Outline your priorities of care for Martin on his arrival in the emergency department at your major metropolitan hospital. Kirkness explains that priority should be given to airway management and oxygenation. Generally, all patients should be placed on oxygen. The head of the bed should be slightly elevated, and a cardiac monitor and intravenous access established. Unless there is hypotension, fluids should be administered judiciously to prevent cerebral edema. 2 Primary assessments are focused on cardiac and respiratory status and neurological assessment.
The nursing history is obtained as follows: 1) description of the current illness with attention to initial symptoms, including onset and duration, nature (intermittent or continuous) and changes. 2) History of similar symptoms previously experienced. 3) Current medications. 4) History of risk factors and other illnesses such as hypertension and 5) family history of stroke or cardiovascular disease (2000 p. 1526). Miller & Elmore explain the following guidelines for responding to a stroke; Within 10 minute of arrival: Asses patient’s ABCs and vital signs -Provide oxygen by nasal cannula -Establish IV access -Collect blood sample -Perform a 12-lead electrocardiogram and attach patient to a cardiac monitor -Perform general neurological screening, including motor function, strength and equality Within 25 minutes of arrival: -Review patient’s history -Establish the time of stroke onset -Perform physical examination -Determine patient’s level of consciousness using the Glasgow coma scale, and stroke severity
Smith, Johnston and Easton further add that clinical examination should be focused on the peripheral and cervical vascular system (carotid auscultation for bruits, blood pressure and pressure comparison between arms), the heart (dysrhythmia, murmurs), extremities (peripheral emboli), and retina. A neurological examination is performed to localise the site of the stroke, imaging study of the brain is nearly always performed and is requirement for patients being considered for thrombolysis. Discuss your rationales for these orders.
MRI is currently preferred over CT for the diagnosis and localisation of ischemic stroke. Smith, Johnston, and Easton explain MRI has the potential for identifying a cerebral abnormality earlier and more clearly than other diagnostic tests. MRI uses a powerful magnetic field to obtain images of different areas of the body. Protons within the body align like small magnets in a magnetic field. In combination with radiofrequency pulses, the protons emit signals, which are converted to images.
Wisselink & Panetta explain that with CT scanning, small hematomas, hemorrhagic infarcts, subarachnoid blood, clots surrounding aneurysms and arteriovenous malformations, shifts of the midline and deformities of the ventricles can be diagnosed. Acute ischemic stroke is usually not visualised with until frank infarct necrosis occurs, usually 15 to 30 hours after the initial insult. MRI demonstrates all of the above lesions, with the additional ability to image areas of hypoperfusion (eg, fresh ischemic infarctions). Karch 2000 describes the therapeutic actions of mannitol.
Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsorption of water leading to a loss of water, sodium, chloride; creates an osmotic gradient in the eye between plasma and ocular fluids, thereby reducing IOP; creates an osmotic effect, leading to decreased swelling in post-transurethral resection. How would you explain the current understandings around this issue? Smith and Johnston et al explain a cautious approach to the management of elevated blood pressure is recommended in acute ischemic stroke.
In general, frequent monitoring of blood pressure in hypertensive stroke is indicated and a persistent, severe hypertension (greater than 220 mm Hg systolic or more than 130 mm Hg mean arterial pressure) should be considered for treatment. Pharmacological lowering of systemic blood pressure may reduce perfusion to the penumbra, converting an area with reversible injury to an area of infarction. a. Discuss the rationales for this decision in terms of the potential actions of the drugs. b. Outline the nursing actions and precautions that would precede/accompany administration of these medications.
Shannon, Wilson, Stang Appleton, Lange explain recombinant DNA-derived form of human tissue-type plasminogen activator (t-PA) is a thrombolytic agent. In contrast to anticoagulants, which prevent propagation of thrombi, t-PA and plasminogen activators such as streptokinase promote thrombolysis by hydrolysing the arginine-valine peptide bond in plasminogen to form the active proteolytic enzyme plasmin (p. 98) -Before administration, coagulation tests need to be done including APTT, bleeding time, PT and TT. -Blood for Hct, Hgb and platelet count should be drawn before administration for baseline values in case of bleeding. Check vital signs frequently. Be alert to changes in cardiac rhythm. Dysrhythmias signal need to stop therapy at once. -Monitor excess bleeding. -Monitor neurological checks throughout drug infusion. -Spontaneous bleeding occurs twice as often with alteplase as with heprin. Protect patient for invasive procedures. -Patient is at risk for post thrombolytic bleeding for 2-4 days. Karch 2001 Rapid diagnosis of stroke and initiation of thrombolytic therapy in patients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
The patient is admitted to the intensive care unit, where continuous cardiac monitoring is implemented. Vital signs are obtained every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, then every hour for 16 hours. Miller & Elmore 2005 state the blood pressure should be maintained with the systolic pressure less than 100mm Hg. Airway management is instituted based on the clinical condition of the patient and arterial blood gas values. Discuss the pathophysiology and aetiology of the disease process which is the probable precursor for Martin’s problem.
Smith & Johnston et al describe although the initial management often does not depend on aetiology, establishing a cause is essential in reducing the risk of recurrence. The clinical presentation and examination findings often establish the cause of stroke or narrow the possibilities to a few. Judicious use of laboratory testing and imaging studies completes the initial evaluation. Nevertheless nearly 30% of strokes remain unexplained despite extensive evaluation. Prevention of stroke is the primary concern Wisselink & Panetta explain early recognition and treatment of persons at risk may lead to a decreased incidence.
Risk factors for cerebrovascular arterial disease include hypertension, smoking, obesity, aging, male gender and hyperlipidemia. With regard to aetiology, a stroke can be ischemic or hemorrhagic. Kirkness adds non-modifiable risk factors include age, gender, race and hereditary. Stroke risk increases with age, doubling each decade after 55 years. Hypertension is the single most important modifiable risk factor but is often undetected and inadequately treated. Increases in systolic and diastolic blood pressure independently increase the risk of stroke.
Heart disease, including atrial fibrillation, myocardial infarction, cardiomyopathy, cardiac valve abnormalities and cardiac congenital defects, is also a risk factor for stroke (2002 p. 1527). Discuss your plan of care for Martin, in terms of what you perceive to be four nursing ‘problems’ ; the care that would be provided to address these needs and the resources that might be used/ included in the care. Remember to prioritise and rationalise your decision. Rehabilitation of patients with stroke is aimed toward a return to the highest level possible.
Often, people who have had a stroke have chronic or long-lasting residual deficits that make full recovery impossible. In these situations, patients are encouraged to lead a full life within the constraints of disability. Walsh (2002) further adds that the care required by the stroke patient during the acute phase following the initial onset differs from that required during the convalescent and rehabilitative phase. The care will also vary with the severity of the stroke and extent of brain damage. During the acute phase, ntervention is directed principally towards maintaining life and preventing increased neurological deficits and complications. Physiotherapy traditionally is begun within 2 to 4 weeks after stabilisation of the clinical course. Occupational, speech, and language therapy, reorientation to visuospatial relations, and re-establishment of the patients’ role in family life are all addressed early if appropriate. Neuromuscular defect is a problem which may be experienced after a stroke. The immediate onset may be accompanied by convulsive movements which may be local or general.
Walsh states that protection from injury is necessary because of the motor deficits and possible seizures. Contractures and deformities may develop as flexor muscles take over and loss of range of joint movement occurs. Passive movements of all joints are carried out at regular intervals (2002 p. 692). Nutrition is also a problem after suffering a stroke. When consciousness is regained, the gag reflex is tested before giving any fluids orally. If the patient can swallow, a soft diet is given and increased progressively to a full balanced diet as tolerated.
If one side of the face is paralysed, food is placed in the opposite side of the mouth. Mouth care is then given following each meal to remove retained food particles from the affected side to prevent aspiration and the development of ulcers. Discuss the resources you might access in developing a rehabilitation plan for Martin. Rehabilitation really commences with the initial onset and acute phase: certain aspects of the care received in the early stage of the illness play an important role in the patient’s rehabilitation. As soon as the patient is well enough, an assessment is made of residual disabilities and remaining capacities.
After discharge from hospital both patient and family will still require considerable support and assistance, referrals should be made to appropriate support and community services. Modifications of the home may be necessary to facilitate the development of independence and prevent accidents. The assistance of social services may be necessary to help solve the problems imposed by the illness and residual disabilities Discuss how you could help Alison/ what resources might be enlisted. References Kirkness (2000) in Medical Surgical Nursing; assessment and management of clinical problems Edited by S, M Lewis M, Mclean S, R Pirksen
M, T Shannon. B, A Wilson. C, L Stang Appleton & Lange Govoni and Hayes Drugs and Nursing Implications Walsh, M (2002) Watson’s Clinical Nursing and Related Sciences Elsevier Science Ltd. W, Wisselink. T, F Panetta (2000) Primary Care; Chapter 58 Stroke, Transient Ischemic Attacks and Carotid Stenosis. W, S Smith. J Claibourne Johnston. D, Easton (2001) Harrisons Internal Medicine; Chapter 349 Cerebrovascular Disease. A, M Karch (2000) Lippincotts Nursing Drug Guide Lippincott. J, Miller. S, Elmore