NURSING CASE STUDY (Ischemic Stroke)
Stroke refers to an acute neurologic dysfunction of part of brain. The signs and symptoms involve the focal areas of the brain. There are two main types of stroke, hemorrhagic and, ischemic. A stroke can attack people of all ages; however, elderly people especially those above 60 years are more at risk of suffering from ischemic stroke. Ischemic stroke is the main cause of long-term disability for most of the people living in United States and ne of the main causes of death. The paper focuses on the pathology of ischemic stroke, risk factors, and clinical manifestations. The paper uses a Mr. Murray as the case study where through his experience with ischemic stroke, the paper outline important medical method that regards stroke diagnosis, treatment, as well as prevention. Most of the paper focuses on nursing evaluation of Mr. Murray’s case, assessment, and intervention methods. Again, the paper looks at nursing therapy as one of the models that can be utilized to ensure quick recovery. Mr. Murray our case study is an old man, childless and living with his wife independently. In determination of Murray’s recovery, the paper will focus on Roper, Logan and Tierney’s model as one of the nursing interventions. The model outline ways through which Murray’s condition is handled in practicing communication, working and regain other distorted physical activities. Therefore, some of the main nursing interventions include ways through which Murray can manage his condition after being discharged from the hospital. These methods include treatment, exercise to ensure quick recovery and medication (Chau, Tang, Yeung, Chan, Cheng, & Woo, 2014).
Pathophysiology of Ischemic Stroke
Ischemic stroke refers to the death of brain tissue or cerebral infarction. The death of such area in the brain results to the blocking of a particular artery in the brain. These arteries are essential in supplying the brain with fresh blood from the heart rich in nutrients and oxygen. As the blood exits the brain, waste products such as cellular waste and carbon dioxide are eliminated. Therefore, if a particular artery is blocked, the neurons cannot sustain energy enough for the brain functions. Due to lack of enough energy, these brain cells stop working. Blocking of brain artery for over a minute leads to the death of brain cells. People who suffer from ischemic stroke such as our case study Mr. Murray require immediate medical attention for diagnosis and treatment (A.-L.a, L.b, J.b, K.c, L.d, & T, 2014).
The cause of ischemic stroke is broad. However, other diseases, especially those affecting functions of the heart such as hypertension, cause stroke. Mostly, narrowing of arteries in the head or neck triggers an ischemic attack. The main cause of this particular blocking is gradual deposition of cholesterol and arteriosclerosis within the vessels. Continuous narrowing of these vessels lead to blood clots formed due to the collection of those cells in one place. The clots can cause thrombosis (blocking artery where they are formed) or from embolism (dislodging and becoming trapped within the arteries that are close to the brain). Ischemic stroke can also be caused by blocking the arteries in the heart. The blocking of heart arteries is triggered by irregular heartbeat (atrial fibrillation), abnormalities of the valves in the heart or heart attack. Although these are the generally know causes of stroke, there are other possible causes such as traumatic injury, street drugs, disorders that causes blood clotting and injury of neck blood vessel. There are two types of ischemic stroke: the thrombotic and embolic stroke. Thrombotic stroke refers to blocking of an artery within the brain. It is clinical called cerebral thrombosis or infarction. Almost 50% of reported cases of stroke are thrombotic. The second type of stroke is referred to as embolic stroke caused by blood clotting within an artery somewhere other than the brain. The clotting usually occurs in the heart, and the emboli would travel until no bloodstream move. The flowing blood to the brain would then be blocked resulting in neurological deficits, hence stroke (C, E., BSN, E., RN, & I, 2014).
Symptoms of ischemic stroke include weakness or face numbness, legs, and the arm affecting one body side. Confusion and trouble is another sign of stroke followed by lack of understanding and speaking (American Heart Association, 2015). In some cases, person experiences headaches, dizziness, trouble walking, and lack of coordination or balance. Ischemic stroke can be diagnosed through imaging diagnostic tests. The tests include CT scan, arteriography, CTA, carotid ultrasonography, transcranial Doppler and MRA. Treatment method for stroke includes administration of medicines that would dissolve the clotting components. Therapy is another important method used in the treatment of ischemic stroke. Surgery is also another important measure for treatment. These surgeries include carotid stenting, craniotomy, and many others (Dhaliwal, Kaur, Kaur, & Kaur, 2014).
Nursing care rationale (Roper, Logan, and Tierney Model)
Roper, Logan and Tierney’s model is one of the most used models in nursing. The activities involved within the model include breathing, communication, eating and drinking, dressing, elimination, and cleansing. Expressing sexuality, playing, working, and sleeping activities are important for the model. Through the model, Mr. Murray would receive care, maintain a safe environment, and work as therapy over the healing process. RLT model describes a reliable model in producing a sufficient care plan for Mr. Murray and carrying out a proper assessment program. The assessment provides critical information in developing an action plan for improving the health status of the patient.
Murray since he is a victim of Ischemic stroke may have trouble in swallowing. Eating and drinking remain as one of the main reason leading to mortality for people such as Mr. Murray. Therefore, Mr. Murray is swallowing need evaluation before he is discharged. Since most stroke patients, face difficulties in swallowing, means of administering food should be considered. If Murray cannot swallow foods normally, he should not be forced since there is a risk of choking. Therefore, fluids and nutrition should be administered intravenously or through a pipe or tube inserted into the stomach through the nose. For an independent person like Mr. Murray, the doctors should keep the feeding tube. Otherwise, the wife can assist in improvising a plan to improve the swallowing. For instance, good positioning and triggering the secretion of saliva by placing food close to the nose can be used. The person feeding him should give him small portions of food. He should also use verbal coaching, insisting on holding food, chewing, as well as trying to swallow the food (McAlister, et al., 2014).
The plan consists of a dietitian, responsible for monitoring, assessing, and ensuring there is no risk of malnutrition. The dietitian serves in ensuring Murray sits properly during feeding and Murray’s hygiene. He should also ensure clean environment free from unpleasant smell. Hygiene is another important factor to consider. There should be a well-set plan on Murray’s hygiene where a nurse is assigned a duty of dealing with these aspects. Since Mr. Murray cannot move around, talk, or take care of himself, someone should be there to wash, dress, assist in brushing teeth, keep his nails neat, and keep his hair and skin clean. All those activities are important to avoid losing self-esteem hence frustrations or depression (Outpatient Service Trialists, 2004).
Before discharge, a physiotherapist should be referred to Murray’s case to improve his health, as well as assist in the processes of rehabilitation through restoring and developing body functions. Occupational therapist should also look after Murray to help in assessing mental, social, and physical challenges.
Since Murray cannot move around due to unexpected disability, a mental problem is likely to occur. Again, Murray’s social life is distracted due to the attack, and thus the therapist should address this feeling. The therapist also should exercise Murray occasionally and offer massage on his muscles. These are some of the activities required to make him regain his body functions. Since the stroke affects the brain, Murray’s muscle tones are dysfunctional. Muscle tone handles mobility, and if damaged, the movement becomes a challenge (Miller, 2015).
Primary and Secondary information
The information about risk factors that helps the patient to identify and avoid future attacks should be considered. As a nurse, one of the main reasons to gather this type of information is to promote compliance to medications, investigate on unidentified risk factors, and make lifestyle recommendations. Some of the information that should be gathered includes the history of some diseases. For instance, diabetes, hypertension, breathing problems, atrial fibrillation, or dyslipidemia can trigger stroke. History or information about particular lifestyle should be taken. Some of these lifestyle factors include poor nutrition, drug abuse, alcohol consumption, smoking and physical inactivity. These factors increase the chance of ischemic stroke. For Hypertension and stroke are proportionally related. People are at risk of suffering from a stroke when the blood pressure shoots above normal. Scientifically, the normal blood pressure should range from 140/90 mm Hg to 130/80 mm Hg (Buttaro & Barba, Nursing Care of the Hospitalized Older Patient, 2012,pp 23). In case Murray if practices such lifestyle habits, proper counseling should be administered as an intervention.
Therefore, Mr. Murray should provide history any disease that might have affected him or any member of the family. The blood group should also be taken to more analysis of the situation.
Information on Murray’s history identifies his common demographics such as, age, sex, and race: his last neurologic examination, any occurrence or signs of presenting illness, history of medication administered, as well as relevant medications such as anticoagulants. Mr. Murray can provide the history independently. Otherwise, in case he is unable to provide the required information, the clinician or the nurse should consult reports from the recent medics, a witness, or his wife for reliable and up-to-date information. In addition to that, Dispatcher information can be used to assist in gathering the accurate time of onset of the symptoms. The rationale for this information is providing information on the symptoms to focus on to avoid future emergency attacks (J, L., Guanci, & McKenna, 2007).
Assessment Evaluation and intervention
Assessment of factors that might decrease potential for increased ICP should be performed. The Cerebral tissue perfusion might be related to occlusive disorder, interruption of blood flow or cerebral vasospasm. Murray may express memory loss, change in vital signs and restlessness. If such symptoms are noted, Mr. Murray should be transferred to a critical area for comprehensive monitoring. Vital signs should be used such as changes in blood pressure. For instance, If Murray’s blood pressure reading is different in his two hands; he should be retained for more treatment (Huijben-Schoenmakers, Rademaker, Rooden, & Scherder, 2014). The fluctuation in blood pressure occurs due to cerebral injury in an area in the brain called vasomotor. The rationale is that blood pressure should be controlled since it is a sign of hypertension, one of the risk factors of stroke.
Before discharging Murray, a post-acute surveillance phase of care is administered. The care comprises of 24 hours of monitoring in the intensive care unit to point out the procedure-related complications, serial neurologic examination, and blood pressure management. Since Murray is elderly and does not have anyone to take care of him, the phase is important since it identifies any possibility of instant or unexpected attacks. Through the process, identification of possible unexpected attacks calls for close attention. The main objective of this phase of nursing care comprises of early detection of ischemic stroke complications, initiating rehabilitation process, procedures, and stroke etiology determination, as soon as Murray is stable (Easton, et al., 2009).
Depending on the condition of Murray during discharge, medication should accompany his discharge letter. After evaluating that Murray is legible to start rehabilitation at his home, antiplatelet agent drugs should be provided. Antiplatelet drugs are important in the prevention of secondary stroke. Depending on the condition of discharge, there are other alternative drugs available for prevention of secondary attack. After the assessment, evaluation, and detection of possibilities of future attacks, dipyridamole or clopidogrel are administered with aspirin, and aspirin. If the nurse detects atrial fibrillation, it means that Murray should be given anticoagulation (Nishio, Takahashi, Hayashi, Hirano, Minakawa, & Kigawa, 2015).
Therefore, identification of possibility of future complications or suffering secondary attack should be followed by rapid solutions or intervention to deter or prevent such unexpected attacks. Thus, physicians, rehabilitation therapists, as well as pharmacists assigned to handle Murray’s case during the recovery period should all be well informed and educated on the latest stroke handling and management. Patients who receive such care end up having successful healing processes, and there are no occurrences of future stroke. To achieve a good function operation for Murray continues therapy and medication can result to fast healing.
Evaluation of physical problems should assess factors like sensory impairment, contradictions in joint coordination, muscular mass reduction, and control, and rigidity in joints. These issues might be expressed by the inability to move or lack of stability. The nursing intervention would be talking to Murray about change in position to balance muscle stress. Therapy is another intervention. Therapy includes taking a walk to assist the legs and muscle in coordination. Advice Murray to wear footwear that can easily allow movement helps him in carrying out the activities. Aid device should be provided to make movement easy and for support (Kalra, Donaldson, Knapp, Perez, & Kalra, 2000). Another intervention is determining joint limitation and acting upon the limitations.
Assessment of communication is another factor to be considered. The problem can be associated with changes in self-esteem, weakening of muscle and anatomy defects. The rationale for this problem is difficulty or challenge in communication, sentence formation, or expressing thought verbally. The intervention required for such problem would be the use of short sentences and words in a communication. Mr. Murray should be encouraged to repeat some words. Also, the most important is the performance of language-speech therapy (K1, Mathers, & R, 2007).
Mr. Murray’s preferences should also be included in the nursing plan. For instance, the nurse should establish foods that Murray prefers. In addition to that, he should be allowed to choose the time to sleep and wake up. Therapists can talk to Murray to ensure he takes a balanced diet. The rationale is to avoid putting Murray through a stressful recovery.
Ischemic stroke refers blocking of the blood vessel that supplies the brain with nutrients and oxygen. Insufficient supply of nutrients and oxygen to the brain leads to the death of cells in the brain. Signs and symptoms of stroke include numbness of arm, leg, and face. A person experiences a headache, loss of body balance and dizziness. The paper focused on nursing care for Mr. Murray after being discharged from the hospital. The nursing plan comprises of assessment through Roper, Logan and Terney model. The model outline guidelines for dealing with Murray’s recovery comprising of speech coordination, communication, eating, and other therapies required to ensure a quick recovery. The paper also provides the rationale through which these assessments and evaluation are handled. These methods include intervention methods for nursing. Some of these nurse interventions include regular check up and monitoring of the patient, therapy related to recovering speech content, coordination of legs, ensuring a balanced diet and ensuring Murray takes the medication properly. For instance, if cannot chew food, food should be administered by a tube through the nose. Most of the food includes fluids and other easily digestible foods. Mr. Murray’s preferences should be considered to avoid development of stress or depression. Mr. Murray’s wife should also be taught on how to manage secondary stroke.
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