NU263 Unit 7 Stroke Thrombolysis Case Study Example

Forty Minutes Into the Infusion, a Sudden Headache: A Neurologic Case Study of a Composite 72-Year-Old Woman Given Alteplase for a Left-Hemisphere Ischemic Stroke, From Last Known Well Through the Moment the Drip Was Stopped and the Scan That Followed

[Student Name]

Purdue University Global

NU263: Medical-Surgical Nursing III

Unit 7 Neurologic Case Study

[Instructor Name]

[Date]

The patient is composite; scale scores, values and times are bracketed where illustrative, and every decision to treat, stop or reverse belongs to the stroke team.

Arrival

[Mrs. O.], composite, 72, with hypertension and atrial fibrillation not on anticoagulation, was found by her husband at [0815] unable to speak clearly, with a weak right arm. She had been normal when he left for a walk at [0730]. Last known well: [0730], not the time she was found. On arrival at [0840]: blood pressure [192/100], glucose [138], NIH Stroke Scale [14] with expressive aphasia, right facial droop and right arm and leg weakness. CT at [0855] showed no bleeding.

Last Known Well, Not Found

The clock for treatment starts at the last moment someone saw her normal, which may be well before anyone noticed a problem. If her husband had found her on waking with no knowledge of when symptoms began, last known well would be the night before, and she might not have been eligible.

Pressure Before and After

Alteplase is given only if blood pressure can be lowered below [185/110] and then kept below [180/105] for the following day, because high pressure raises the risk of bleeding into the brain. Her pressure was lowered with IV labetalol as ordered to [178/96], and the alteplase bolus and infusion began at [0920] (Harding et al., 2023).

Forty Minutes In

At [1000], she said, through her aphasia, "head," and pointed to it. She vomited once. Blood pressure [196/104]. NIH Stroke Scale rose from [12], measured at [0945], to [17].

A new headache, vomiting and a rising score during alteplase are treated as bleeding until the scan says otherwise.

The nurse stopped the infusion immediately, notified the stroke team and prepared her for an emergency CT. Symptomatic bleeding into the brain is the most feared complication of thrombolysis: in the original trial it occurred in about 6 percent of treated patients compared with under 1 percent of those given placebo (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995), and later trials in extended windows also found a higher rate than with placebo (Hacke et al., 2008).

The Scan and What Followed

CT at [1012] showed a small bleed within the area of the stroke. The team gave treatment to reverse the clot-dissolving drug as ordered and lowered her pressure further. Her NIH Stroke Scale peaked at [18] and was [16] at [1400].

Scores, Not Impressions

Neurologic checks followed the post-thrombolysis schedule: every [15] minutes for two hours, every [30] minutes for six hours, then hourly. Each check included the NIH Stroke Scale or the unit's focused version, pupils, level of consciousness and blood pressure. Recording a number rather than "no change" let the team see that her score had risen by five points in fifteen minutes.

No Sip Before the Screen

She remained nothing by mouth, including her medications, until a bedside swallow screen was passed. Trouble speaking and a drooping face often mean trouble swallowing, and pneumonia is a common complication after stroke. Her screen at [1600] was failed; speech therapy evaluated her the next morning.

Why the Nurse Did Not Wait for the Scan

Stopping the infusion before the scan confirmed bleeding meant accepting that the scan might be normal and the drug would have been stopped early. The team accepted that trade because continuing a clot-dissolving drug into a growing bleed can be catastrophic, while stopping it in a patient without bleeding usually costs less. Unit protocols for thrombolysis list a sudden severe headache, vomiting, rising blood pressure or worsening neurologic score as reasons to stop the infusion at once. The nurse's role is to recognize those signs, act on the protocol and report, not to decide whether bleeding is present.

Priorities in Her First Hours

1. Neurologic status: scale scores on schedule, any change reported at once.

2. Blood pressure: below the post-treatment target, with IV medication as ordered.

3. Airway and aspiration: head of bed raised, nothing by mouth, suction available.

4. Her husband: kept informed in plain language, including the bleed and what it means.

Teaching Her Husband

Her husband asked why the drug had been given if it could cause bleeding. The nurse explained that the drug offered the best chance of restoring blood flow to the part of her brain that controls speech and movement, that bleeding is a known risk the team had weighed with him before starting, and that stopping early limited the harm. He was told what would happen next: close checks, blood pressure control, swallowing tests and therapy.

Evaluation

By day three, her score was [11]. She remained aphasic but could follow simple commands and was moving her right leg. Her husband said the most helpful thing was being told why the drip was stopped.

References

Hacke, W., Kaste, M., Bluhmki, E., Brozman, M., Dávalos, A., Guidetti, D., Larrue, V., Lees, K. R., Medeghri, Z., Machnig, T., Schneider, D., von Kummer, R., Wahlgren, N., & Toni, D. (2008). Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England Journal of Medicine, 359(13), 1317-1329. https://doi.org/10.1056/NEJMoa0804656

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. (1995). Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 333(24), 1581-1588. https://doi.org/10.1056/NEJM199512143332401