocoria; extraocular movements intact, no evidence of hemianopsia, negative for ptosis, ophthalmic artery pressure, decreased bilaterally. Reflexes were hyperreflexic on right; Babinski sign positive on right. Lumbar puncture yielded negative result for blood, total cell count, protein, and glucose were normal. EEG showed localized focal activity in the left hemisphere. Chest x-ray revealed a normal chest, no cardiomegaly. ECG was normal. Blood studies showed clotting profiles, CBC, electrolytes, and triglycerides all within normal levels, except for elevated blood glucose at 140 mg/dL. CT scan showed increased density on the left indicating an infarction. Digital angiogram revealed a narrowing of the carotid arteries bilaterally with greater involvement on the left. Evidence of ulcerated plaques in both arteries. Middle cerebral branches indicate narrowing and occlusion on the left.

Medications ordered for immediate IV administration: 250 mg ASA; clopidogrel 600 mg; labetalol 1-2 mg/min by continuous IV infusion; total dose of 300 mg has been used; lorazepam 0.05 mg/kg IM

Identify the risk factors that J. R. demonstrates to predispose her to a stroke.

Use the NIH stroke scale to assess this client and based on the results and other assessment findings, describe two nursing interventions you will need to implement.

Describe the purpose of each of the ordered medications.

Why is thrombolytic therapy not ordered by the provider?

ANSWER

Risk Factors Predisposing J. R. to a Stroke

Smoking: J. R. has a history of smoking half to one pack of cigarettes per day for 50 years. Smoking is a major risk factor for arteriosclerosis, which can lead to narrowing and blocking of blood vessels, increasing the likelihood of a stroke.

Age and Gender: Being a 68-year-old female, J. R. falls within an age group that is more susceptible to stroke. Additionally, females have a slightly higher lifetime risk of stroke compared to males.

History of Arteriosclerosis Obliterans: J. R. had surgery for femoral-popliteal bypass due to arteriosclerosis obliterans, which is a condition involving the hardening and narrowing of arteries. This history indicates an underlying vascular disease that can contribute to stroke risk.

Obesity: J. R. is mildly obese with a weight of 140 lbs. and a height of 5′ 2″. Obesity is associated with an increased risk of hypertension, diabetes, and cardiovascular diseases, all of which are stroke risk factors.

Alcohol Consumption:J. R. consumes a daily glass of wine. While moderate alcohol consumption might have some cardiovascular benefits, excessive intake can elevate blood pressure and contribute to stroke risk.

Estrogen Use: J. R. has been on estrogen for 20 years. Prolonged use of estrogen, especially in combination with smoking, can raise the risk of clot formation and stroke.

Family History: J. R.’s family history includes diabetes, hypertension, and stroke. Genetic factors can play a role in predisposing individuals to these conditions.

Hypertension: On admission, J. R. exhibited significantly elevated blood pressure (230/110 mmHg and 225/120 mmHg). Hypertension is a major risk factor for stroke as it strains blood vessels and increases the chances of vessel rupture.

Carotid Artery Disease: The digital angiogram revealed narrowing and ulcerated plaques in both carotid arteries. Carotid artery disease is a direct risk factor for ischemic stroke as it can lead to embolization of clots to the brain.

NIH Stroke Scale Assessment and Nursing Interventions

The NIH Stroke Scale (NIHSS) is a tool used to evaluate stroke severity.

Motor Function Assessment:Assess strength, drift, and grip strength in both upper and lower extremities. Nursing intervention: Frequent turning and positioning of the patient to prevent pressure ulcers due to decreased mobility.

Sensory Assessment: Test sensation to pinprick. Nursing intervention: Regular skin assessments to identify areas of decreased sensation and prevent skin breakdown.

Purpose of Ordered Medications

Aspirin (250 mg): Aspirin is an antiplatelet medication that inhibits platelet aggregation, reducing the risk of clot formation in blood vessels and preventing further clotting in case of a stroke.

Clopidogrel (600 mg): Clopidogrel is another antiplatelet drug that works to prevent blood clot formation by inhibiting platelet activation. It complements the action of aspirin to reduce the risk of clot-related complications.

Labetalol (1-2 mg/min IV): Labetalol is a beta-blocker used to lower blood pressure by reducing the force of the heart’s contractions and dilating blood vessels. It helps control hypertension, which is a risk factor for stroke.

Lorazepam (0.05 mg/kg IM): Lorazepam is a sedative that can help manage anxiety and promote relaxation in the patient. This can be particularly important in reducing stress and blood pressure levels.

Thrombolytic Therapy Consideration

Thrombolytic therapy involves using medication to break down blood clots and restore blood flow. While it can be highly effective if administered promptly, it carries a risk of bleeding complications, especially in patients with certain conditions.

In J. R.’s case, the presence of elevated blood pressure, recent surgery, and potentially large infarcted area on the CT scan might raise concerns about an increased risk of bleeding. Given the potential risks and the individualized nature of thrombolytic therapy, the healthcare provider may have deemed it inappropriate in this specific case.

In conclusion, J. R. presents multiple risk factors that predispose her to stroke, including her history of smoking, age, vascular disease, obesity, alcohol consumption, estrogen use, family history, hypertension, and carotid artery disease. The NIHSS assessment highlights motor and sensory deficits that require vigilant nursing interventions to prevent complications. The ordered medications aim to address clot formation, blood pressure, and anxiety. The decision to not use thrombolytic therapy may be based on her individual clinical profile and associated risks.