Clinical Decision Making Case Study

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Clinical Decision Making
Pathophysiology: Cerebrovascular Accident (CVA) A cerebral vascular accident (CVA) is defined as “a sudden loss of brain functioning from a disruption of blood supply to a part of the brain causing temporary or permanent loss of movement, thought, memory, speech, or sensation”(Belleza, 2016, p. 1). CVA is categorized as ischemic or hemorrhagic. Hypertension accounts for the majority of ischemic CVAs or strokes. According to the American Heart Association, ischemic strokes are “caused by narrowed or clogged blood vessels in the brain that cut off the blood flow to the brain cells”("Stroke and High Blood Pressure," 2016, p. 1). The following are the main causes of ischemic stroke:
• Thrombosis: An obstruction of a blood vessel leading to localized occlusion. A common cause is atherosclerosis, which can lead to narrowing of the diseased blood vessel. Blood flow may be restricted as platelets adhere to atherosclerotic plaque forming a clot.
• Embolism: A clot or other material that forms within the vascular system, travels from that site, and causes blockage and ischemia in distal vessels. This occurs more commonly in the heart and lungs and can lead to hemorrhagic transformation.
• Lacunar infarction: Occurs as a result of small vessel disease, specifically in the brain, and are commonly affected by chronic hypertension. This process leads to “hyperplasia of the tunic media of these vessels and deposition of fibrinoid material leading to lumen narrowing and occlusion”(Majid, 2016, p. 1). (Majid, 2016, p. 1). Leadership / Professional Role: The medical doctor delivered the primary care of this patient.
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The physician reviewed the patient’s lab results and inquired about any changes with his erectile dysfunction. Upon examining the patient, the physician observed a slight change in his facial expression. The physician proceeded to teach the FNP student how to perform an accurate neurological exam and what specific signs to look for. The patient was encouraged to delay treatment for erectile dysfunction until the results of the diagnostic test were received. The FNP student reviewed the importance of medication compliance, along with diet modification and exercise. The patient had a better understanding of the complications hypertension and diabetes and how these factors led to his erectile dysfunction and CVA. Barriers of Care / Ethical and/or Cultural Concerns: This patient has a better understanding of the importance of medication compliance and has no further no knowledge deficit related to his health or current illness. There are no barriers of care and no ethical or cultural issues related to this patient’s care. Pharmacology information: Atenolol Class action: Beta-blocker that competes with sympathomimetic neurotransmitters (catecholamines) for binding at beta (1) – adrenergic receptors in the heart and vascular smooth muscle, inhibiting sympathetic simulation. This results in a reduction in resting heart rate, cardiac output, systolic and diastolic blood pressure, and reflex orthostatic hypotension. ("Atenolol (Tenormin)," 2012, p. 1). Excretion: 50% GI absorption; remainder excreted unchanged in the feces. Side effects: Hypotension, bradaycardia, constipation, dizziness, dry mouth, erectile dysfunction, depression Interactions: • Catecholamine-depleting drugs and calcium channel blockers: May have an additive effect when combined and patients should be closely monitored for hypotension and/or bradycardia. • Antiarrhythmic drugs: Can cause potent negative inotropic and chronotropic effects leading to bradycardia and heart failure. • Can exacerbate rebound hypertension following withdrawal from clonidine. If both medications are prescribed, beta-blockers should be discontinued several days prior to clonidine. Clonidine should be discontinued for several days, if initiating therapy with beta -blockers. • Prostaglandin synthase inhibiting drugs (indomethacin): May decrease the hypotensive effects of beta-blocker. Reason for this particular patient: Atenolol decreases hypertension and in diabetic patients, a beta-blocker can also reduce the risk of cardiovascular problems, kidney disease, and neuropathy. ("Atenolol ," 2016, p. 1). Alternative drug chose: ACE Inhibitors (Lisinopril, Captopril): Inhibits the enzyme ACE, which decreases the production of angiotensin II, decreasing blood pressure. These medication reduce the risk for MI and stroke and delays kidney disease progression. It is most effective in patient’s hypertension, macroalbuminuria, and diabetes, since it does not affect blood sugar levels. (McCarthy, 2011, p. 1). Critical Thinking / Clinical Decision Making: Differential Diagnosis 1. Hypoglycemia: Focal neurologic deficits can be the result of hypoglycemia. These symptoms are thought to be related to lack of glucose due to energy failure, exctitotoxic edema,

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