Case Study: Comprehensive Nursing Care for Ischemic Patient, Mrs. X

This case study focuses on Mrs. X, a 73-year-old widow with a history of transient ischemic attack, atrial fibrillation, coronary heart disease, hyperlipidemia, and controlled hypertension. The case details her current symptoms, including speaking difficulties and right-sided weakness, suggesting a possible recurrence of a transient ischemic attack or a stroke. The essay emphasizes the role of nurses in assessing the patient's condition, monitoring vital signs, and implementing appropriate medical care, including medication management for conditions like hyperlipidemia (atorvastatin) and atrial fibrillation (diltiazem), and addressing her left leg ulcer. It explores the pathophysiology of ischemic stroke and the importance of decision-making in nursing practice, especially in complex situations requiring ethical considerations and patient-centered care. The study highlights the need for continuous nursing care and the potential risks associated with Mrs. X's condition, including the likelihood of transient ischemic attack or stroke, given her symptoms and medical history.

Running head: CASE STUDY ON A STROKE PATIENT
CASE STUDY ON A STROKE PATIENT
Name of Student
Name of University
Author Note

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The essay is based on a case study of an ischemic patient. Ischemic is defined as a heart
disease where there is reduction in a person’s blood supply in heart. Most of the ischemic heart
diseases is caused due to atherosclerosis and is usually present in the angiography the artery
lumen appears to be normal. In the initial days, there is sudden narrowing and sudden closure of
either huge coronary arteries or the coronary artery whose end branches are filled with debris
that is showering in downstream direction in the flowing blood. Ischemic heart disease is also
sometimes felt like angina, especially when the affected area is large (Béjot, Daubail and Giroud,
2016). It also sometimes leads to heart attack but is rare. The heart attack results in the
destruction in heart muscle by switching off its blood supply. Symptoms of this disease varies
from person to person even if the same type of ischemic disease detects them. However, the
problem lies when the person faces no symptoms and suddenly experiences heart attack or
cardiac arrest. In such cases, this disease is very dangerous and is complicated to treat as well.
Therefore, if a person suffers from a high blood pressure, it should treated cautiously and ECG
should be performed in order to detect the risk of the occurrence of ischemic heart disease.
Patients suffering from ischemic diseases more or less suffer from coronary heart disease as well.
In coronary heart disease, the coronary arteries are mainly affected which is responsible for
perfusion in the heart muscle. Coronary heart disease is a subtype of the cardiovascular diseases
like the ischemic heart disease (Sanchis-Gomar, Perez-Quilis, Leischik and Lucia, 2016). This
essay focuses on a particular ischemic patient named as Mrs. X. She had a transient ischemic
attack six months back and is detected to have atrial fibrillation, coronary heart disease,
hyperlipidemia and hypertension; though the hypertension is controlled now. Mrs. X had a left
knee replacement surgery three years back and was diagnosed with left arterial left ulcer. This
ulcer needs dressing three times a week. Mrs. X weighs 57kg. She takes diltiazem, atorvastatin

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and apixaben daily as prescribed by her doctor. Presently, she is having speaking difficulty and
drooping in the right side of her face. The case study also focusses on the recent respiratory and
heart rates and blood pressure of Mrs. X. Therefore, this essay focusses on the required medical
care for Mrs. X and relate it to the nursing practices.
Decision-making is defined as the process in making opinions about identifying a
decision and finding of relevant information as well as assessing alternative methods to solve the
problem (Yu,2013). Therefore, the process of decision-making comprises of seven main step. It
includes identification of the decision to be taken; assembling relevant information needed in
order to make the required decision; identification of alternatives if the taken decision proved to
be fatal; identification of a particular alternative from a lot in accordance with the evidence
found; lastly to take the action by implementing the alternative chosen. Lastly, the taken decision
is reviewed and its consequences are measured. This decision making practice plays an important
role in nursing profession. Nurses have to take prime clinical decisions in their regular practice
(LoBiondo-Wood and Haber, 2017). Nurses have to take decision in medical, surgical as well as
critical care units. It is termed as complexity of clinical decision making which requires wide
educational base and requires entry to reliable information sources and working in a supportive
environment. There are different nurses assigned to take decision and the junior nurses perform
(Jasper, Rosser and Mooney, 2013). This helps in an effective clinical practice by having a
positive impact on patient’s lives as well as in the global health care industry. Several models
have been proposed in order to evaluate the need of decision making in the nursing practice. All
this models proved to be very useful in the nursing practice. According to clinical settings,
nurses in everyday life have to face tough choices regarding decision- making. They have to take
many decisions regarding their patients’ wellbeing, how tough the decision is but they have to

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take it for their patients sake (Standing, 2017). Nurses also have to face ethical problems
regarding their decision making process. Some decisions they could have to take which will be
ethically cumbersome but for their patients’ sake or for their patients’ wish, they have to break
their ethical laws and take the decision. For example, if the patient undergoing a surgery does not
want to opt for another surgery ad it is painful for the individual to handle, then the nurses have
to face the ethical decision making problem where they have to go to against their wish and
support their patient. This is because for all nurses their patients are their first priority and it is
their prime duty to help their patient in recovery, how difficult it is. Nurses have to face
challenges in their day-to-day life and should have that communication skill and mental stability
in order to overcome from that challenging situation. Therefore, decision-making is an important
character in the healthcare industry, which helps the nurses to engage themselves with a
particular patient and in addition helps the patients to reflect their choice of preferences. In the
following case study, the patient named as Mrs. X who is a 73years old widow. She is an
independent woman who lives in a ground floor flat alone after demise of her husband few years
back. She does not have any children. One of her relative mostly visits her to check about her
well-being and to check whether there is any shopping requirement or not. Due to her bad
experiences in hospital, she refuses to be admitted to the hospital. She needs to be under all-time
nursing observation. This case study will help to know the role of nurses played in case of an
emergency stroke patient. Such patients need continuous nursing care. The nurses should know
the patient’s family history and in case of very high blood pressure, should constantly check their
patient’s blood pressure and heart care for future indications. These patients should take their
regular medication on time. Hence, the nurses should look into this matter as well. For ischemic

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patients, the goal for the nurses taking care is to quickly replace brain perfusion in order to save
them (Carey, 2016).
Thus, the case study deals with an ischemic patient named as Mrs. X, who recently had
an ischemic attack, was diagnosed with atrial fibrillation, coronary heart disease, hyperlipidemia,
and controlled hypertension. The patient is taking diltiazem daily in order to overcome from
atrial fibrillation and protect her from future heart attacks. She is also taking atorvastatin due to
hyperlipidemia so that her cholesterol level remains maintained. In addition, patient also has
undergone a knee replacement surgery three years ago, due to which she was prescribes to take
apixaben, an anticoagulant, daily. Recently, Mrs. X is suffering from speaking difficulty as well
as right side weakness. The case study also identifies her blood pressure and respiratory and
heart rates and the clinical care needed for it should be demonstrated. She is now having a left
sided weakness and it is challenging for her to speak. Her left leg arterial ulcer needs dressing
three times a week by a district nurse. Therefore, the chosen nursing field in this case study is
adult field nursing practice. As the patient is having speaking difficulty and have a right sided
weakness, hence we can conclude that there can be reoccurrence of transient ischemic attack
(Sharaf,2013). This is because, in transient ischemia, patients suffer from slurred and garble
speech, which are difficult to understand along with weakness in any side of the face. The patient
also is diagnosed with drooping vision, which is a symptom of myasthenia gravis (Kaminski and
Kusner, 2018). Hence, care should be given to Mrs. X for myasthenia gravis and reoccurrence of
transient ischemic attack.
Mrs. X has a risk of transient ischemic attack as well as that of myasthenia gravis. She
already had a transient ischemic attack two years earlier and is taking daily medications for
prevention of the risk for stroke. As per the symptoms of ischemic attack and the symptoms of

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Mrs. X concludes the risk of ischemic attack. Symptoms of transient ischemic attack are
weakness or paralysis of any parts of one’s body, slurred or garbled speech which is difficult for
others to understand and blindness in a single or both eyes as well as double vision (Searls,2013).
Symptoms of myasthenia gravis includes trouble in talking, difficulty in walking up stairs, lifting
of objects, facial paralysis, problem in swallowing and breathing and most importantly drooping
of eyelids (Suzuki, Utsugisawa and Suzuki, 2013). The old woman is having a speech difficulty
and she is suffering from right sided weakness. She is also having a drooping or bending
downward vision .Hence, it is proved that Mrs. X is at risk of myasthenia gravis and transient
ischemic attack. The old woman also have a high blood pressure of 172/100 and high heart rate
of 86 which adds on to the risk of reoccurrence of ischemic attack or occurrence of stroke. Stroke
is a clinical condition where there is poor flow to blood in the brain, which results on cell death.
Ischemia is a part of stroke, which occurs due to deficiency of blood flow and is hemorrhagic
because of bleeding (Trialists’Collaboration,2013). Both the cases occurs due to high blood
pressure as well as high insulin level. Mrs. X is already hyperlipidemic and takes atorvastatin
daily to treat hyperlipidemia. Atorvastatin belongs to the class of HMG CoA reductase inhibitors
and can be referred to as ‘statins’. Its main function is to reduce the level of bad cholesterol or
LDL mentioned below. It also helps in increasing the level of high-density lipoprotein (HDL)
which in turn decreases the level of triglycerides present in the blood. Hyperlipidemia is a
medical condition where there is increased cholesterol level in the blood especially deposition of
bad cholesterol or light density lipoproteins (LDL) which increases deposition of fat in arteries
and hence this condition increases the risk of blockages. The patient also have hypertension but
is under control by taking diltiazem as its medication. Diltiazem is a calcium channel blocker

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under the class of benzodiazepine, which serves many functions. It can be used to treat high
blood pressure, hypertension as well as diminishes the risk of angina attacks (Mieth et al., 2013).
For taking care of Mrs. X and to decide a care plan for her, one need to first know about
the pathophysiology of the disease she is threatened of. From the above discussions, it can be
inferred that she is at risk of having a stroke. Therefore, knowing the pathophysiology of stroke
or transient ischemic attack one can determine the best care plan for Mrs. X. Stroke mainly
occurs due to two reasons- one is ischemic which is caused mainly due to clot and the other is
hemorrhagic which is mainly caused by bleeding in brain. Two of these occurs due to deficit of
oxygen in the brain tissue, which gradually lead to cell death and at last lead to permanent brain
damage. Mrs. X is at risk of having an ischemic stroke, which is the most common type of
stroke. According to reports, it is found that round 87% of stroke happens are ischemic.
Therefore, hemorrhagic stroke is less common but is found to be more lethal than the ischemic
ones. 40% of hemorrhagic strokes leads to death. An ischemic stroke can lead to either an
embolic one or a thrombotic one. The first one occurs due to migration of thrombus into the
brain from other parts of the body, mostly from heart or carotid artery. Whereas, the latter occurs
due to clotting of thrombus (blood clot that is formed in a vessel and stays there for a time being)
in a cerebral artery. Stroke mainly occurs due to high blood pressure, high level of cholesterol or
due to smoking. Other unnoticeable risk factors may be due to obesity, physical inactivation and
type 2 diabetes. Stroke is directly coordinated to atrial fibrillation (AF). Stroke can also result
due to age factor; person’s attaining the age of 50 years and above are more prone to strokes than
the young ones. It can also occur if the individual have pervious family history of their family
member already had a stroke. Stroke can also occurs due to previous personal history of stroke or
myocardial infarction. Person who already had a stroke are more susceptible of having the

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second one. African-Americans are more prone to stroke than the whites are. Therefore, stroke
can also result due to race difference. Moreover, women are more susceptible to stroke than men
are. Mostly, women death is much higher due to stroke than men are. This is due to the usage of
oral contraceptive or postmenopausal hormone replacement therapy (Mendelow et al., 2015).
The National Institute of Neurological Disorders and Stroke summarizes the main symptoms of
stroke. The symptoms reflected to be unexpected face, arms or legs weakness, unexpected
speaking difficulty, unexpected difficulty in seeing from one or both eyes, sudden walking
problem or dizziness, severe headache without any proper reason (Rao, Levine, Gornbein and
Saver, 2014). From all these above measures, it can be concluded that Mrs. X is susceptible to
stroke. This is because, she had a transient ischemic attack two years before, have a blood
pressure of 172/100, which is very high(normal being 120/80), have a high heart rate of
82(normal being 70-72) and have high respiratory rate of 24 breaths (normal being 12 to 20
breaths). She also have a spO2 of 95%. In normal terms, spO2 is defined as the peripheral
capillary oxygen saturation, which is used to estimate the amount of oxygen that is present in the
individual’s blood (Rodríguez‐Molinero, Narvaiza, Ruiz and Gálvez‐Barrón, 2013). Sp02 should
be between 96% to 99%. Hence, it is again proved that she have deficient of oxygen in blood.
She also have a past family history where her father died die to myocardial infarction. His mental
health is also not upto the mark. She stays alone in her residence after her husband death. Only
one relative visits her to know about her wellbeing and whether he requires any shopping or not.
Her history also reflects that she is hyperlipidemic and takes medication for it but it is not
controlled as her hypertension is controlled by taking the respective medication. In addition, with
respect to the symptoms described by the national institute of neurological disorders and stroke,
one can conclude that Mrs. X is at risk of having a stroke or ischemic attack due to her physical

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symptoms noted. It has been noted that she is suffering from speaking difficulty, right-sided
weakness, drooping of eyelid and left paralysis.
Mrs. X needs immediate nurse care as her first care plan. The nurse appointed for her
should be an expertise in treating stroke patients and in addition to handle it when it occurs
suddenly. They should know how to administer the national institute of health stroke scale
(NIHSS) which consists of facial palsy, motor function, consciousness level, limb ataxia,
language, articulation and many more. The nurse should maintain this scale and record the score
daily. The lower its score, the better is the patient’s projection. The initial treatment for Mrs. X
would be evaluation of her airway, breathing and circulation passages that is then followed by
neurologic examinations with the help of the national institute of health stroke scale (NIHSS).
After all these, evaluation, if the nurse suspects a stroke then she should immediately call Mrs. X
attending physician who will do the necessary measure and will also call for a stroke alert. The
stroke alert consists of continuous monitoring of blood pressure. The patient is immediately
given a beta-blocker or angiotensin converting enzyme inhibitor to maintain blood pressure
below 130 systolic and below 100 diastolic. It is also observed that the blood pressure does not
reduce rapidly; otherwise, it will reduce perfusion to the ischemic tissue of the brain. The doctor
should immediately do a CT scan of the patient in order to know how critical the patient’s state
is. The nurse’s should continue in their monitoring and blood pressure should be checked after
every 15minutes after infusion ends. The most important priority of these stroke patients is the
swallow evaluation, especially for those patients who are at high risk of aspiration pneumonia
(Kernan et al., 2014). The different stroke assessments tools as discovered by the national
institute of neurological disorders and stroke are Cincinnati Prehospital Stroke Scale
(CPSS) ,National Institute of Health Stroke Scale (NIHSS) and Miami Emergency Neurologic

9CASE STUDY ON A STROKE PATIENT
Deficit (MEND). Cincinnati Prehospital Stroke Scale is the most common used medical services
used in emergency as well as paramedics. Hospital associations helps in promoting the
community about the important symptoms like speech difficulty, facial droop and many more , in
addition notifies the emergences services that should be provided in such cases. The National
Institute of Health Stroke Scale was previously described in the essay, about when and how to
use it. It mainly identifies the severity of ischemic stroke. The scores determine the severity of
this treatment. The less the score the less severe the stroke is. It is said that score greater the 22
indicates patient’s severe condition. The last assessment, Miami Emergency Neurologic Deficit
incorporates speech, orientation and other therapies. Mrs. X is taking diltiazem, apixaben and
atorvastatin as her daily medication. Diltiazem is a calcium channel blocker, which helps in
treating angina and hypertension and also reduces the risk of stroke. It is also a very helpful drug
for lowering the levels of blood pressure. Atorvastatin is a HMG-CoA reductase inhibitor, which
helps to treat cholesterol levels. Mrs. X has a high cholesterol level, (is hyperlipidemic), hence
this drug is useful. Lastly, apixaben is an anticoagulant. It also helps to prevent stroke and is
useful as the after treatment drug after a knee replacement therapy.
Therefore, Mrs. X should be under full time nursing observation. She needs to immediate
take beta-blockers like labetalol or propranolol and angiotensin converting enzyme inhibitors
like captopril, enalapril and so on. Beta-adrenergic blockers, commonly known as beta-blockers
is a medication that helps to minimize blood pressure. The mode of action of beta- blockers is by
inhibiting the effect of epinephrine (adrenaline) hormone. When the patient ingests beta-
blockers, their heart beats slowly with reduction in force, thereby reducing the blood pressure. It
also helps in diminishing the risk of stroke as it has anti arrhythmic action as well. It is also
referred to as the type 2 antiarrhythmic drug, thereby inhibiting myocardial infarction (Al-

10CASE STUDY ON A STROKE PATIENT
Gobari, El Khatib, Pillon and Gueyffier, 2013. Angiotensin converting enzyme blockers work by
blocking the activity of angiotensin converting enzyme, thereby diminishing in the angiotensin 2
production. After the reduction of angiotensin 2 production, the blood vessels dilate and in turn,
there is reduction in overall blood pressure (Bansal, Sangha and Khatri, 2013). Apart from taking
these medications daily, she should also carry the SOS drug for myocardial infarction, which is
isosorbite dinitrate or Sorbitrate (brand name). This is the SOS drug for myocardial infarction
because it is administered sublingually and the onset of action of this drug is very fast, therefore
providing instant relief (Lavallée and Amarenco, 2014). Another best combination therapy to
treat transient ischemia is administering aspirin with clopidogrel (Wang et al., 2013). Aspirin is a
non-steroidal anti-inflammatory drug, which is helpful in treating muscle weakness. Clopidogrel,
an antiplatelet drug, is also used to prevent heart attacks and strokes and is used with aspirin for
better duration of action. Mrs. X is also advised to eat healthy food and to lead a healthy
lifestyle. Eating junk food sometimes also increases the risk of this disease. She is also advised to
stay normal that is she is not allowed to get excited in any situation as it may increase the risk of
having a stroke and increase in heart rate. She should immediately start oxygen therapy as she is
suffering from hypoxemia (low oxygen in blood). This can be addressed as she has low spo2
level. Oxygen therapy is referred to as the treatment where supplemental oxygen is given to the
patient. Therefore, for best stroke therapy for Mrs. X, she should take beta-blockers alone ACE
inhibitors along with the calcium channel blocker and should always carry the SOS drug,
isosorbite dinitrate and take atorvastatin and apixaben as advised. As she stays, alone it is also
advised that she should take antidepressant drug that will help her to keep her brain calm and
also will act as a sedative. Many antidepressant drugs are available in the market as fluoxetine,
citalopram and many more.

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According to the discussions above it is hence concluded that Mrs. X is suffering from a
myocardial infarction and there are acute chance of reoccurrence of stroke. In order to protect her
from that, it is claimed that she need to be under nursing supervision and she should include beta
blockers or angiotensin converting enzyme blocker which may help her to regain her normal
blood pressure. It is also advised to take antidepressants in order to keep her mental health stable.
Her nurse should check her blood pressure continuously and should serve her with healthy food
and healthy lifestyle. She should also look into the matter that does not get excited and should
check her NIHHS score daily.

12CASE STUDY ON A STROKE PATIENT
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Appendices
 Beta blockers are used solely
 ACE inhibitors are used along with diltiazem
 Clopidegrol + aspirin therapy
 Oxygen therapy
 Nursing observation all the day
 Eating of healthy food
 Using anti-depressants for keeping the mind peaceful
 SOS drug (isosorbide dinitrate)