POLICIOS, SHARMAINE ANNE M.

BSN 3Y2 – 3A

Consider the short scenarios and answer the questions:

A. Mrs. Clot, a 51-year-old woman, is brought into the emergency department by her
husband. Her husband states, "She began slurring her words about 30 minutes ago," and
he noticed that her mouth is turned down on the left side. He recognized that she was
exhibiting signs of a stroke and brought her immediately for treatment.

1. Mrs. Clot was immediately taken for a CT scan of the brain and it was determined that
she suffered an ischemic stroke. The healthcare provider prescribed t-PA. What should be
done prior to initiating the therapy?

Prior to receiving t-PA, the patient is evaluated using the National Institutes of Health Stroke
Scale (NIHSS), a standardized assessment tool that helps evaluate the severity of a stroke.

https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf

The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of
acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss,
extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained
observer rates the patent’s ability to answer questions and perform activities. Ratings for
each item are scored on a 3- to 5-point scale, with 0 as normal, and there is an allowance
for untestable items. Scores range from 0 to 42, with higher scores indicating greater
severity. A single patient assessment requires less than 10 minutes to complete.

The evaluation of stroke severity depends upon the ability of the observer to accurately and
consistently assess the patient. Stroke severity may be stratified on the basis of NIHSS
scores as follows:
 Very Severe: >25
 Severe: 15 – 24
 Mild to Moderately Severe: 5 – 14
 Mild: 1 – 5

2. After the nurse gives the t-PA, what common side effect is it important that Mrs. Clot be
monitored for?    

A stroke drug known as tPA, or tissue plasminogen activator, has been a lightning rod since it
was first approved in the United States in 1996. Although studies have found that the drug can
reduce the brain damage wrought by strokes, it can also cause potentially fatal bouts of cerebral
bleeding. Now a team of researchers has identified one reason for tPA's ill effect. And it turns
out that in mice, the problem can be eased by administering a cancer drug.

TPA works by dissolving blood clots. That helps to restore blood flow to the brain after a stroke,
potentially preventing additional brain cells from dying. tPA is only recommended if it can be
given within 3 hours of a stroke; otherwise, doctors deem that the drug will do more harm than
good, causing hemorrhages in the brain.

Bleeding is the most common side effect of t – PA administration, thus the patient is closely
monitored for any bleeding (IV insertion sites, urinary catheter site, endotracheal tube,
nasogastric tube, urine, stool, emesis, and other secretions.

Minor bleeding is more common, but significant bleeding such as into the brain (intracranial
hemorrhage) or fatal bleeding also occurs.

Other important side effects include:

 Nausea
 Vomiting

Other possible serious side effects include:

 Pulmonary embolism
 Cholesterol embolism
 Abnormal heartbeats
 Allergic reactions
 Re-embolization of deep DVT venous thrombi during treatment of acute
massive pulmonary embolism
 Angioedema
 B. Alexa, a 32-year-old mother of two, has had MS for 5 years. She is currently
enrolled in a school of nursing. Her husband is supportive and helps with the care of
their preschool sons. Alexa has been admitted to the acute care facility for diagnostic
studies related to symptoms of visual disturbances.

3. Alexa is enrolled full time in the nursing program and has classroom and clinical
activities 4 days per week. What should the nurse educate Alexa regarding the cause of
relapsing episodes of MS?

Exacerbations and remissions are characteristic of MS. During exacerbations, new

symptoms appear and existing ones worsen; during remissions, symptoms decrease or
disappear. Relapses may be associated with emotional and physical stress, which Alexa is
experiencing related to her clinical and classroom schedule.

When you experience a multiple sclerosis relapse (also known as an exacerbation or flare-
up), it's because new damage in the brain or spinal cord disrupts nerve signals. That's why
you might notice new symptoms or the return of old symptoms. A true relapse lasts more
than 24 hours and happens at least 30 days after any previous relapses. Relapses vary in
length, severity, and symptoms. Over time, symptoms should improve. Many people recover
from their relapses without treatment.

Weakness

Damage to the protective covering of nerve fibers interrupts normal signals from the brain to the
body. When those signals are disrupted, your body doesn't function like it once did. Things you
did easily before can seem difficult -- like opening a jar or turning a doorknob. Sudden or
worsening weakness that doesn't go away could mean you're having a relapse.
Vision Problems

If your vision is blurred or you're seeing double, you could be starting to relapse. Some people also
lose their depth or color perception as the optic nerve becomes inflamed. Taking a hot shower or bath
or having a viral infection like the flu can sometimes trigger vision problems, but these are only
temporary and should go away within a day.

Numbness or Tingling

Numbness is one of the most common signs of a multiple sclerosis relapse. You can lose so much
feeling that it's hard to use your hands or other affected body parts. You might not be able to write or
hold a coffee cup. If numbness is new or getting worse, it's time to call your doctor.

Thought Problems

It's frustrating to forget where you left your car keys, or to have to re-read the same paragraph over
and over just to understand it. MS can affect your mind in many ways, interfering with memory,
concentration, language, and information processing, especially as the disease progresses. Any new
trouble thinking clearly or remembering past events is a warning that you could be in the midst of a
relapse.

Dizziness

Feeling lightheaded or unsteady on your feet can be an unsettling experience, but it's a common sign
of MS relapses. The dizziness is due to damage in the parts of your brain that control equilibrium. A
motion sickness drug can take away that 'room-is-spinning' feeling in the short term, but if it lasts
more than a day you may need to be treated for an exacerbation.

Balance and Coordination

"Somebody may start to feel like they're drunk when they walk, or they [may] have trouble
coordinating movements in their arm," says John Ratchford, MD, MSc, assistant professor of
neurology at the Johns Hopkins University School of Medicine. Muscle weakness or spasm,
numbness, and a loss of balance during a relapse can make you uncoordinated and unsteady on your
feet.

Does Heat Trigger Relapses?

Soak in a hot tub or sit outside on a muggy day and you might feel like you're having a flare-up -- but
you're not. "There's a lot of confusion among patients about heat," says Aaron Miller, MD, medical
director of the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at the Mount Sinai School
of Medicine. Heat may bring on MS symptoms, but they'll go away as soon as you cool off.

What Causes a Relapse?

A recent bout of the flu or other infection can trigger an MS relapse, some studies have suggested.
Other suspected triggers are less certain, including stress, which is hard to study because it affects
everyone differently. "I think it's quite possible that for some people, stress can have effects on the
immune system and potentially increase the risk for a relapse," Ratchford says.

Preventing Relapses

The best way to prevent relapses is to take the medicine your doctor prescribes. "All of the medicines
we use for relapsing MS have been shown to reduce the frequency of relapses -- that's the main reason
they were approved," Miller says. Eating well, sleeping enough, and reducing stress are also good
advice. Call your doctor if any new symptom appears or gets worse, and doesn't go away after 24
hours.

Treating Relapses

Not every relapse needs to be treated. If movement isn't limited and you're not uncomfortable, your
doctor might recommend waiting until the symptoms improve on their own. For more bothersome
exacerbations, intravenous steroids can speed recovery. Sometimes plasma exchange -- removing the
blood and replacing the liquid part -- is used to treat more severe relapses.
 4. Alexa is prescribed IV prednisolone 1g IV daily for 3 to 5 days, followed by an oral taper
of prednisone. What will the nurse educate Alexa regarding the side effects of the
medication?

Side effects include mood swings, weight gain, and electrolyte imbalances.

Prednisolone is an adrenocortical steroid used for multiple conditions including endocrine

disorders, rheumatic disorders, collagen diseases, skin diseases, allergies, eye diseases,
respiratory diseases, blood disorders, cancers, edematous states, gastrointestinal diseases, and
nervous system disorders, among others. The brand name of this medication is discontinued,
but generic versions may be available. Common side effects of prednisolone include:

 infections,
 heartburn,
 trouble sleeping (insomnia),
 hunger,
 nausea,
 headache,
 dizziness,
 menstrual period changes,
 increased sweating,
 acne, and
 nervousness

Serious side effects include:

 Hiccups
 Puffiness of the face (moon face)
 Growth of facial hair
 Thinning and easy bruising of the skin
 Impaired wound healing
 Glaucoma
 Cataracts
 Ulcers in the stomach and duodenum
 Worsening of diabetes
 Irregular menses
 Rounding of the upper back ("buffalo hump")
 Obesity
 Retardation of growth in children
 Convulsions
 Anaphylaxis (severe allergic reactions like hives, itching, skin rash, swollen
lips/tongue/face)
 Vision changes
 Congestive heart failure
 Heart attack
 Pulmonary edema
 Syncope
 Tachycardia
 Thrombophlebitis
 Vasculitis
 Allergic dermatitis
 Low blood pressure
 Amenorrhea (lack of menstruation)
 Newly onset diabetes
 Hyperglycemia
 Hypothyroidism
 Pancreatitis
 Anemia
 Amnesia
 This drug also causes psychiatric disturbances, which include:
 Depression
  Euphoria
 Insomnia
 Mood swings
 Personality changes
 Psychotic behavior

ORAL TAPER OF PREDNISONE.

The initial dosage of

prednisolone varies from 5 mg to
60 mg per day depending on the
disease being treated.
Prednisolone may interact with
other drugs. Tell your doctor all
medications and supplements you
use. 

If you abruptly stop taking

prednisone or taper off too
quickly, you might experience
prednisone withdrawal
symptoms:

 Severe fatigue
 Weakness
 Body aches
 Joint pain
 Nausea
 Loss of appetite
 Lightheadedness
Prednisone is similar to cortisol, a hormone naturally made by your adrenal glands. If you take
prednisone for more than a few weeks, your adrenal glands decrease cortisol production. A
gradual reduction in prednisone dosage gives your adrenal glands time to resume their normal
function.

The amount of time it takes to taper off prednisone depends on the disease being treated, the dose
and duration of use, and other medical considerations. A full recovery can take anywhere from a
week to several months. Contact your doctor if you experience prednisone withdrawal symptoms
as you are tapering off the drug.