A nurse is caring for a client who experienced an acute isch… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for a client who experienced an acute ischemic stroke 6 hours ago and is receiving tissue plasminogen activator (tPA). Which assessment finding requires the nurse's immediate attention?

해설
New onset of severe headache with nausea and vomiting indicates potential intracranial hemorrhage, a life-threatening complication of tPA requiring immediate intervention. Other findings (hypertension, facial drooping, dysphagia) are expected or less urgent in this context.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the critical nursing responsibility of monitoring for a life-threatening complication of a high-risk medication. The patient is receiving tissue plasminogen activator (tPA) for an acute ischemic stroke. The core mechanism of tPA is to break down blood clots (thrombolysis), but this action also carries the significant risk of causing intracranial hemorrhage (ICH). The nurse's primary role is vigilant assessment for signs of this complication.

Answer Rationale: Key Point! The correct answer is New onset of severe headache with nausea and vomiting. This symptom triad is a classic and critical indicator of increased intracranial pressure (ICP), which, in a patient receiving tPA, is most likely caused by an intracranial bleed. This is a neurological emergency requiring immediate cessation of the tPA infusion (if still running), notification of the physician, and preparation for interventions like a stat CT scan and possible neurosurgical consultation.

Distractor Analysis:
  • Blood pressure of 160/90 mmHg: While hypertension needs to be managed in a stroke patient (often with parameters like keeping SBP < 185 mmHg and DBP < 110 mmHg for tPA eligibility), it is an expected finding and a known risk factor, not an immediate life-threatening sign of hemorrhage on its own. It requires intervention, but not with the same urgency as neurological deterioration.
  • Slight facial drooping on the affected side: This is an expected symptom of the stroke itself. The question states the stroke was 6 hours ago, so this finding is part of the patient's baseline neurological deficit and does not indicate a new, acute complication.
  • Difficulty swallowing liquids (Dysphagia): This is also a common and expected sequela of a stroke, especially if brain areas controlling cranial nerves or swallowing are affected. While it requires assessment and management (e.g., NPO status, speech therapy consult) to prevent aspiration, it is not the most urgent sign of a hemorrhagic complication.
Related Concepts: The nurse must understand the strict inclusion/exclusion criteria for tPA administration (e.g., time window, blood pressure limits, recent surgery/trauma), the continuous monitoring protocol during and after infusion, and the difference between expected stroke symptoms and signs of deterioration.

Concept Summary
ConceptExplanationNursing Implication
tPA (Alteplase)Thrombolytic agent that dissolves clots. Used within a narrow time window (typically 3-4.5 hours) of ischemic stroke onset.Monitor for bleeding (ICH, GI, GU). Strict BP control. Know contraindications.
Intracranial Hemorrhage (ICH)Bleeding into the brain tissue or surrounding spaces. A major complication of tPA therapy.Assess for sudden severe headache, nausea/vomiting, decreased LOC, new neurological deficits, seizure.
Increased Intracranial Pressure (ICP)Rise in pressure inside the skull. Caused by hemorrhage, edema, or mass effect.Classic signs: Headache, vomiting (often projectile), decreased level of consciousness (LOC), Cushing's triad (late sign).

Side-by-Side Comparison!
Assessment FindingLikely Cause in This ScenarioNursing Priority
New Severe Headache + N/VAcute Complication: Probable Intracranial HemorrhageHIGHEST PRIORITY. Immediate intervention required.
Elevated Blood PressureExpected Finding / Risk Factor: Common in acute stroke; must be controlled for tPA safety.High Priority. Administer ordered antihypertensives per protocol.
Facial Drooping, DysphagiaExpected Deficit: Symptoms of the original ischemic stroke.Core Priority. Part of ongoing stroke care and rehabilitation planning.

Anatomy, Physiology & Pharmacology Points
  • Pharmacology: tPA converts plasminogen to plasmin, which degrades fibrin in blood clots. This systemic fibrinolytic state increases bleeding risk everywhere, but bleeding into the already injured brain (ICH) is the most catastrophic.
  • Pathophysiology: An ischemic stroke causes brain cell death due to blocked blood flow. tPA aims to restore flow but can rupture weakened blood vessels in the infarcted area, causing hemorrhage and a rapid rise in ICP.
  • Neurological Assessment: Use a standardized tool like the National Institutes of Health Stroke Scale (NIHSS) to objectively document any change from baseline.

Memory Tips
  • Mnemonic for tPA Bleeding Complications: "Hemorrhage Headache = Halt tPA!"
  • Think of the "Worst Headache of My Life" phrase often associated with subarachnoid hemorrhage. Any new, severe headache in a tPA patient is a red flag.

High-Frequency NCLEX Topics NCLEX heavily tests priority setting and complication recognition. tPA for stroke is a classic scenario. Remember: New neurological symptoms or deterioration > management of pre-existing or chronic conditions. The exam wants you to identify the finding that signals an immediate threat to life (hemorrhage).

Watch Out for Question Variations!
  • Instead of "assessment finding," the question could ask: "Which action should the nurse take first?" The answer would be to stop the tPA infusion and notify the provider.
  • The scenario could shift to post-tPA administration (e.g., 12 hours later) and ask about signs of other bleeding sites (e.g., hematuria, gingival bleeding, hematemesis).
  • It could test contraindications to tPA (e.g., recent major surgery, history of intracranial hemorrhage, current anticoagulant use).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the Neuro-ICU. Mr. Johnson, 68, received a tPA bolus 30 minutes ago for a left MCA ischemic stroke and is now on the maintenance infusion. During your neuro checks every 15 minutes, he was stable. On this check, he groans when you say his name (previously he was alert), complains of a "sudden, terrible headache," and then vomits.

Nursing Intervention Strategy:
  1. Immediate Action (Within seconds): Stop the tPA infusion immediately. Do not flush the line. Maintain IV access with normal saline.
  2. Assessment & Stabilization: Perform a rapid neurological assessment (GCS, pupil check, limb movement). Check vital signs. Ensure patient safety—position on side if decreased LOC to protect airway.
  3. Communication: Call a rapid response or stroke alert per hospital protocol. Stat page the neurologist and report: "Patient on tPA has new decreased LOC, severe headache, and vomiting."
  4. Preparation: Anticipate and prepare for a stat non-contrast head CT to confirm hemorrhage. Have emergency medications (e.g., antihypertensives, anticonvulsants, reversal agents like cryoprecipitate) ready per protocol.
  5. Documentation: Precisely document the time of symptom onset, your assessment findings, actions taken, and communications.
Patient Safety and Precautions:
  • Contraindications are Absolute: Never administer tPA if any contraindication is present (e.g., time of onset unknown > 4.5 hrs, SBP >185, recent intracranial surgery). The nurse is the final safety check.
  • Blood Pressure Vigilance: Monitor BP every 15 minutes during infusion and for several hours after. Administer ordered labetalol or nicardipine drips precisely to maintain SBP < 180/105.
  • No Invasive Procedures: Avoid unnecessary venipunctures, injections, or insertion of NG tubes/Foley catheters during and after tPA due to bleeding risk.

Nursing Procedure & Medication Flow tPA Administration & Monitoring Protocol:
  1. Pre-Administration: Verify exact time of stroke onset. Confirm CT scan shows no hemorrhage. Verify BP is within parameters. Obtain informed consent.
  2. Administration: Administer 10% of dose as IV bolus over 1 minute. Infuse remaining 90% over 60 minutes via an infusion pump. Use a dedicated IV line.
  3. Monitoring During Infusion: Nurse at bedside. Continuous cardiac monitoring. Neuro checks and BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly.
  4. Post-Infusion: Monitor for bleeding from all sites (neurological, GI, GU, gums, IV sites). Bed rest for 24 hours. Avoid antiplatelets/anticoagulants for 24 hours.

A Word from Your Senior Nurse "Caring for a stroke patient on tPA is one of the most time-sensitive and high-stakes responsibilities in nursing. Your vigilance is the patient's safety net. That severe headache isn't just a complaint—it's a screaming alarm bell from the brain. In clinical practice and on the NCLEX, always think: 'What is the change from baseline? What is the worst possible complication of this treatment?' Your ability to connect the drug's mechanism (clot-busting) to its greatest risk (bleeding) and then to the clinical signs of that risk (headache, vomiting, neuro changes) is what makes you a safe and effective nurse. Trust your assessment skills—they save lives."

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