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Hemorrhagic Stroke: Taylor Henderson
Background
Meet Taylor Henderson, a 66 year-old caucasian female with a passion for art and southern hospitality. She loves cooking with butter and salt, and has a history of hypertension and high cholesterol to go with it. She has never smoked and has no history of alcohol abuse. She takes metoprolol for her hypertension and atorvastatin for her hyperlipidemia. Both her mother and father had a history of hypertension, hyperlipidemia, and smoking. Mrs. Henderson’s mother passed away from an ischemic stroke at the age of 82. Her father is still alive, lives with her, and smokes in their shared house.
Story
Mrs. Henderson had been an aspiring artist as a young woman before she settled down, had 5 kids, and became an elementary school teacher. She was in the middle of guiding her students through water coloring project (her favorite!) when she suddenly got a really bad headache. She knew deep down that something was wrong, but felt like she couldn’t leave her young students, so she took an aspirin for the headache and finished the rest of the school day. She wanted to go to the hospital but felt like her body wasn’t working right and that she couldn’t drive herself. She thought about calling her son to pick her up, but didn’t want to bother him while he was at work. It was really bad now, she had never been in so much pain! She called 911 and was able to tell them her location and that she had a horrible headache, but couldn’t give them any more information than that. She felt weak like she couldn’t stand up anymore and fell to the ground. The ambulance arrived in 10 minutes and took her to Los Robles Hospital. Upon initial assessment the paramedics noticed left-sided facial drooping, slurred and disorganized speech, and generalized left-sided weakness. On the way to the hospital the paramedics initiated a code stroke through calling Los Robles Emergency Department.
Day 1
Because the paramedics had called ahead, the triage nurse was able to immediately place mrs. Henderson in an exam room, her vitals were taken, two 18 gauge IVs were started, blood glucose was checked, and labs were drawn immediately. Upon arrival to the hospital Mrs. Henderson’s vital signs were: BP 160/9, HR 104, RR 11, O2 saturation 84% on room air. Mrs. Henderson was quickly intubated to protect her airway. After intubation her O2 saturation increased to 96%. She was then assessed using the NIH stroke scale and scored 18 for being not alert and requiring repeated stimulation to arouse, unilateral facial palsy, motor and sensory deficits on her left side including drift, and visual, auditory, and spatial inattention. Within 10 minutes the emergency department physician arrived to assess Mrs. Henderson. He ordered a CT scan of the head and neck which confirmed that she had right-sided hemorrhagic stroke. After consulting with a neurosurgeon, the physician decided against surgery and instead to treta Mrs. Henderson conservatively. He admitted her to the neuro ICU floor and ordered hourly neuro checks, NPO status, telemetry monitoring, 0.9% normal saline running to 125mL/hr, and ventilator setting of: SIMV 12, FiO2 30%, tidal volume 500, and a PEEP 5.
Nursing actions included monitoring: airway protection, vitals, changes in level of consciousness, neurologic checks, signs and symptoms of increased ICP such as headache, nauseam, and vomiting, and labs (CBC with differential, chemistry, coagulation, blood type & screen, cardiac panel, and alcohol level) Other nursing actions include keeping the head of the bed at 30 degrees, medication reconciliation to make sure that she keeps receiving her home medications to control blood pressure and hyperlipidemia, administering oral care, and calling her son to let him know his mom was in the hospital.
Day 2
In the Neuro ICU, Mrs. Henderson’s neurological status continually improved. In the morning the respiratory therapist assessed Mrs. Henderson who was able to pass her spontaneous breathing trials which enabled her to extubated that morning and was placed on 2L nasal cannula with O2 saturation of 94%. By the end of the shift she was ale to recall her name, the year, and that she was in the hospital, but her memory of her hospitalization was still a little spotty and her speech was slightly slurred. She was able to move her right extremities against gravity, but she was still experiencing significant left-sided weakness and had drift in both extremities. Her vital signs were within normal limits (WNL) aside from her blood pressure being slightly elevated, which is a normal finding after a stroke: BP 146/88, HR 89, RR 19, Temp 99.0, and O2 Sat 97% on 2L NC and her NIHSS score decreased to 13.
Orders
Mrs. Henderson’s doctor ordered Physical, Occupational, and Speech therapy with a swallow evaluatioin.
Swallowing Screen
Mrs. Henderson was kept NPO up to this point in her hospitalization due to high risk of aspiration status post stroke. In the afternoon, the speech therapist arrived to administer Mrs. Henderson’s swallow evaluation. She determined that it was safe to advance Mrs. Henderson’s diet to Dysphasia 1 with nectar thick liquids as long as appropriate precautions were implemented such as eating slowly and keeping the head of the bed 90 degrees during feedings.
Physical and Occupational Therapy
Mrs. Henderson’s physical therapist worked with her throughout the day to perform range of motion exercises. She was able to complete active range of motion exercises on her right side, but her left side required passive range of motion. In addition the occupational therapy worked with Mrs. Henderson to perform basic ADLs such as changing clothes and brushing her teeth. Unfortunately, Mrs. Henderson was left handed, so her left sided weakness made tasks such as writing difficult which was difficult for her to realize. Her nurse was able to remind her that recovery can be a slow process and remind her how far she has already come on only the second day. This reassured Mrs. Henderson and allowed her to keep positive outlook on her care.
Day 3
On day 3 Mrs. Henderson was transferred from the ICU to the general medical surgical unit. Upon assessment Mrs. Henderson had stable vital signs WNL: BP of 130/80, HR of 80, RR of 17, Temp. 98.0 F, O2 Saturation 98% on 1L NC, 0/10 for pain, and an NIHSS score of 8. Neurologically Mrs. Henderson was alert and oriented x 4. Her left-sided weakness was still significant and since she is left handed she has had to depend on others and adapt to conducting activities of daily living with her right hand. Due to the marked weakness on the left side, continued work with PT and OT was needed.
PT, OT, and Speech Therapy Services:
Due to the residual effect of Mrs. Henderson’s recent hemorrhagic stroke PT, OT and speech therapy were scheduled daily. Due to the generalized weakness she is still on a thickened liquids and soft food diet. Mrs. Henderson was still dependent on the nurses, CNAs and family members to perform activities of daily living. Mrs. Henderson ambulates with the use of four-wheel walker and the use of a gait belt with the help of a rehabilitation therapist. Mrs. Henderson continued to have slurred speech but has passed the swallow studies. Speech therapy is still working with Mrs. Henderson to make sure that she is effectively eating food and to improve her speech.
Day 4-6
On day 4-6 Mrs. Henderson continued to receive PT, OT, and speech therapy on the medical surgical unit. Mrs. Henderson started to use the assistive eating devices with her left hand while working with the rehabilitation therapists. her strength on the left side was still weak but has definitely improved since the hemorrhagic stroke. During these three days Mrs. Henderson was able to ambulate for a longer period of time with the therapists each day, but still needed the therapists to use the gait belt while she used the four-wheel walker. Mrs. Henderson was determined at first, but at her last OT session she asked her therapist, “Am I always going to have to struggle like this for everything? Will I ever get to eat without someone helping me? Or pet the dog or paint again? How could I ever go back to the classroom like this?” and broke down crying. Mrs. Henderson was reassured that with time and determination she will get stronger, but that it will be slow process.
Day 7+
On day 7 Mrs. Henderson was discharged from Los Robles Hospital and Medical Center to the Acute Rehabilitation Unit (ARU) that is associated with Los Robles Hospital. The plan is for Mrs. Henderson to stay at the ARU for at least two weeks. Her goals while she is at the ARU are to increase her independence in completing her activities of daily living, increase her strength on the left side of her body, and improve her quality of speech. Her time at the ARU was frustrating for Mrs. Henderson because it took a lot of patience for her to recover from the stroke. Two weeks after being transferred to the ARU, Mrs. Henderson was discharged home. Although she was discharged home she needed to continue to attend physical therapy appointment to ensure that she will continue to get stronger and improve her independence. It is unclear if she has transportation to get to these appointments. Although she lives with her husband and father and son lives in town, Mrs. Henderson is reluctant to ask them to drive her places because she doesn’t want to be a burden.
Case Management
Throughout Mrs. Henderson’s recovery, a key member of her healthcare team was her case manager. Oliver. Oliver was able to uncover Mrs. Henderson’s livelihood. As a result, he was able to educate her about healthier options to substitute in her diet and cooking in order to ensure that she was still able to continue doing things she loved. In addition, he determined that another area of concern was Mrs. Henderson’s father, Arthur, continuing to smoke in their shared house. Arthur was aware of his risk factors resulting from smoking, but he had no intention of quitting. However, he deeply cares for his daughter, so Oliver was able to teach him to smoke outside and away from the house in order to protect his daughter from the effects of secondhand smoke. Lastly, Oliver was able to help Mrs. Henderson with her feelings of being a burden on her family. He arranged a family meeting with Mrs. Henderson, her father, and her son, and they all assured Mrs. Henderson that they wanted to do everything they could to assist with her recovery. This allowed Mrs. Henderson to feel more upon and willing to accept the help she knew she would need in order to recover.
Case Study Questions
- Did Mrs. Henderson’s family history increase her risk of experiencing a stroke? Why or why not?
- What are some lifestyle modifications Mrs. Henderson should consider?
- Explain whether or not Mrs.Henderson’s care was provided in a way that is backed up by current evidenced-based research.
