Nursing Case Study: Mr. Brown

This nursing case study discusses the assessment procedures for Mr. Brown's post-angioplasty risk of developing an ischemic stroke and the assessments that should have been performed but were not done. It also includes a clinical handover of Mr. Brown using the ISBAR format.

Running head: NURSING CASE STUDY: MR. BROWN
NURSING CASE STUDY: MR. BROWN
Name of the Student:
Name of the University:
Author note:

1NURSING CASE STUDY: MR. BROWN
Question 1
From the assessment reports performed for Mr. Brown, the following assessment
procedures were correct as per his post-angioplasty risk of developing an ischemic stroke:
1. Pain Assessment: The risk of ischemic stroke is associated with a hematoma or a
thrombus blocking the blood vessels, resulting in disrupted circulation to surrounding
muscles, resulting in pain, which is a why a PQRST assessment is of utmost importance.
Hence, an adequate PQRST will involve a enquiring Mr. Brown using a patient, centered
approach, on how palliative or provoking his pain his pain is, the quality of his pain,
where does his pain radiate to, the severity of his pain and the timing of his pain. A
PQRST was performed adequately as observed from Mr. Brown’s description that his
pain radiated from his chest, arm and to the jaw (Raina, Krishnappa & Gupta, 2018).
2. Neurovascular Observation: A possible ischemic stroke post angioplasty, due to
disrupted circulation and hemorrhage resulting in hindered cerebral and neurovascular
functioning. A neurovascular observation as evident from the handover is performed
every 15 minutes and will involve nursing inspection of the reaction to towards light by
Mr. Brown’s pupil, the accommodation of the same, the presence of any form of
asymmetry in his face and a complete evaluation of his level of consciousness, such as
the presence of lethargy, coma, stupor and obtundation in Mr. Brown (Schreiber, 2016).
However, considering the condition of pain, risk of hematoma-induced ischemia in the
wound as well as history of diabetes, the following assessments should have been performed but
were not done so:

2NURSING CASE STUDY: MR. BROWN
1. Lower Limb and Wound Assessment: It has been mentioned that no form of lower
limb and wound assessment for the presence of any adenoma or bleeding surrounding
the puncture site. A major complication associated with angioplasty is the emergence of a
perfusion in the tissues resulting in an adenoma and hence the risk of an ishchemic
stroke. Hence, a lower limb assessment must be performed which will include the nurse
inspecting the wound are of Mr. Brown (Spillerova et al., 2015). This will involve
nursing inspection for any form of bleeding, oozing or exudates secretion from the
wound. The nurse must also inspect the wound site for the presence of any form of
hematoma which can be indicated by the presence of purple discoloration, redness,
swelling and increase of temperature. In the situation of any form of bleeding or
hematoma, the nurse then proceed to induce some form of compression using which may
encourage blood flow and stimulate homeostasis (Rahimi et al., 2016).
2. Vital Signs: A complete vital sign assessment was not performed in Mr. Brown. Hence
the nurse must be proceed to check Mr. Brown’s pulse, his rate of respiration,
temperature and rate of oxygen saturated in his blood. A vital signs assessment indicates
basic body functioning and hence abnormal finding is indicative of an emergency or
disease condition (Guy Jr et al., 2017).
3. Blood Glucose Assessment: There was no monitoring of the patient’s blood glucose
level despite knowing that the patient has a history of diabetes. Hence, Mr. Brown’s
blood glucose level must be evaluated immediately in order to monitor his diabetic status,
since metabolic complications are key facilitator in the development of an ischemic
stroke (Lau et al., 2018).

3NURSING CASE STUDY: MR. BROWN
4. Head-to-Toe/ABCD assessment: A complete physical assessment must be performed in
the patient since an ischemic stroke can be predicted with the detection of any form of
deformities. Hence the nurse must perform a head-to-toe assessment of Mr. Brown an
check him for any signs of abnormal mobility such as paralysis, discoloration and facial
deformities (Poggenborg et al., 2015). An ABCD assessment will include evaluating Mr.
Brown’s airways, his rate of breathing for any form of abnormal sounds, his blood
circulation, such as pressure, heart rate or capillary refill time (a key marker of adenoma)
and presence of disability (due to ischemia induced blood loss) (Smith & Bowden, 2017).
5. FAST Assessment: The nurse check Mr. Brown, for any form of drooping in his facial
features, weakness in his arms, abnormalities while speaking and the requirement to call
for an emergency stroke management plan (Sheppard et al., 2015).
6. Pain Score: Merely evaluating the pain score is a violation of clinical quality in nursing
practice in terms of the NMBA standards. Hence, the score must be determined using
evidenced based frameworks such as the Flacc tool Faces Rating Scale (Samona et al.,
2017).
7. GCS: A Glasgow Coma Scale will aid in the determination of Mr. Brown’s level of
consciousness since altered mental state is a key symptom of ischemic stroke (Chou et
al., 2017).
Question 2
Hence the clinical handover of Mr. Bright as per the ISBAR format will be as follows
(Kitney et al., 2018):

4NURSING CASE STUDY: MR. BROWN
 Indentify: As per the first step of the ISBAR tool, the nursing student must aim to first
introduce herself or himself as the nurse allocated for the care and assessment of Mr.
Bright. After this, the nurse must proceed by identifying the situation that and state that
he or she has arrived with the care handover details of Mr. Brown.
 Situation: After this, the nurse will then proceed to explain the concerned situation to the
clinician or medical officer in charge Mr. Brown. Hence the nurse must enlighten the
doctor that the Mr. Brown has just received an angioplasty and is complaining of
radiating pain in his arms, jaws and chest. The nurse must also inform that at present, in
addition to PQRST and Neurovascular Observation, additional vital signs, pain score,
ABCD and wound assessments have also been performed.
 Background: The nurse discuss the medical history of Mr. Brown and enlighten that he
has a history of diabetes and chronic smoking and is currently complaining of pain after
administration of angioplasty.
 Assessment: Using pain score, vital signs, wound assessment, blood glucose monitoring
and neuro obs assessment the nurse will highlight that the patient’s pain and his
assessment results indicate a risk of ischemic stroke after angioplasty.
 Recommendation: As per the assessment results and medical history of Mr. Brown, the
nurse will recommend that consideration of his blood glucose levels and pain is of utmost
importance and mere pharmacological interventions may not be sufficient to mitigate his
risk of ischemic stroke. Hence, the need of the hour is to conduct further cardiovascular
assessment and considering administration of appropriate medications for the purpose of
pain and stroke mitigation.


5NURSING CASE STUDY: MR. BROWN
References
Chou, R., Totten, A. M., Pappas, M., Carney, N., Dandy, S., Grusing, S., ... & Newgard, C.
(2017). Glasgow coma scale for field triage of trauma: a systematic review.
Guy Jr, G. P., Zhang, K., Bohm, M. K., Losby, J., Lewis, B., Young, R., ... & Dowell, D. (2017).
Vital signs: changes in opioid prescribing in the United States, 2006–2015. MMWR.
Morbidity and mortality weekly report, 66(26), 697.
Kitney, P., Bramley, D., Tam, R., & Simons, K. (2018). Perioperative handover using ISBAR at
two sites: A quality improvement project. Journal of Perioperative Nursing, 31(4), 17.
Lau, L. H., Lew, J., Borschmann, K., Thijs, V., & Ekinci, E. I. (2018). Prevalence of diabetes
and its effects on stroke outcomes: A meta‐analysis and literature review. Journal of
diabetes investigation.
Poggenborg, R. P., Eshed, I., Østergaard, M., Sørensen, I. J., Møller, J. M., Madsen, O. R., &
Pedersen, S. J. (2015). Enthesitis in patients with psoriatic arthritis, axial
spondyloarthritis and healthy subjects assessed by ‘head-to-toe’whole-body MRI and
clinical examination. Annals of the rheumatic diseases, 74(5), 823-829.
Rahimi, R., Ochoa, M., Parupudi, T., Zhao, X., Yazdi, I. K., Dokmeci, M. R., ... & Ziaie, B.
(2016). A low-cost flexible pH sensor array for wound assessment. Sensors and
Actuators B: Chemical, 229, 609-617.
Raina, R., Krishnappa, V., & Gupta, M. (2018). Management of pain in end‐stage renal disease
patients: Short review. Hemodialysis International, 22(3), 290-296.

6NURSING CASE STUDY: MR. BROWN
Samona, J., Cook, C., Krupa, K., Swatsell, K., Jackson, A., Dukes, C., & Martin, S. (2017).
Effect of intraoperative dexamethasone on pain scores and narcotic consumption in
patients undergoing total knee arthroplasty. Orthopaedic surgery, 9(1), 110-114.
Schreiber, M. L. (2016). Neurovascular assessment: an essential nursing focus. MedSurg
Nursing, 25(1), 55.
Sheppard, J. P., Mellor, R. M., Greenfield, S., Mant, J., Quinn, T., Sandler, D., ... & McManus,
R. J. (2015). The association between prehospital care and in-hospital treatment decisions
in acute stroke: a cohort study. Emerg Med J, 32(2), 93-99.
Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating
patient. Nursing Standard (2014+), 32(14), 51.
Spillerova, K., Biancari, F., Leppäniemi, A., Albäck, A., Söderström, M., & Venermo, M.
(2015). Differential impact of bypass surgery and angioplasty on angiosome-targeted
infrapopliteal revascularization. European Journal of Vascular and Endovascular
Surgery, 49(4), 412-419.