Place 2 in text citation for each of the references listed below into the following completed case study.

Critical Thinking Table

Clinical Manifestations Describe the clinical manifestations present in Mrs. T., focusing on what is normal and abnormal and how this relates to her current condition.
Subjective	Mrs. T. is described as mumbling and not making sense, indicating confusion or aphasia. She denies pain, which is significant because strokes can present without pain.
Objective	Right arm weakness (hemiparesis), facial droop, slurred or nonsensical speech, BP 184/92, HR 101, RR 24. Positive FAST and VAN score, NIHSS = 12. These findings are abnormal and suggest an acute cerebrovascular event (likely ischemic stroke).
Primary and Secondary Diagnoses Discuss the primary and secondary medical diagnoses that should be considered for Mrs. T., and why you chose this diagnosis.
Primary medical diagnosis and why you chose this diagnosis.	Reason: Sudden onset of neurological symptoms (facial droop, speech disturbance, right sided weakness), along with a high NIH Stroke Scale score (12), indicate moderate stroke severity. CT head shows no hemorrhage, supporting ischemia.
Secondary medical diagnosis and why you chose this diagnosis.	Reason: AFib increases risk of thromboembolic stroke due to potential clot formation in the atria. Her AFib, even though medicated, is a major contributing factor.
Formulate a nursing diagnosis from the medical diagnoses	Impaired verbal communication related to neurological deficits as evidenced by nonsensical speech. Impaired physical mobility related to right sided weakness. Risk for aspiration related to impaired swallowing due to stroke.
Pathophysiological Changes Explain the pathophysiological changes in Mrs. T.
What pathophysiological changes would you expect to be happening to Mrs. T.?	Expected Pathophysiological Changes: In ischemic stroke, blood flow to parts of the brain is interrupted due to a thrombus or embolus. Neurons in the affected area are deprived of oxygen and nutrients, leading to tissue infarction. Given her AFib, a clot likely formed in the left atrium, traveled to the cerebral circulation, and occluded a cerebral artery.
How will pathophysiological changes transition in the subacute phase after diagnosis and initial treatment?	Subacute Phase Transition: As the acute phase resolves, neuronal cell death may continue if perfusion is not restored. Edema may increase temporarily. Over time, neuroplasticity may allow for some recovery of function, but deficits may persist depending on the location and extent of the stroke.
Health Status Effect Describe the effects Mrs. T.'s current health status may have on her.
Describe the physical, psychological, and emotional effects Mrs. T.'s current health status may have on her.	Physical Effects: Right sided weakness may result in decreased mobility and independence. She may need assistance with daily living activities and communication. Psychological/Emotional Effects: Depression, frustration, and anxiety are common post-stroke. The sudden change in health can be mentally distressing.
Discuss the impact it can have on her role in the family.	Impact on Role in Family: As a wife, mother, and teacher, her ability to fulfill daily responsibilities may be impaired. Role reversal may occur as she becomes dependent on others, affecting family dynamics.
Treatments and Support Discuss treatments and support that can be completed for Mrs. T.
Discuss the immediate treatments that can be completed for Mrs. T.	Immediate Treatments: Rapid initiation of thrombolytic therapy (e.g., alteplase) if within the therapeutic window (<4.5 hours from symptom onset). Antiplatelet or anticoagulant therapy, BP management, stroke unit care, and neurological monitoring.
Describe the long-term support she may need to return to baseline activity level.	Long term Support: Physical, occupational, and speech therapy to restore functional abilities. Ongoing medical management of AFib and cholesterol. Lifestyle changes (quitting smoking, reducing alcohol, diet modification).
Explain how the interdisciplinary team is utilized to help her family support and cope with her diagnosis.	Interdisciplinary Team Support: Nurses, neurologists, physical therapists, speech language pathologists, social workers, and psychologists collaborate to create a care plan. Family education on stroke recovery, emotional support, and involvement in rehabilitation planning is essential.

Clinical Manifestations

Mrs. T. presents with several clinical manifestations that suggest a neurological emergency. Subjectively, she is reported to be mumbling and not making sense both signs of expressive and receptive aphasia. She does not report pain, which is not uncommon in stroke cases, especially ischemic strokes. Objectively, she has right arm limpness, facial drooping on the right side, and slurred or incoherent speech. These signs align with the FAST (Face, Arm, Speech, Time) and VAN (Vision, Aphasia, Neglect) stroke assessment tools. Her vital signs also show hypertension (184/92), mild tachycardia (HR 101), and a slightly elevated respiratory rate, which are common physiological responses to stroke. Her NIH Stroke Scale (NIHSS) score of 12 indicates a moderate stroke, further confirming that her symptoms are significant and require immediate intervention.

Primary and Secondary Diagnoses

The primary diagnosis for Mrs. T. is an acute ischemic stroke. This is supported by her sudden onset of neurological deficits facial droop, slurred speech, and weakness in the right arm along with a positive FAST score and a moderate NIHSS score. Although the CT scan shows no bleeding, this does not rule out an ischemic stroke in the early stages, as it may take hours for infarcted tissue to appear on imaging. The secondary diagnosis is atrial fibrillation (AFib), which is a known risk factor for embolic strokes. AFib can cause clots to form in the atria due to ineffective blood flow, and these clots can travel to the brain, leading to a blockage in cerebral circulation. Although she is on metoprolol, it is unclear whether she is receiving anticoagulation therapy, which may increase her risk for thromboembolism.

Nursing Diagnosis

Based on the medical diagnoses and observed symptoms, several nursing diagnoses can be formulated. The first is impaired verbal communication related to neurological deficits, as evidenced by her inability to speak clearly. The second is impaired physical mobility, due to right sided weakness affecting her ability to walk or move. Because strokes often impair swallowing, she is at risk for aspiration, which can lead to pneumonia if not managed promptly. These nursing diagnoses help guide interventions to promote safety, communication, and mobility.

Pathophysiological Changes

In an ischemic stroke like Mrs. T.'s, a clot obstructs blood flow to parts of the brain, depriving neurons of oxygen and glucose. This leads to a cascade of cellular death and brain tissue damage. Since Mrs. T. has AFib, it's likely that a clot originated in her heart and traveled to her brain, occluding a cerebral artery. In the subacute phase, the brain may swell around the area of injury, and inflammation may persist for several days. Neuroplasticity begins during this phase, where unaffected parts of the brain may attempt to compensate for damaged areas. Recovery varies depending on how much brain tissue was affected and how early treatment was administered.

Health Status Effect

The physical effects of Mrs. T.'s stroke may include partial paralysis or weakness on the right side, difficulty walking, and problems with speaking or understanding language. Emotionally, she may feel frustration, anxiety, or depression, which are common after a stroke due to sudden changes in independence and cognitive function. Psychologically, the trauma of losing control over her body may affect herself image and mental well-being. In terms of family dynamics, she may no longer be able to fulfill her role as an active parent, teacher, and spouse, creating emotional and financial stress. This shift can affect her children, spouse, and even her career, requiring adjustment from everyone in her household.

Treatments and Support

Immediate treatment for Mrs. T. would focus on reestablishing blood flow to the brain. If she is within the 4.5-hour window from symptom onset, she may be eligible for thrombolytic therapy (e.g., tPA). Blood pressure and heart rate should be closely managed, and neurological assessments should continue in a stroke unit. Long term, she may need extensive rehabilitation, including physical therapy to regain movement, occupational therapy to relearn daily tasks, and speech therapy to recover communication skills. Ongoing treatment of AFib and hyperlipidemia is also crucial to prevent recurrence. The interdisciplinary team plays a vital role in her recovery. This includes neurologists, nurses, physical therapists, speech-language pathologists, psychologists, and social workers. They provide not only clinical care but also emotional support and education to her family, helping them adjust to her condition and participate in her care plan.

References

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & Tirschwell, D. L. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines.Stroke, 50(12), e344-e418.

• https://www.ahajournals.org/doi/10.1161/STR.0000000000000211

Tomaselli, G. F., Mahaffey, K. W., Cuker, A., Dobesh, P. P., Doherty, J. U., Eikelboom, J. W., ... & Lip, G. Y. H. (2020). 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants.Journal of the American College of Cardiology, 76(5), 594-622.

• linkinghub.elsevier.com/retrieve/pii/S0735109720351548

American Heart Association. (2023).Life after stroke: Our guide to recovery. Retrieved from

• https://www.stroke.org/en/life-after-stroke

Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Das, S. R., Delling, F. N., Djousse, L., Elkind, M. S. V., Ferguson, J. F., Fornage, M., Jordan, L. C., Khan, S. S., Kissela, B. M., Knutson, K. L., ... & Virani, S. S. (2020). Heart disease and stroke statistics2020 update: A report from the American Heart Association.Circulation, 141(9), e139-e596. doi:10.1161/CIR.0000000000000757