Mrs. Blossom is a 57-year-old female who presented to the Emergency Room with new onset Atrial Fibrillation with Rapid Ventricular Response (RVR). She is admitted to the cardiac telemetry unit after being converted to normal sinus rhythm with a calcium channel blocker (diltiazem). When you enter the room to assess Mrs. Blossom, her daughter looks at you concerned and says “mom’s acting kinda funny.”
Critical Thinking Check
Bloom's Taxonomy: Application
What nursing assessments should be completed at this time?
You call a Code Stroke and notify the charge nurse for help. You obtain suction to have at bedside just in case. The neurologist arrives at bedside within 7 minutes to assess Mrs. Blossom. He notes her NIH Stroke Scale score is 32. He orders a STAT CT scan, which shows there is no obvious bleed in the brain.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What are the possible interventions for Mrs. Blossom at this time?
Since there is no bleed evident on scan, Mrs. Blossom would qualify for a thrombolytic like tPA (alteplase) or for surgical intervention, as long as there are no contraindications
Critical Thinking Check
Bloom's Taxonomy: Comprehension
What are the contraindications for thrombolytics like tPA (alteplase)?
She may bruise easily or bleed from IV sites or her gums
Monitor for s/s bleeding or worsening stroke symptoms, which may indicate a hemorrhagic stroke has developed.
After 2 hours, Mrs. Blossom is showing signs of improvement. She is able to speak more clearly, though with a slight slur. She is still slightly weak on the left side, but is able to hold her arm up for 10 seconds now. Her NIHSS is now 6. Mrs. Blossom’s daughter asks you why this happened.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What would you explain has happened to Mrs. Blossom physiologically?
Because of her new onset atrial fibrillation, the blood was likely pooling in her atria because they were just quivering and not contracting. When blood pools, it clots. When she was converted back into a normal rhythm and her atria began contracting again, that likely dislodged a clot, which went to her brain.
The clot in her brain caused brain tissue to die → ischemic stroke.
Two days later, Mrs. Blossom has recovered fully. She will be discharged today on Clopidogrel and Aspirin, plus a calcium channel blocker, with a follow up appointment in 1 week to see the neurologist.
Critical Thinking Check
Bloom's Taxonomy: Application
What education topics should be included in the discharge teaching for Mrs. Blossom and her family?
Anticoagulant therapy is imperative to prevent further clots from forming within Mrs. Blossom’s atria if she stays in Atrial Fibrillation.
They should be taught the signs of a stroke (FAST) and call 911 if they notice them.
They should be taught signs of Atrial Fibrillation with RVR and be sure to go to the hospital if this occurs – the patient is at higher risk for stroke.
Medication instructions for calcium channel blockers and anticoagulants.
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 