Left-sided Cerebrovascular Accident (CVA)

SBAR 69 N.H

Scenario N.H., an 89-year-old widow, recently experienced a left-sided cerebrovascular accident (CVA). She has right-sided weakness and expressive aphasia with minimal swallowing difficulty. N.H. has a medical history of a minor left-sided CVA 2{1/2} years ago, chronic atrial flutter, and hypertension. She has lived with her daughter’s family in a rural town since her previous stroke. Since admission to an acute care facility 5 days ago, N.H. has gained some strength, has become oriented to person and place, and is anxious to begin her rehabilitation program. She is transferred for rehabilitation to your skilled nursing facility with the orders shown in the chart. Chart View Admission Orders

Hydrochlorothiazide 25 mg/day PO

Digoxin 0.125 mg/day PO

Warfarin (Coumadin) 5 mg/day PO

Acetaminophen 325 mg q6h PO prn for pain

Zolpidem (Ambien) 5 mg PO at bedtime prn for sleep

Diet: Mechanical soft, low sodium with ground meat

Foley catheter to gravity drainage, and then begin bladder training

Referrals for speech therapy, occupational therapy, and physical therapy to evaluate and treat swallowing, communication, and functional abilities

CASE STUDY PROGRESSA week later, at the interdisciplinary care conference, you report that bladder training is progressing and recommend removing the catheter if N.H.’s mobility and communication abilities have progressed sufficiently. The group and N.H. agree that she is ready for the Foley catheter to be removed

CASE STUDY PROGRESS Two days after the Foley catheter is removed, you observe that N.H.’s urine is cloudy and concentrated and has a strong odor, even though the volumes voided have been adequate

CASE STUDY PROGRESSN.H. is started on sulfamethoxazole 800 mg/trimethoprim 160 mg (Bactrim DS) 1 tab PO bid × 10 days for a urinary tract infection (UTI). However, 2 days later, N.H. is in the bathroom and she is very upset. She has just voided; there is blood on the toilet, and the water is bright red with blood. You help the UAP clean N.H. and help her into bed

4. Describe your assessment steps.5. Identify at least 2 potential causes for N.H.’s hematuria.6. Using SBAR, what information would you provide to the physician when you call?

CASE STUDY PROGRESSN.H.’s physician changes her antibiotic to oral ciprofloxacin (Cipro) and holds the warfarin for 2 days. Two days later, N.H.’s UTI is responding to antibiotics and she has had no further bleeding in the urine. You want to prepare her and her daughter for eventual discharge.7. You have provided teaching about preventing a recurrent UTI to N.H. and her daughter. You use the Teach-Back technique to confirm understanding. Which statement by N.H.’s daughter indicates an adequate understanding of the information provided?

CASE STUDY OUTCOMEN.H.’s right-sided weakness and expressive aphasia do not resolve. Her daughter takes N.H. home and, with the help of her sister, nieces, and a home health aide, they have adjusted well to living together