Pathophysiology Of Stroke And Aspects Of Nursing Care
The purpose of this essay is to investigate and provide account of the health needs assessment process of Joan, 65 years old female who suffered stroke (Appendix I). The paper will provide discussion of pathophysiology of stroke, causes, clinical manifestation and aspect of care related to the management of patient condition.
Furthermore the essay will also include the importance of stroke subject in adult nursing.
The following paper will also focus on detailed examination of a nurse role in holistic assessment of Joan’s needs.
The essay will further provide patient actual and potential health needs based on Roper, Logan and Tierney’s (2000) Activity of Living Model (Appendix III). This particular model will outline different ways through which Joan’s condition can be controlled and manage after being discharged from hospital.
The care delivered will be analysed and ethical consideration will be identify. It will also debate the contribution of the assessment tools have made in developing care plans and identifying nursing interventions.
This paper will also concentrate on the impact of the effective nursing assessment on person-centred -care. Furthermore, will provide discussion about nurse role within multidisciplinary team. Moreover it will provide brief discussion about nurse’s role based on Peplau’s Model of Nursing.
In conclusion, I hope to summarise the key issues obtained within this case study.
World health organisation (WHO, 2019), describes stroke as a Cerebrovascular Accident (CVA) caused by interruption of the blood source to the brain. Stroke is usually caused by a blood clot formed in brain arteries or by embolus elsewhere in the body’s circulation.
It is important for healthcare professional to know about stroke and how to care for patients presenting with this condition. The nurse plays an important role in caring for the patients who suffered stroke in acute and post-acute phase and promotes positive role inpatient family’s life throughout the recovery period.
Three Categories Of Stroke
Acute stroke can be defined into three categories: Ischemic, Haemorrhagic and Transient Ischemic Attack (TIA).
Ischemic stroke can be caused by cerebral thrombosis (blood clot forms within artery leading to the brain), or cerebral embolism (blood clot from another part of body is carried in bloodstream to the brain).The patient generally presenting with symptoms such as: headache, aphasia, dysarthria, reduction or loss of strength, confusion, imbalance and weakness of the face, arms and legs (National Stroke Association, 2019).
The other type of stroke is Haemorrhagic stroke. This stroke may be caused by intracerebral haemorrhage (there is rapture or a burst artery within a brain causing bleeding in the brain) or subarachnoid haemorrhage (bleeding into the cranium or skull). (American Stroke Association, 2019).
Transient Ischemic Attack (TIA) also called a ‘mini stroke’ it is temporally disruptions of blood supply to the brain (nursing times, 2017). The patients might present with signs and symptoms related to stroke but usually can resolve from few minutes to hours. Evidence suggests that patients who previously have had TIA most likely at are risks of having stroke (NICE, 2019).
Factors Which Contribute To Stroke
The factors which contribute to stroke are: problem of age, people over 55 years old are in greater risks to have stroke (the arteries becoming narrower). Other features are medical conditions like: high blood pressure, diabetes, atrial filtration and high cholesterol. Family history, people of South Asian and African or Caribbean background are at higher risk to of stroke. Lifestyle factors can also contribute like: smoking, drinking alcohol, being overweight, eating unhealthy or lack of exercises (Stroke Association, 2018).
Timing and immediate treatment are significant to preserve life, prevent further brain damage and reduce disability in patients. NICE recommends using validated tools to help healthcare professionals to recognise stroke (Nursing Times, 2017).
There are specific tests performed to help with diagnosis of stroke include computer tomography (CT), magnetic resonance imagining (MRI) and computed tomography angiography (CTA). A different method of treatments for stroke includes administration of medication that would dissolve the clots or surgery. (Stroke Association, 2018).
The following assessment is a case study of Joan, 65 years old woman (see Appendix II). Joan was referred to Accident and Emergency room and presented with suspicion of stroke following earlier GP assessment. She was admitted to acute ward after getting confirmed diagnosis of stroke in A&E. On admission patient was complaining about left side numbness with no pain.
On enquiring’s Joan’s history has been established. She is a chronic smoker for the past 40 years and there is no medical history of any chest pain or ischemic heart disease. Patient is taking oral medication daily and also using skin patches.
Patient vital signs presents as follows: Temperature: 37.2 C, Pulse: 86, Respiratory Rate: 22, Blood Pressure: 185/90, Oxygen Saturation (SPO2): 94% (on air).
On general examination, Joan is orientated to a place and date. Patient is presenting tachypnic and hypertensive. Alert with equal pupils reacted to light but a bit drowsy. She is able to speak sentences and named 3 items. Investigations have been carried included ECG which confirmed no ischemic changes. CT has confirmed left side hemiplegia.
Motor function presents with left facial droop and she is unable to move her left side.
Observation will allow the nurse to check Joan’s bodily function in order to carry assessment and evaluate (The Royal Marsden NHS Fundation Trus, 2014).
Assessment is defined as collection of information and interactive processes that underpin aspect of nursing care. Through assessment, the process assists nurses with patients and family to recognise problems and set goals alongside resources, resulting in a holistic care plan with minimal errors. (The Royal Marsden Manual, 2014).
Part of the assessment process will establish the level of care Joan will need. According to NMC (2018) to recognise risk of deteriorating further, each of the results would be recorded and given score using Modified Early Warning Score (MEWS).
Walker (2008) claimed that effective assessment plays a huge role in the standard of care and patient health outcomes. It allows health independence and supports well-being by having awareness of individual and cultural variances.
The Resuscitation Council UK (2014) recommends that healthcare professionals should follow ‘ABCDE’ algorithm for ill and deteriorating patients.
Before any assessment the nurse would explain the purpose of the visit and the procedures to be carried on in order to get an informed consent from Joan (NMC, 2015).
Patient airway is assessed first. Joan’s is able to answer which indicates patent airway.
Breathing is assessed next, because breathing is a sensitive indicator of health deterioration, furthermore, can compromise her ability to think. An observation of Joan’s rate, depth and rhythm of respiration and the use of the National Early Warning Score (NEWS) would provide an indicator of her respiratory function. Respiratory rate is 22 breaths per minute- which point to that she is tachypneic. Oxygen saturation is 94% on room air which indicates is within the normal range 94% -98% (BTS, 2017). If oxygen saturation levels (SpO2) drops below 94% Joan will require oxygen therapy because that may points she is becoming hypoxic.
Radial pulse is 86 beats per minute and it’s within the normal range between 60-100 beats per minute (British Heart Foundation, 2014).
Blood pressure is elevated 185/90 patient is hypertensive and temperature is 37.2 C.
NICE guidelines (NICE, 2017) recommends lowering systolic BP to 140mmHg for seven days. Evidence suggests if systolic BP is greater than 150mmHg, hypertension control should be started within six hours of the onset.
The nursing care for Joan within first 24 hours would involve a neurological assessment such as level of consciousness, visual fields, motor function and sensory function ( NICE, 2018). Nurse will need to use Glasgow coma scale (GCS), pupil reaction, check the vital signs and limbs assessment.
Joan’s blood sugar levels would be monitored as it is common for stroke patients to become hypoglycaemic. Also she would have to have her head at 30-degree angle, which will reduce risk of her chocking.
After a thorough nursing assessment the activities of living (ADLs) are appropriate to meet Joan’s health needs. In this case patient breathing, eating and drinking, communication, mobilising, eliminating, dressing and controlling body temperature would be assessed and prioritise (Appendix III).
Breathing would normally be assessed since this is the first sign healthcare professional look for during patient assessment. In Joan’s case breathing can be compromised due to her neurological state and because she is a chronic smoker for past 40 years.
On admission, Joan’s eating, drinking and communication will be highly prioritise as Joan has suffered stroke she would have to be assessed and supported by speech and language therapist (SALT). Swallowing ability is usually assessed immediately post-stroke before given any food, fluid or medication (dysphasia, dysarthria and apraxia). The intervention will require use of short sentences and words in a communication also Joan should repeat some words.
Joan’s receptive speech was normal on admission however common problems with dysphasia can be getting the words mixed up or understanding them. The nurse involved in feeding patient and oral care are responsible to prevent patient from developing aspiration pneumonia. (BJ of Healthcare Assistants, 2016).
NMC (2015) states that ensuring adequate nutrition and hydration for patients must be met because food and fluids are essential in order to maintain body physiological function and providing energy. She might be dehydrated and need assistance to eat later or need enteral tube feeding. Patients who suffered stroke are at risk of other complication such as malnutrition, dehydration, infection, hypoxia and hypoglycaemia. (NICE, 2019).
MUST would be used to identify whether or not Joan was malnourished or at risk of malnutrition (BAPEN, 2015), because is recommended by NICE.
Joan would need additional support at mealtimes. Food and fluid balance charts would be put in place to monitor the situation, which could support further actions, such as food supplementation and referrals to the nutritional community team.
Mini-Mental State Examination (MMSE) and a conversation with Joan will be used as a tool, as an evaluation of cognitive impairment, any changes be recorded (Heart & Stroke Foundation, 2010). Mental Health assessment could provide information that would indicate deterioration in quality of life, such as anxiety, depression or isolation. Joan’s thoughts processes, orientation to time and place, short- term verbal memory could be evaluated. Psychological comfort for Joan would be provided and assurance that she is in safe environment.
This information will help nurse to implement interventions that provide person-centred care and support referrals to community team where the role would be to recognising any mood disorders and supporting patient.
Additional, Joan’s dependence on washing and dressing would require attention, these aspects could lead to self-neglect. These actions would prevent reduce risk for any further infection and improve body image.
Moreover, Joan’s motor function deficits and physical fitness will also be assessed.
Joan is mobile, due to possible ataxia and dizziness potentially could affect her mobility falls may occur (Ryan, 2008). Joan needs to be encouraged for early rehabilitation. Patient who suffered acute stroke will lose cardiorespiratory fitness and strength; Joan could find exercise pointless and difficult especially at the beginning of rehabilitation (Nursing in Practice, 2016).
The Barthel Index would be useful for linking Joan’s level of independence in walking with a previous assessment (Lee, Tsai and Wang, 2015).
Further Joan’s continence will be also assessed. Loss of bladder and bowel control is a common in patient who suffered stroke which can be frustrating and embarrassing for Joan. It would be practical to perform a Waterlow Score in order to distinguish incontinence risk and the potential risk of pressure ulcers, intervening with preventative actions, like air mattresses (Solomon, 2008).
The Bristol Stool Chart would be used to observe bowel patterns.