Case Study: Vertebral Artery Occlusion in a Patient with Diabetes and Hypertension

This case study explores the manifestation, causes, and management of vertebral artery occlusion in a patient with diabetes and hypertension. It discusses the patient's symptoms, vital signs, and discharge planning.

Running head: CASE STUDY
Case study
Name of the Student:
Name of the University:
Author Note:

1CASE STUDY
Part 1:
The patient, James Bourne in the provided case study has been presented to the
emergency with the primary problems of severe headache and a feeling of dizziness. The
provided patient data also suggests that the Mr.James suffers from the chronic illness of Diabetes
and Hypertension. During the time of patient, admission, the pain assessment score for the
patient was 8/10 which suggested that the intensity of the pain experienced by the patient was
severe. Also, the presenting complaints of the patient included a double vision as well as feeling
of dizziness. A vital assessment of the patient was conducted before admission which revealed
abnormality of the vital signs. The temperature was reported to be to 36.5ᵒ C which was around
the normal range and the pulse rate was reported to be 73 beats per minute, which again was
normal as the normal pulse range is between 60 to 100 beats per minute. The respiratory rate was
observed to be around 15 breaths per minute which was also within the normal range of 12 to 20
breaths per minute. The blood pressure and SpO2 was assessed to be 170/90 and 94% at room
temperature. The blood pressure was significantly elevated considering the normal range of
120/80 mm Hg. The SpO2 level however was estimated lower than the normal range of 96% to
99%. In addition to this, the blood glucose level was reported to be 6.5 mmol/L suggesting that
the patient’s blood glucose level was poorly managed. The eye assessment stated that the pupil
response was brisk and was equivalent, round as well as appropriately reactive to light. The
Glascow Coma Score had been reported to be 15 and the pupil size was reported reported
equivalent to 3mm on the left as well as right side. In addition to this, the other complaints
included weakness and loss of strength of the let limb. The right limb on the other hand was
normal and overall the patient was diagnosed for the medical condition of vertebral artery
occlusion.

2CASE STUDY
The evidence base in this regard states that the manifestation and clinical symptoms of
the disorder widely vary from one person to other. The cause that can be attributed to the same
can be explained as the condition that triggered occlusion as well as the place where the ischemia
has supposedly taken place (Naylor et al., 2018). It is pivotal to note here that the most prevalent
symptoms of the medical condition comprise of headache, feeling of stiffness or numbness
within the muscles, experiencing vertigo and dizziness (van Houwelingen et al., 2016). Also,
symptoms such as diplopia, altered mental status as well as weakness or hemiparesis are
common and manifest with the disorder.
The vertebrobasilar arterial system consists of the vertebral as well as basilar arteries and
is located in the posterior-region of the brain. The vertebrobasilar arterial system is responsible
for maintaining the optimal supply of oxygenated blood and important nutrients to different parts
of the body that includes vital organs such as brain stem and the cerebellum (Moon et al., 2017).
The deposition of cholesterol and fatty acid substances within the arterial surfaces causes
contraction of the arterial surface. This leads to interrupted blood circulation which triggers the
formation of a blockage or an occlusion (Qureshi et al., 2017). The formation of occlusion is
even more risk prone in patients suffering from hypertension and this is broadly on account of
the excess strain that is exerted within the arteries. Therefore, in a nutshell it can be said that the
constriction of the arteries on account of deposition of fatty substance or cholesterol increases the
probability of formation of clot and the formation of clot can cut down the supply of nutrition
and oxygen to other parts of the body which can leads to paralysis or stroke (Jenkins & Stewart,
2017).

3CASE STUDY
Part 3:
During the time of discharge, the priority nursing diagnoses would include;
 Pain management
 Lack of strength in the left limb
In order to facilitate complete recovery of the patient, the short-term and the long-term illness
goals would be specified. The short-term goals would essentially focus on immediate
recovery goals and the long-term goals would focus on the attainment of the holistic recovery
goal. Thus, the short-term goals for the patient would comprise of the following:
 Demonstration of stable vital signs
 Effective pain management
The long term recovery goals would include the following:
 Patient would be able to walk without assistance
 Patient would be able to regulate and monitor the blood glucose level
Demonstration of stable vital signs: According to Vargas et al. (2017), it has been mentioned that
a stable set of vital signs exhibits a stable physiological state. This accounts for the reason why
prior to discharge planning it is integral to ensure that the vital signs of the patient is stable. In
order to ensure the same hourly vital sign assessment of the patient would be carried out.
Effective pain management: During presentment, the patient had complained of pain with pain
score (8/10). During discharge planning the pain score suggests minimal pain, however, the
patient would still be prescribed over the counter aspirins or other non-steroidal pain relief
medication so as to assist with the recovery process (Shafafy et al., 2017).

4CASE STUDY
Patient would be able to walk without assistance: Post the latest assessment, it can be said that
the patient is unable to walk independently without assistance and is devoid of energy in his left
limb (Zhou et al., 2015). In order to facilitate recovery, the patient would be referred for
physiotherapy. The rationale can be explained as the positive recovery that can be fostered with
the effective use of physiotherapy techniques.
Patient would be able to regulate and monitor the blood glucose level: As has already been
discussed the patient already has poorly managed symptoms of Diabetes Type II and this can
exacerbate the symptoms of vertebral artery occlusion (Savastano et al., 2016). In order to ensure
prevention, health literacy would be imparted to the patient so as to ensure that the patient adapts
a healthy lifestyle and is also able to self-monitor the blood glucose level using the glucometer
strips (Gerber et al., 2017).
Part 4:
Before releasing the patient, the patient would be first asked to attend the discharge
planning. The discharge planning for the patient would be conducted at the discharge planning
unit where in the multidisciplinary health professionals involved in the care process of the patient
would collectively plan an effective discharge plan for the patient. The patient would be referred
to a physiotherapist for the ensuring recovery of the left limb. In addition to this, the patient
would also be referred to a nutritionist who would appropriately devise nutritional charts in order
to ensure that the blood glucose level of the patient is managed (Viso et al., 2019). Also, the
nutritionist would devise an effective diet plan that would help to effectively manage the
symptoms of hypertension. The rationale for the same can be explained as the close association
of hypertension with the exacerbation of the symptoms of vertebral artery occlusion (Aboyans et

5CASE STUDY
al., 2017). In addition to this, during the discharge planning process, the nurse would impart
health literacy to the patient and the family members of the patient about the existing physical
health problem of the patient and disseminate awareness about the risk factors that could
possibly aggravate the symptoms of the disorder. Also, the patient would be taught self-
management strategies such as how to manage his medication and monitor his blood glucose
level so that recovery is acquired (Roche et al., 2017). The family members of the patient would
be made aware about the warning symptoms which could relapse in patient and would be asked
to contact the emergency at the earliest (Fujita et al., 2018). The patient would then be asked to
attend the follow up visit and discharged from the hospital.
Part 5:
The clinical reasoning cycle is an important reflective model that helps nursing
professionals to closely assess a live-patient scenario (Rossen et al., 2019; Holder, 2018). It helps
nurses to identify cues and make best use of the knowledge and the evidence base to create and
implement a recovery plan. Working on this experience was indeed an incredible one as I learnt
to make use o the clinical reasoning cycle and evaluate a case scenario with the help of the
clinical reasoning cycle (Kim et al., 2016). Also, this assignment helped me identify cues from
the patient’s case study and accordingly make use of the evidence base to address the identified
care priorities with appropriate supporting rationale (Hunter & Arthur, 2016). Further, this
assignment also helped me to apply appropriate interventions for patients affected with multiple
co morbidities. Overall, this assignment helped me to gain an effective understanding about how
the clinical reasoning cycle can be put to practice, Further, it also helped me enhance my
professional skills on providing holistic care to the patient (Dalton et al., 2016). The assignment
also helped me to improvise professionally and appropriately address the assignment using

6CASE STUDY
proper writing styles. I have also learnt the correct way to identify patient cues, look up the
evidence base and how to connect the two facts and present in the assignment (Gummesson et
al., 2018). Earlier, I faced problem with respect to these aspects but I feel that now I have
acquired substantial expertise to address tasks of similar nature in future.

7CASE STUDY
References:
Aboyans, V., Björck, M., Brodmann, M., Collet, J. P., Czerny, M., De Carlo, M., ... & Ricco, J.
B. (2017). Questions and answers on diagnosis and management of patients with
Peripheral Arterial Diseases: a companion document of the 2017 ESC Guidelines for the
Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the
European Society for Vascular Surgery (ESVS) Endorsed by: the European Stroke
Organisation (ESO) The Task Force for the Diagnosis and Treatment of Peripheral
Arterial Diseases of the European Society of Cardiology (ESC) and of the European
Society for Vascular Surgery (ESVS). European heart journal, 39(9), e35-e41. Retrieved
from: https://academic.oup.com/eurheartj/article/39/9/e35/4095044
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing,
The, 33(2), 29. Retrieved from:
https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHEA
Fujita, Y., Aihara, H., Nagashima, H., Morishita, A., Aoki, K., Takayama, H., ... & Kohmura, E.
(2018). Clinical Features and Treatment Strategy of Vertebral Artery Injury Associated
with Cervical Spine Trauma. No shinkei geka. Neurological surgery, 46(8), 663-671.
DOI: 10.11477/mf.1436203791
Gerber, J. C., Daubner, D., Kaiser, D., Engellandt, K., Haedrich, K., Mueller, A., ... &
Abramyuk, A. (2017). Efficacy and safety of direct aspiration first pass technique versus
stent-retriever thrombectomy in acute basilar artery occlusion—a retrospective single

8CASE STUDY
center experience. Neuroradiology, 59(3), 297-304. DOI: https://doi.org/10.1007/s00234-
017-1802-6
Gummesson, C., Sundén, A., & Fex, A. (2018). Clinical reasoning as a conceptual framework
for interprofessional learning: a literature review and a case study. Physical Therapy
Reviews, 23(1), 29-34. DOI: https://doi.org/10.1080/10833196.2018.1450327
Holder, A. G. (2018). Clinical Reasoning: A State of the Science Report. International journal of
nursing education scholarship, 15(1). DOI: https://doi.org/10.1515/ijnes-2016-0024
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, 73-79. DOI:
https://doi.org/10.1016/j.nepr.2016.03.002
Jenkins, J. S., & Stewart, M. (2017). Endovascular treatment of vertebral artery
stenosis. Progress in cardiovascular diseases, 59(6), 619-625. DOI:
https://doi.org/10.1016/j.pcad.2017.02.005
Kim, Y. W., Hong, J. M., Park, D. G., Choi, J. W., Kang, D. H., Kim, Y. S., ... & Lee, J. S.
(2016). Effect of intracranial atherosclerotic disease on endovascular treatment for
patients with acute vertebrobasilar occlusion. American Journal of
Neuroradiology, 37(11), 2072-2078. DOI: https://doi.org/10.3174/ajnr.A4844
Moon, K., Albuquerque, F. C., Cole, T., Gross, B. A., & McDougall, C. G. (2017). Stroke
prevention by endovascular treatment of carotid and vertebral artery dissections. Journal
of neurointerventional surgery, 9(10), 952-957. DOI:
http://dx.doi.org/10.1136/neurintsurg-2016-012565

9CASE STUDY
Naylor, A. R., Ricco, J. B., De Borst, G. J., Debus, S., De Haro, J., Halliday, A., ... & Markus, H.
S. (2018). Editor's choice–management of atherosclerotic carotid and vertebral artery
disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery
(ESVS). European Journal of Vascular and Endovascular Surgery, 55(1), 3-81. DOI:
https://doi.org/10.1016/j.ejvs.2017.06.021
Qureshi, A. I., Chaudhry, S. A., Eckstein, H., Jansen, O., & Ringleb, P. A. (2017).
Asymptomatic extracranial vertebral artery disease in patients with internal carotid artery
stenosis. Neurosurgery, 81(3), 531-536. DOI: https://doi.org/10.1093/neuros/nyx092
Roche, A. D., Murphy, B., Adams, N., Sheahan, R., Brennan, P., & Looby, S. (2017). Direct
common carotid artery puncture for endovascular treatment of acute large vessel
ischemic stroke in a patient with aortic coarctation. Journal of Stroke and
Cerebrovascular Diseases, 26(11), e211-e213. DOI:
https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.07.017
Rossen, J., Limaye, K., & Hasan, D. (2019). Tandem Occlusion Causing Acute Ischemic Stroke.
In Acute Stroke Management in the Era of Thrombectomy (pp. 119-128). Springer, Cham.
Retrieved from: https://link.springer.com/chapter/10.1007/978-3-030-17535-1_10
Savastano, L., Gemmete, J. J., Pandey, A. S., Roark, C., & Chaudhary, N. (2016). Acute
ischemic stroke in a child due to basilar artery occlusion treated successfully with a stent
retriever. Journal of neurointerventional surgery, 8(8), e33-e33. DOI:
http://dx.doi.org/10.1136/neurintsurg-2015-011821.rep

10CASE STUDY
Shafafy, R., Suresh, S., Afolayan, J. O., Vaccaro, A. R., & Panchmatia, J. R. (2017). Blunt
vertebral vascular injury in trauma patients: ATLS® recommendations and review of
current evidence. Journal of Spine Surgery, 3(2), 217. DOI: 10.21037/jss.2017.05.10
van Houwelingen, R. C., Luijckx, G. J., Mazuri, A., Bokkers, R. P., Eshghi, O. S., &
Uyttenboogaart, M. (2016). Safety and outcome of intra-arterial treatment for basilar
artery occlusion. JAMA neurology, 73(10), 1225-1230. DOI: DOI:
10.1001/jamaneurol.2016.1408
Vargas, J., Spiotta, A. M., Fargen, K., Turner, R. D., Chaudry, I., & Turk, A. (2017). Experience
with A Direct Aspiration First Pass Technique (ADAPT) for thrombectomy in distal
cerebral artery occlusions causing acute ischemic stroke. World neurosurgery, 99, 31-36.
DOI: https://doi.org/10.1016/j.wneu.2016.11.035
Viso, R., Lylyk, I., Perez, N., & Lylyk, P. (2019). Posterior Inferior Cerebellar Artery Aneurysm:
Dissecting Aneurysm Treated in Multiples Sessions and Multiple Endovascular
Modalities. The Aneurysm Casebook: A Guide to Treatment Selection and Technique, 1-
13. Retrieved from: https://link.springer.com/content/pdf/10.1007/978-3-319-70267-
4_57-1.pdf
Zhou, M., Zheng, H., Gong, S., Guo, J., Chen, N., Zhou, D., ... & He, L. (2015). Vertebral artery
hypoplasia and vertebral artery dissection: a hospital-based cohort
study. Neurology, 84(8), 818-824. DOI:
https://doi.org/10.1212/WNL.0000000000001284