CEREBROVASCULAR ACCIDENT

Patient A, 85 years of age, wakes in the morning to paralysis on his whole right side and no sensation in his arm or leg. He tries to get up with help from his wife but cannot. Mrs. A calls their physician and describes the situation. The physician instructs her to call 911 to have her husband taken to the hospital by ambulance, where he will meet them. Patient A protests but ultimately cooperates with emergency medical services when they arrive. He is quickly evaluated upon arrival in the emergency department and is admitted to the critical care unit (CCU).

Patient A lives with his wife in their own home in a lower-middle class neighborhood. They have four sons who are living in different parts of the country. Until five years ago, Patient A had worked as a house painter.

Patient A's wife provides the patient's medical history. Patient A has not had any significant illness until two years ago, when he began to develop bilateral cataracts. Since then, he has consumed increasing amounts of alcohol as the encroaching cataracts impaired his ability to pursue his hobby of building ship models. Six months ago, the cataracts were successfully removed and lenses implanted. Since then, Patient A's alcohol consumption has decreased and he has resumed work on his models.

Mrs. A reports no knowledge of high blood pressure, heart disease, lung disease, kidney disease, cancer, or any other serious medical illness in the patient. He has no history of surgery or serious injuries during their 65 years of marriage.

When Patient A is admitted to the CCU, the nurse orients him and his wife to the physical layout and pertinent policies of the unit. The nurse also completes an initial physical assessment while carrying out the medical and nursing orders for supportive management. Nursing actions include:

Twelve hours after admission, the nurse assessing Patient A notes that his eyes are half open, with ptosis of the right eyelid, and eye movements occur when the nurse or his wife speaks his name. Patient A's right cheek is more flaccid than the left. His right arm and leg are limp with no muscle tone. There is some grasp strength in the patient's left hand, although he does not grasp on command. Patient A responds with grunts to painful stimuli but does not attempt to speak, follow commands, or answer questions.

ACUTE PYOGENIC MENINGITIS

Patient B is a White woman, 67 years of age, who felt well until approximately one week ago, when she developed an upper respiratory tract infection. She has improved slowly, but during the past 48 hours she has developed a more severe cough with significant production of rust-colored sputum, fever with occasional shaking chills, and muscle aches. Patient B arrives at the hospital emergency department. She is transported by her husband, who was concerned when the patient woke in the morning mildly confused and complaining of a severe headache.

At the hospital, Patient B informs the physician (with some difficulty concentrating) that she has had a "bad cold" for about a week. She explains that her neck feels stiff, sore, and extremely painful when she tilts her head forward and bright lights hurt her eyes. She also tells the physician that she has had no skin rashes, nausea, or vomiting but has had some severe chills. She does not recall any of her recent contacts being ill, and she denies any difficulty breathing or chest pain.

Patient B denies any past history of head trauma, sinus infection, immunodeficiency disorders, or medications that cause immunosuppression. She has smoked a half-pack of cigarettes each day for the last 45 years, was diagnosed with emphysema five years ago, and had several severe episodes of chronic bronchitis and one episode of pneumonia in the past two years. Her emphysema is being managed with ipratropium bromide delivered with a metered-dose inhaler (two to four puffs every six hours). She has never suffered from episodes of angina or symptoms of heart failure. She has an allergy to peanuts but not to any medications. She is taking no medications other than ipratropium and combined estrogen plus progestogen therapy for menopausal symptoms. The patient was vaccinated for influenza six months previously and pneumococcus when she turned 65 years of age.