Victoria Tapia
ABSN Student
NMNC 4410
NMNC 4410 Intracranial Regulation NGN Case Study
Triage note 0700: The client presented to the ED with reports of weakness on the right side and syncope.
The client was able to stand after the syncopal episode and walk into his home. He was able to contact
his daughter, who found him on the floor and brought him to the emergency department. He states he
has been feeling off “for some time.”
H&P: History of HTN, HLD, Hypothyroidism, smoking x1 pack every two days.
Medication Reconciliation: Lisinopril, Levothyroxine, simvastatin
Vital signs: temp 98.4 (36.9), BP 168/88mmHg, HR 120 beats/min and irregular, RR 22 breaths/min,
SPO2 96% room air
1. Highlight all the risk factors that this client has presented with for stroke.
● BMI: 42 kg/m2
● Works as an independent contractor (psychosocial stress d/t high stress job)
o Reddin, C., Murphy, R., Hankey, G. J., Judge, C., Xavier, D., Rosengren, A., Ferguson, J.,
Alvarez-Iglesias, A., Oveisgharan, S., Iversen, H. K., Lanas, F., Al-Hussein, F., Czlonkowska, A.,
Oguz, A., McDermott, C., Pogosova, N., Málaga, G., Langhorne, P., Wang, X., Wasay, M., …
INTERSTROKE investigators (2022). Association of Psychosocial Stress With Risk of Acute
Stroke. JAMA network open, 5(12), e2244836.
https://doi.org/10.1001/jamanetworkopen.2022.44836
● History of Hypertension
● A1C: 11%
● History of hypothyroidism
● LDL level: 234 mg/dL
● Family history of hemorrhagic strokes (mother)
● Is divorced with adult children
● Smoking x1 pack every two days
+/- scoring
Assessment:
Neuro: Alert to person, states that it is 1983 and he is at the “community center where they check my
blood pressure”. +1 strength in his right arm/leg, +3 strength on left extremities. Visible droop to left side
of face. Client is anxious and requests to go outside to smoke. C/O pain 6/10 in right hip and 8/10 in head
(headache).
Cardiac: +3 pulses in all extremities, heart rhythm irregular, capillary refill ≤ 2 seconds
Respiratory: Clear in all lobes
GI/GU: unknown
Skin: Large hematoma noted in Right hip.
2. Fill in the blanks: There is one answer for (1) and two for (2) and (3).
The nurse in triage determines the client most likely had an ischemic stroke. The nurse
would ask the priority initial question of (1) The nurse would further assess the client
for (2) and____(3)_____. (2 points)
● Answers for (1) One answer only: (a) when the symptoms began, (b) last oral intake,
(c) when he last took his meds, (d) has this ever happened in the past
ABSN Student
NMNC 4410
NMNC 4410 Intracranial Regulation NGN Case Study
Triage note 0700: The client presented to the ED with reports of weakness on the right side and syncope.
The client was able to stand after the syncopal episode and walk into his home. He was able to contact
his daughter, who found him on the floor and brought him to the emergency department. He states he
has been feeling off “for some time.”
H&P: History of HTN, HLD, Hypothyroidism, smoking x1 pack every two days.
Medication Reconciliation: Lisinopril, Levothyroxine, simvastatin
Vital signs: temp 98.4 (36.9), BP 168/88mmHg, HR 120 beats/min and irregular, RR 22 breaths/min,
SPO2 96% room air
1. Highlight all the risk factors that this client has presented with for stroke.
● BMI: 42 kg/m2
● Works as an independent contractor (psychosocial stress d/t high stress job)
o Reddin, C., Murphy, R., Hankey, G. J., Judge, C., Xavier, D., Rosengren, A., Ferguson, J.,
Alvarez-Iglesias, A., Oveisgharan, S., Iversen, H. K., Lanas, F., Al-Hussein, F., Czlonkowska, A.,
Oguz, A., McDermott, C., Pogosova, N., Málaga, G., Langhorne, P., Wang, X., Wasay, M., …
INTERSTROKE investigators (2022). Association of Psychosocial Stress With Risk of Acute
Stroke. JAMA network open, 5(12), e2244836.
https://doi.org/10.1001/jamanetworkopen.2022.44836
● History of Hypertension
● A1C: 11%
● History of hypothyroidism
● LDL level: 234 mg/dL
● Family history of hemorrhagic strokes (mother)
● Is divorced with adult children
● Smoking x1 pack every two days
+/- scoring
Assessment:
Neuro: Alert to person, states that it is 1983 and he is at the “community center where they check my
blood pressure”. +1 strength in his right arm/leg, +3 strength on left extremities. Visible droop to left side
of face. Client is anxious and requests to go outside to smoke. C/O pain 6/10 in right hip and 8/10 in head
(headache).
Cardiac: +3 pulses in all extremities, heart rhythm irregular, capillary refill ≤ 2 seconds
Respiratory: Clear in all lobes
GI/GU: unknown
Skin: Large hematoma noted in Right hip.
2. Fill in the blanks: There is one answer for (1) and two for (2) and (3).
The nurse in triage determines the client most likely had an ischemic stroke. The nurse
would ask the priority initial question of (1) The nurse would further assess the client
for (2) and____(3)_____. (2 points)
● Answers for (1) One answer only: (a) when the symptoms began, (b) last oral intake,
(c) when he last took his meds, (d) has this ever happened in the past
