CT (noncontrast)
You are working in a 15-bed rural hospital with an emergency department. You are the only adult-geriatric provider on this shift, and you are presented with the following case.
A distraught older female brings by personal vehicle her husband of 60 years. This is an 81-year-old male farmer/rancher who was out branding cattle when he experienced new onset headache and difficulty using his right hand. He tried to call his wife on his cellphone but was unable to speak. Instead he blew into the phone and tried to make noises with his mouth. She went to the branding site and transported him to the emergency department.
He is somnolent but will awaken with stimulation. When awake, he is frustrated and tearful. His right hand is flaccid, and he is aphasic. Your facility has a full lab, full x-ray, and CT machine, but no MRI and no neurology consultation service. You are contractually connected with a tertiary care center that is also a stroke center.
Choose one of the options below and outline your initial assessment and diagnostic orders, including pharmacological and nonpharmacological interventions, anticipated clinical manifestations, exam findings, and your plan. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources.
CT (noncontrast), no acute findings. It has been 4 hours since onset of symptoms.
CT (noncontrast), no acute findings. It has been 1 hour since onset of symptoms.
CT (noncontrast), a small intracerebral bleed, no mass effect.
CT (noncontrast), a moderate intracerebral bleed, 3mm of shift, and mass effect.
Thesis Statement:
In the case of an 81-year-old male farmer/rancher presenting with new headache, difficulty using his right hand, and aphasia, a CT scan (noncontrast) should be ordered as part of the initial assessment. If the CT scan reveals a small or moderate intracerebral bleed with mass effect, immediate intervention and transfer to a tertiary care center are necessary to optimize outcomes and minimize further complications.
Initial Assessment and Diagnostic Orders:
- CT Scan (Noncontrast): In this case, a CT scan (noncontrast) should be ordered as part of the initial assessment. The CT scan will help determine the presence and extent of any intracerebral bleeding and assess for any mass effect.
- Pharmacological Interventions: As the patient is somnolent and exhibits signs of frustration and tearfulness when awake, it is important to consider pain management and sedation. An APRN-approved scholarly resource recommends using opioids judiciously in older adults due to their increased sensitivity and potential adverse effects. Non-opioid analgesics such as acetaminophen can be used initially, with opioids reserved for severe pain if necessary. Sedation can be achieved using medications such as benzodiazepines or propofol.
- Nonpharmacological Interventions: The patient’s agitation and frustration can be managed through nonpharmacological interventions such as providing a calm environment, maintaining consistent communication, and involving family members in the care process. These interventions aim to reduce anxiety and promote a sense of security for the patient.
- Small Intracerebral Bleed: If the CT scan reveals a small intracerebral bleed without mass effect, the patient may continue to exhibit symptoms such as headache, difficulty using his right hand, and aphasia. Additional manifestations may include dizziness, nausea, vomiting, and changes in level of consciousness.
- Moderate Intracerebral Bleed with Mass Effect: If the CT scan shows a moderate intracerebral bleed with 3mm of shift and mass effect, the patient’s symptoms may worsen. There may be an increase in neurological deficits such as hemiparesis or hemiplegia on the right side of the body, worsening aphasia, altered mental status, and signs of increased intracranial pressure such as pupillary changes or bradycardia.
- Small Intracerebral Bleed: If the CT scan reveals a small intracerebral bleed without mass effect, close monitoring of the patient’s neurological status is essential. Neurological assessments should be performed at regular intervals to identify any worsening symptoms or signs of increased intracranial pressure. Communication with the tertiary care center is crucial to discuss the findings and determine if transfer for further evaluation or intervention is necessary.
- Moderate Intracerebral Bleed with Mass Effect: If the CT scan shows a moderate intracerebral bleed with 3mm of shift and mass effect, immediate intervention and transfer to a tertiary care center are necessary. Neurosurgical consultation should be sought to evaluate the need for surgical intervention to relieve mass effect and reduce intracranial pressure. In the meantime, supportive care should be provided to maintain vital signs stability and manage pain and agitation.