CNA540: Cardiovascular Nursing 1 - SAO Report on Stroke Patient

This assignment is a CNA540 Cardiovascular Nursing 1 Situation, Action, Outcome (SAO) report detailing the care of a patient presenting with an acute left middle cerebral artery (MCA) parietotemporal infarct and severe hypertension (270/130). The report outlines the initial assessment, escalation to the team leader and doctor, and the subsequent interventions, including the administration of Aspirin, Hydralazine, Amlodipine, and a GTN patch to manage the patient's blood pressure. The nurse's actions are described, including vital sign monitoring and adherence to clinical guidelines. The outcome was stabilization of the patient's blood pressure. The report includes a reflection on the nurse's actions, supported by relevant literature, and emphasizes the importance of understanding the rationale behind treatment decisions and the role of nursing responsibilities in managing hypertensive stroke patients. References include Lonn (2016) on blood pressure management and Tan (2015) on cerebral infarction.

CNA540
Cardiovascular Nursing 1
Situation, Action, Outcome (SAO)
Name:___________________________ Student ID:____________________
Skill title __________________________________________________________
Situation (Briefly description of the situation)
This was Cat 1 patient who was found to be very confused in kitchen by sister. sister noted
R sided facial droop and slurred speech with confusion (no unilateral weakness) and
called Ambulance. This patient was brought by paramedic to resus bay and went to CT and
found out that patient had acute Left middle cerebral artery (MCA) parietotemporal infarct.
On return back when we were doing primary assessment I found that the patient seems to
be hypertensive 270/130.I have escalated to my team leader and doctor.
Action (Clearly outline what you did and why)
Patient was alert and orientated to person not time (date not month/year) / place. Patient
was not symptomatic to the high blood pressure. I escalated to my TL and doctor. Patient
was connected to cardiac monitor which showed patient was on sinus rhythm. After
doctors review patient had Aspirin 300mg followed by IV Hydralazine 5mg x 3 times
every 15 min to a total of 15mg and Amlodipine 5mg but still BP was persistently over 200
and patient was commenced on GTN patch. Doctor want SBP between 180 - 200 and
doesn’t want to drop BP too quickly. Patient’s blood pressure dropped to 175 systolic after
15 minutes of GTN patch.TL and Doctor advised me to make sure systolic blood pressure
doesn’t go below 170 and make sure to take the patch off if it goes below 170.
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CNA540
Cardiovascular Nursing 1
Outcome (Briefly include what the outcome was and why)
After the senior nurses and doctors review and invasive treatment patient’s blood pressure
dropped and stabilized. Patient didn’t have any more episode of high blood pressure.
patient was closely monitored with frequent blood pressure monitoring. He also had more
oral blood pressure table, bloods and CT scan (Abdomen) to rule out Abdominal aortic
aneurism.
Feedback from Observing RN/Reviewer (if applicable)
* Feedback from practice is an important consideration for professional development. We understand that this may be challenging to obtain depending upon
your workplace circumstances.
Sidhi was able to escalate early by recognising high blood pressure and asked for urgent doctor’s review. I would advise Sidhi to research on why blood
pressure should not be dropped too quickly for patients with stroke and the effect of hydralazine for patients with high blood pressure. I would like sidhi to
look for nurse’s responsibility when patient is having hydralazine medication.
Signature of observing RN (thus validating SAO ‘Situation’ as a true and accurate
account)
Name in Full: Francis Joseph Signature:
Designation: Clinical Nurse Date: 3/05/2019
Signature of Student (CNA540)
Name in Full: Sidhi Raju Signature:
Designation: Registered Nurse Date:3/05/2019
Reflections on YOUR actions in this SAO. Could they have been improved/changed?
Support with appropriate literature.
Based on the clinical findings, I understood that the patient had a grade 3
hypertension which has led to a haemorrhagic stroke. The stroke affected left middle
cerebral artery and as because there is a midline crossing of motor neurons in the
pyramidal tract, the stroke affected the contralateral side of the face with facial
muscles drooping, slurred speech and acute mental confusion. The confusion has
resulted from disruption of the cognitive processes due to impairment of
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CNA540
Cardiovascular Nursing 1
neuropsychological functions.
This was the first time I have seen patient with that kind of high blood pressure. My
previous experience with that high blood pressure usually resolved with GTN patch
but for this patient GTN patch did not bring his blood pressure down. I did some
reading and found out that intravenous hydralazine is the drug of choice for rapid
reduction in blood pressure (Lonn 2016). When I found the initial blood pressure to
be that high, I did manual BP to confirm. MO told that we have to reduce the BP but
as per the reading I have done there is no evidence to prove that in reducing the Blood
pressure rapidly will change the outcome of the patient’s condition .I was not sure
how to give the medication and then my team leader pulled out the hospital policies
and gone through the nursing responsibilities. Once I gave the hydralazine patient
had heart rate, rhythm and blood pressure as base line and then 5 minutely for 30
minutes, 10 minutes for 30 minutes, 30 minutely for 1 hour, and hourly thereafter .
At first, a mini mental status examination was performed to which the patient was
found oriented just to person( which means the person could tell his own name and
could recognise himself ) but he was not at all oriented to place and time which
indicates the severity of the cerebral infarction (Tan 2015). Then, as per the clinical
guidelines – I checked the patient’s vitals and observed a sinus rhythm which meant
the heart was not yet affected by the hypertension or the cerebral infarction. I applied
a clinical reasoning to understand the pharmacological management action – aspirin
was administered to reduce the extent of ischemic changes in the brain. Hydralazine
(a vasodilator drug) was administered to reduce the hypertensive state. Amlodipine
was administered to manage patient’s hypertension and this is pertinent to the
situation for an elevated blood pressure level can lead to more cerebral tissue damage
and aggravation of symptoms.
Due to the administration of antihypertensive drugs, adhering to the evidence based
clinical guidelines – the blood pressure was brought under control and within the
physiological controllable limit. As because, the patient was oriented according to the
mini mental status examination I performed, I ensured acute rest and relaxation in
the patient as because with regression of infarction symptoms when treated with
proper medications, the cognitive properties of mind are restored as well. Resting
conserves energy and accelerates the healing process. It was really astounding to see
that within a few days, the symptoms were no more present and but I kept on
monitoring the signs.
References used
Lonn, E.M., Bosch, J., López-Jaramillo, P., Zhu, J., Liu, L., Pais, P., Diaz, R., Xavier, D.,
Sliwa, K., Dans, A. and Avezum, A., 2016. Blood-pressure lowering in intermediate-risk
persons without cardiovascular disease. New England Journal of Medicine, 374(21),
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pp.2009-2020.
Tan, X.L., Xue, Y.Q., Ma, T., Wang, X., Li, J.J., Lan, L., Malik, K.U., McDonald, M.P.,
Dopico, A.M. and Liao, F.F., 2015. Partial eNOS deficiency causes spontaneous
thrombotic cerebral infarction, amyloid angiopathy and cognitive impairment. Molecular
neurodegeneration, 10(1), p.24.
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