Clinical Care Case Study: Vertebrobasilar Artery Occlusion and SAH

This case study presents a comprehensive analysis of clinical care for a patient presenting with symptoms suggestive of vertebrobasilar artery occlusion and subarachnoid hemorrhage (SAH). The assignment begins with an exploration of the relevant pathophysiology, focusing on the vestibular system and the impact of hypertension and vascular complications. The core of the assignment is a detailed care plan, differentiating between the two potential diagnoses and outlining nursing interventions, goals, and evidence-based rationales for each. The care plan addresses both short-term and long-term objectives, including hemodynamic and respiratory management, as well as considerations for thrombolysis and anticoagulation. Furthermore, the study provides a detailed discharge plan, including short-term and long-term discharge goals, and five key discharge interventions. The assignment concludes with reflections on the assignment and where the patient should go after discharge.

Running head: CLINICAL CARE 1
Clinical Care
Student’s Name
Institutional Affiliation

CLINICAL CARE 2
Clinical Care: Case Study
PART 1: Appropriate Pathophysiology
The vestibular system is characterized by a robust circulation pattern, which has been the
reason for prevalence labyrinth symptoms among patients with hypertension-related
complexities. The vestibular system is irrigated by tiny vessels originating from basilar artery as
well as the internal auditory artery (IAA) (Fargen et al., 2015; Namini, Naylor, & Koenigsberg,
2015). A greater percentage of IAA supply comes from anterior-inferior cerebellar artery
(AICA) accounting for about 80% of the total circulation in the region while the remaining 15%
comes from the posterior-inferior cerebellar artery (PICA) (Wheedon et al., 2015). Since PICA
has limited collateral branches, the IAA supplies blood to cochlea nerve and labyrinth. Now
considering the complex nature of the labyrinthine branches, it is usually affected by any form of
blockage of the arterial system (Waetherall, 2015). In this case, cases of positional dizziness and
electronystagmography incidence are common. The clinical symptoms such as imbalance,
dizziness, diplopia, severe headaches, repeated seizures, anxiety, and ischemic symptoms
originate from occlusion and stenosis, which commonly occur within the proximal segments
(Jauch et al., 2013; Derdeyn et al., 2014).
It is paramount to highlight that the small arteries are occluded because of their small
diameter through the lipohyalinosis process (Wheedon et al., 2015). Lipohyalinosis is common
in patients with hypertension, which leads to lacunes appearing as small lesions within the
brainstem. The rapturing of these small arteries could cause focal hemorrhage (Sina et al., 2017).
Since there is a close physiological association between the cervical spine and the vertebral
arteries, there is a possibility of chiropractic distortion that eventually traumatizes the arteries
within the neck (Searls et al., 2012). However, some scholars have argued that there is little

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relationship between vertebrobasilar hemorrhage and chiropractic manipulation within the
cervical spine (Wheedon et al., 2015).
PART 2: Care Plan
Patients with a history of hypertension and diabetes Type 2 who are presented to the ED
complaining of severe headache, double vision, loss of function on the left side, and spinning
head could be diagnosed with vertebrobasilar artery occlusion or the subarachnoid hemorrhage
(SAH) as the priority conditions. The two diagnoses present intertwining symptoms; however,
through clinical testing, it is possible to clearly identify the specific condition that is affecting the
patient. The following table is comprehensive care plan for the identified two priority diagnoses.
Nursing
Problem
Goal Intervention Evidence-Based Rationale Expected Outcomes
DIAGNOSIS
ONE:
Subarachnoid
Hemorrhage
S.T
To determine
nature of
symptoms
(Sadoughi,
Rybinnik, &
Cohen, 2013)
L.T
To prevent the
subsequent
complications
associated
with the
condition
1. Blood
Pressure
Control and
Fluid
Restriction
2. Antihypertens
ive Therapy
3. Intubation
and
Hyperventilat
ion
4. Intravenous
Steroids
5. Complication
1. High morbidity and
mortality rate associated
with increased pressure in
SAH diagnosis.
2. It could be titrated easily,
has a short lifespan, and
does not enhance ICP,
which guarantees MAP
stabilization.
3. Intubation and
hyperventilation are
recommended in moderate
and controlled level to
prevent ischemic and
vasospasm complications
(Nouh, Remke, & Ruland,
2014).
4. Although studies have
provided different clinical
conclusions regarding this
intervention, it is essential
in achieving significant ICP
reduction.
5. Management and prevention
of complications are needed
to prevent relapse and
i. A tidal volume of 5-8
mL/kg should be achieved
under ventilation especially in
the absence of pulmonary
comorbidities.
ii. The systolic blood
pressure (SBP) should be
between 130 and 140 mm Hg.
iii. The interventions
should restore motor, verbal
and pupil response (Strbian et
al., 2013).
iv. There should be
improved coordination with
support, which should
stabilize with time.
v. Patient should be able
to achieve the desired oxygen
saturation on room air without
artificial ventilation (greater
than 90%)
vi. A stable body
temperature between 360C -
370C and a corresponding pain
scale less than 2/10 should be

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Control enhance quality of treatment
outcomes.
equally recorded.
DIAGNOSIS
TWO:
Vertebrobasilar
Artery
oOcclusion
S.T
To increase
the level of
consciousness
and mitigation
of
neurological
abnormalities
L.T
To restore
mean arterial
pressure
(MAP) and
cerebral
perfusion
pressure (CPP)
To ensure the
difference
between
Intracranial
Pressure (ICP)
and MAP
balances with
the CPP
(Sadoughi,
Rybinnik, &
Cohen, 2013)
1. Hemodynami
c
Management
2. Respiratory
Management
3. Thrombolysi
s
4. Anticoagulati
on Therapy
(Heparin
Infusion)
5. Angioplasty
and
Endovascular
Therapy
1. Under ischemic
impairments, blood flowing
in cerebral region depends
on pressure (Nouh, Remke,
& Ruland, 2014). The goal
is to achieve the desired
autoregulation of 50 to 150
mm Hg MAP.
2. This intervention is needed
because the airway
functionality depends on the
lower cranial nerves.
Unconsciousness among
patients and impairment of
cranial nerves (Derdeyn et
al., 2014).
3. Thrombolysis is not
favorable for patients above
80 years with a history
coexistence of diabetes and
stroke (Strbian et al., 2013).
This intervention is essential
because it is highly effective
when treating acute
ischemic stroke
complications within a
three-hour window of onset
(Nouh, Remke, & Ruland,
2014).
4. This intervention is
important because it
prevents coagulation while
optimizing long-term
outcomes.
5. It is effective in preventing
thrombosis (Broderick et al.,
2013; Ciccone et al., 2013).
There is a possibility of
thrombosis occurring within
the segments of stenosed
arteries (Hatano &
Tsukahara, 2014; Alexander
et al., 2015).
i. A tidal volume of 5-8 mL/kg
should be achieved under
ventilation especially in the
absence of pulmonary
comorbidities.
ii. The systolic blood
pressure (SBP) should be
between 130 and 140 mm
Hg.
iii. The interventions
should restore motor, verbal
and pupil response (Strbian
et al., 2013).
iv. There should be
improved coordination with
support, which should
stabilize with time.
v. Patient should be able
to achieve the desired
oxygen saturation on room
air without artificial
ventilation (greater than
90%)
vii. A stable body
temperature between 360C -
370C and a corresponding pain
scale less than 2/10 should be
equally recorded.

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PART 3: Discharge Plan
Discharge Nursing Diagnosis
During the discharge, the clinical review should focus on the patient’s data and the rate of
improvement registered during the hospitalization period. The nurse should ensure that the
patient attests to low pain scale and improved vision and response, which should be clinically
confirmed. At the same time, the discharging nurse should ensure that the blood pressure, body
temperature, and oxygen concentration on room air are optimal and stable. One of the major
concerns should be blood pressure and the presence of any treatment-related complications.
Therefore, the nurse should ensure that the patient does not present any form of unstable or
changing neurological symptoms, decreased consciousness, or respiratory problems. Moreover,
the nurse should consider other factors such as verbal communication, swallowing, and active
participation in OT and PT.
Short and Long-term Discharge Goals
Discharge goals could be categorized into short-term and long-term. Short-term discharge
goals include the reduction of in-hospital stay, which opens a way to increase patient satisfaction
through discharge interventions. Additionally, discharging a patient paves the way to a transition
to special, nursing or home care to meet the specific needs of the patients. On the other hand, in
the long-run discharge offers the opportunity for prevention and reduction of possible
readmission that could originate from delayed discharge intervention during hospital stay.
Moreover, discharging vertebral artery occlusion or subarachnoid hemorrhage patients creates an
avenue that supports independence and improvement of clinical outcomes.

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Five Discharge Interventions and Rationale
Patients with chronic conditions, who overstayed in hospital, and those who have not
fully recovered require discharge intervention programs to enable them to cope up with recovery
process (Allum, Connolly, & McKeown, 2018). The severity of the symptoms presented during
admission determines the length of in-hospital period as well as the discharge interventions. In
vertebral artery occlusion or subarachnoid hemorrhage among patients with historical
hypertension and diabetes, five key discharge interventions are needed to foster and enhance the
quality of long-term outcomes as outlined below.
i. Prevention of recurrent stroke
A patient who had been diagnosed with vertebral artery occlusion or subarachnoid
hemorrhage requires stroke prevention intervention. In most clinical cases, the patient is at risk
of repeated stroke after discharge when preventive mechanisms are not in place. The nursing
goal after discharge should, therefore, be focused on controlling the risk factors that could plunge
back the patient into unconsciousness. The justification of stroke prevention as a discharge
intervention stems from the clinical evidence that pints out how stroke recurrence could
exacerbate the recovery process.
ii. Physical Therapy
The discharged patients will be recovering from a motor impairment, which implies that
they require physical therapy to regain gross motor functionality. Scholarly evidence has shown
that PT enhances the prognosis outcome for patients with acute care needs (Soans & Khatri,
2014). PT programs could be used to instruct the patient on how to achieve progressive motor
stability through the help of family members (Soans & Khatri, 2014). PT as a discharge
intervention is important because vertebral artery occlusion or subarachnoid hemorrhage entails

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cerebellar and vestibular interaction; therefore, there is need to enhance positional, static, and
dynamic balance.
iii. Occupational Therapy
Apart from TP, the patient will also require OT, which is tailored to regain fine motor
skills such a self-grooming, bathing, and dressing. OT support TP and they are usually
implemented as part of the numerous therapy interventions for different conditions. OT should
be part of discharge intervention because it focuses on improving general strength such as the
movement of arms and wheelchair mobility (Stones et al., 2017).
iv. Speech and Swallowing Therapy
Regaining speech and swallowing are part of the discharge goals to be achieved in short
and long-term. The range of retraining to be carried out includes language, safety, speaking, and
swallowing skills. Speech and swallowing therapy is needed because in some cases the
cricopharyngeus muscle could fail to open during treatment. In such a case, the treatment process
could entail intubation, which implies that upon discharge the patient require additional
assistance to achieve full recovery.
v. Recreational Therapy, Continuous reassessment, and General Consultations
Vertebral artery occlusion or subarachnoid hemorrhage patients require additional care
intervention after discharge such as finding alternative recreational activities for those who are
unable to attain optimum premorbid capacity, managing and preventing depression, memory, and
family dysfunction. These additional interventions are incorporated with the primary discharge
intervention to enhance the experience of patients during recovery (Allum, Connolly, &
McKeown, 2018). The discharge nurse could recommend additional interventions based on the
progress made by the patient in subsequent prognosis assessment.

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PART 4: Where to go After Discharge
There are different factors that determine where a patient should go after discharge. The
nature of the condition is a primary factor; however, other issues such as the ability of the family
to offer the post treatment support also influence this fundamental decision. After the discharge,
the patient should go home but remain under the supervision of a family caregiver with relevant
knowledge and experience relating to interventions for aged patients with hypertension and
diabetes history. Family caregivers face challenges such as lack of support, limited access to
health facilities and help, and insufficient knowledge; however, they offer professional and
effective alternatives for special care after discharge (Baltar et al., 2018). The patient requires
strict supervision and since the wife passed and the kids are still young, his mother, who is
apparently aged too, cannot meet the current needs of the patient for positive outcomes and
experience. Home care will give the patient a favorable recovery environment through the
support of the caregiver and other family members (Guerrero, Puls, & Andrew, 2014).
PART 5: Reflection on the Assignment
The scope of this assignment has covered multiple areas linked to clinical diagnosis,
treatment, and prognosis of acute illness among aged patients. The magnitude of research carried
out to achieve the objectives and requirements of this assignment is extensive. While interacting
with the literature, I discovered that vertebral artery occlusion management is an area that
requires a further clinical-based assessment to provide a clear, precise, and reliable framework
for diagnosis, treatment, and prognosis. Such a move will enhance healthcare outcomes among
the affected patients.

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