Stroke.docx

Case study paper stroke

STROKE (Case study paper) -----------------------------------------------------------------------------------------------------Critical care Nursing (NUR-418) FAZAL RAHMAN BScN02161010 Ms Sana Saher Date: April 04, 2019

LAHORE SCHOOL OF NURSING --------------------------------------------------------------------------------------------------

THE UNIVERSITY OF LAHORE (2016 – 2020)

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Case study paper stroke

Section

Guidelines of Case Study Paper Writing 10% Information to Include

1. Introduction: (Patient and Problem)

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2. Pathophysiology

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3. History

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4. Nursing Physical Assessment

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5. Related Treatments

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6. Nursing Diagnosis & Patient Goal

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7. Nursing Interventions

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8. Evaluation

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9. Recommendations

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Explain who the patient is (Age, gender, etc.) Explain what the problem is (What was he/she diagnosed with, or what happened?) Introduce your main argument (What should you as a nurse focus on or do?) Explain the disease (What are the symptoms? What causes it? And what’s pathological mechanism behind disease) Explain what health problems the patient has (Has she/he been diagnosed with other diseases?) Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?) List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.) Explain what treatments the patient is receiving because of his/her disease Nursing Care Plan Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?) Explain what your goal is for helping the patient recover (What do you want to change for the patient?) Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature) Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?) Explain what the patient or nurse should do in the future to continue recovery/improvement

Total Marks (100) 10 Marks

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Case study paper stroke

1. Introduction Explain who the patient is (Age, gender, etc.) Patient’s Name: Mrs. Bashiran Bibi

Age: 60 years

Sex: Female

D.O.A: 25-03-2019

Religion: Islam

Occupation: Housewife

Marital status: Married

Medical Diagnosis: Stroke

Surgical Procedure: Nil Address: Lahore Explain what the problem is (What was she diagnosed with, or what happened?) Two days prior to admission, the patient experienced generalized weakness, decrease power in all four limbs, Increase BP, and Aphasia. A complaint of dizziness was noted. He was responsive and slurring of speech is noted. He was brought to emergency department of University of Lahore Teaching Hospital at 3:30 P.M. The patient was admitted on March 25, 2019 at 3:50 P.M. with vital sign of Temp: 36.8°C, PR: 85bpm, RR: 19/min, BP: 150/80 mmHg. The patient was diagnosed with Ischemic Stroke. Introduce your main argument (What should you as a nurse focus on or do?) As a Nurse I will focus on 1. To obtain the knowledge to enhance skills and to develop the attitude towards caring of the patient with cases regarding ischemic stroke. 2. Demonstrate stable vital signs and absence of signs of increased ICP. 3. Observation for developing complications. 4. Provide information about disease process, prognosis, and treatment needs.

2. Pathophysiology: Definition: Stroke is defined by the World Health Organization as “A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin.” (WHO, 2016). Page 3 of 13

Case study paper stroke The damaging or killing of brain cells starved of oxygen as a result of the blood supply to part of the brain being cut off. Types of stroke include Ischemic stroke caused by blood clots to the brain or hemorrhagic stroke caused by bleeding into/of the brain (Tony Rudd, 2016). Pathophysiology: A Stroke is a sudden impairment of cerebral circulation in one or more blood vessels. It occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood vessel breaks, interrupting blood flow to an area of the brain (Mergenthaler, Dirnagl, & Meisel,. 2015). Regardless of the cause, the underlying event is deprivation of oxygen and nutrients. Normally, if the arteries become blocked, auto regulatory mechanisms help maintain cerebral circulation until collateral circulation develops to deliver blood to the affected area. If the compensatory mechanism becomes overworked, or if cerebral blood flow remains impaired for more than a few minutes, oxygen deprivation leads to infarction of brain tissue (Tony Rudd, 2016). Stroke interrupts or diminishes oxygen supply and commonly causes serious damage or necrosis in the brain tissues. When either of these things happens, brain cells begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These include functions such as speech, movement, and memory. The specific abilities lost or affected depend on the location of the stroke and its severity (Caplan, 2016). There are two types of “brain attacks” 

Ischemic Stroke: a blood clot blocks or plugs a blood vessel in the brain.

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Hemorrhagic Stroke: a blood vessel in the brain breaks or ruptures.

An ischemic stroke can occur in several ways – embolic, thrombotic, Transient ischemic attack, and lacunar infarcts (Caplan, 2016) Embolic stroke occurs when a blood clots forms in the body (usually the heart) and travels through the blood stream to the brain. Once in the brain, the clot eventually travels to a blood

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Case study paper stroke vessel small enough to blocks its passage. The clot lodges there, blocking the blood vessel causing a stroke. Thrombotic stroke, blood flow is impaired because of the blockage to one or more arteries supplying blood in the brain. Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with the build up with fatty acids and cholesterol. Transient ischemic attacks, or TIAs, are brief episodes of stroke symptoms resulting from temporary interruptions of blood flow to the brain. It can last anywhere from a few seconds up to 24 hours. Lacunar infarcts are small (1.5 to 2.0 cm) to very small (3 to 4 mm) infarcts located in the deeper non cortical parts of the brain or in the brain stem. They are found in the territory of single deep penetrating arteries supplying the internal capsule, basal ganglia, or brain stem. They result from occlusion of the smaller branches of large cerebral arteries, commonly the middle cerebral and posterior cerebral arteries and less commonly the anterior cerebral, vertebral, or basilar arteries. In the process of healing, lacunar infarcts leave behind small cavities, or lacuna. Six basic causes of lacunar infarcts have been proposed: embolism, hypertension, small-vessel occlusive disease, hematologic abnormalities, small intracranial hemorrhages, and vasospasm (Caplan, 2016). Causes: Stroke is a disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a leading cause of disability in the United States. Each year in England, approximately 110,000 people have a first or recurrent stroke and a further 20,000 people have a TIA. More than 900,000 people in England are living with the effects of stroke (Great Britain, 2018). Risk factor: Uncontrollable risk factor

Controllable risk factor

Increasing age. Stroke affects people of all High blood pressure. This is the single most ages But the older have high risk.

important risk factor for stroke because it’s the leading cause of stroke

• Gender. Women have a higher lifetime risk of Page 5 of 13

Case study paper stroke stroke than men do. Use of birth control pills • Smoking. Smoking damages blood vessels. and pregnancy pose special stroke risks for • Diabetes

women. • Heredity and race. People whose close blood relations have had a stroke have a higher risk of stroke.

• High cholesterol. High cholesterol increases the risk of blocked arteries. • Physical inactivity and obesity.

• Prior stroke. Someone who has had a stroke

• Carotid or other artery disease.

is at higher risk of having another one. • Excessive alcohol intake. (Silva, Koroshetz, González, & Schwamm, 2017). Sign & symptoms: Followings are the sign and symptoms of stroke. 

Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body

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Sudden confusion, trouble speaking, or difficulty understanding speech

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Sudden trouble seeing in one or both eyes

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Sudden trouble walking, dizziness, loss of balance, or lack of coordination

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Sudden severe headache with no known cause

Acting F.A.S.T. is key for Stroke 

Face Drooping

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Arm Weakness

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Speech Difficulty

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Time to call 911 (Tony Rudd, 2016).

3. History PERSONAL DATA Patient initial is Bashiran Bibi. She is 60 years old. She was born on June 5, 1960. She currently resides at Lahore City. She was married and has 5 children. Educational attainment was high school graduate. She was a housewife and her sons and daughters support him. My source

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Case study paper stroke of reliability of information is her eldest son and his 3rd child. And the date of interviewed was March 25, 2019. REASON FOR SEEKING CARE Loss of power in all four limbs. HISTORY OF PRESENT ILLNESS Two days prior to admission, the patient experienced generalized weakness, decrease power in all four limbs, Increase BP, and Aphasia. A complaint of dizziness was noted. She was responsive and slurring of speech is noted. She was admitted on March 25, 2019 at 3:50 P.M. with vital sign of Temp: 36.8°C, PR: 85bpm, RR: 19/min, BP: 150/80 mmHg. HISTORY OF PAST ILLNESS It was known that she is hypertensive and have Diabetes Mellitus. The patient doesn’t have any allergies in medications, foods and environment. She didn’t go in any surgery. CURRENT MEDICATION For now, she has current medication which includes inj oxidil 1g, inj Teph 40 mg OD, inj mulamid, Losartan 50 mg/tab 1 tab OD hypertension and Metformin 500 mg 1 tab OD for her Diabetes Mellitus. LIFESTYLE She is non-smoker and non-alcoholic drinker. FAMILY HISTORY As verbalized by the son, she has familial history of Hypertension and Diabetes Mellitus.

4. Physical assessment & laboratory findings VITAL SIGNS

Patient’s Temp: 36.8°C, PR: 85bpm, RR: 19/min, BP: 150/80 mmHg. GENERAL APPEARANCE The client is in medium frame with stooped posture, the client is bedridden since she was admitted to the hospital last March 25, 2019. Well groomed and has no body odor. He doesn’t have any deformity. MENTAL STATUS The client is conscious and cooperative. The client can’t talk because she was stroke. SKIN Page 7 of 13

Case study paper stroke The client’s skin is of normal racial tone which is brown. It is dry and smooth. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. She doesn’t have any edema. But she has popular lesion and pigmentation on her skin. NAIL The client’s nail shape is convex clubbing, the nail is rough and the nail bed is pink. The capillary refill is within 3 seconds and there is an absence of beau’s line. HEAD AND FACE The client’s skull is proportionate to the body size; there were no tenderness in the scalp. There were no presence of nodules, and infestation. Her hair is evenly distributed and the strands are thin and brittle. The color of her hair is a mixture of white and black. Her head is round and symmetrical its consistency is hard. She can’t control her head and the shape of her face is round and asymmetrical and its consistency is soft. EYES The condition of her eyes is straight normal; the eye brows are evenly distributed. The blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The color of her eyes is brown, the shape is equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. EAR, NOSE AND TROAT The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. Her septum is in the midline. The mucosa is pink; nostrils are both patent, nasal flaring is absent. There is an NGT in her left nostrils. The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. NECK The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable. CHEST AND LUNGS Chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. Page 8 of 13

Case study paper stroke The lung expansion is normal. When percussed the sound is resonance. When auscultate brondual is absent. No adrentition sound. HEART The rhythm is regular. PMI is located in the apical pulse. Heart rate is 85 beats per minute. ABDOMEN The bowel sound is normo active and no bruits. When percussed the sound is tympany. The liver is not palpable. UPPER AND LOWER EXTREMITIES The patient cannot resist force when asked to resist.

Laboratory and radiographic findings Her hemoglobin level is 10.8 g/dL, with a hematocrit of 32%. His WBC count is 8.8 cells10µ/L, and 28% lymphocytes. Her platelet count is 399cells10µ/L. The results of a multichemistry screen are unremarkable. Abdomen Ultrasound documents gall bladder is partially contracted and shows multiple calculi collectively measuring 3.5cm. No evidence of abnormal wall thickening or pericholecystic fluid is seen.

5. Related treatment Drug Therapy Ultrasound abdomen revealed that gall bladder is partially contracted and shows multiple calculi collectively measuring 3.5cm. The treatment for her in hospital is IV antibiotic treatment, received azithromycin and oxidil with improvement in his symptoms. Malin lotions apply at night below the neck all over the body to treat popular lesion and pigmentation on skin. Tab Ivermite to treat certain parasitic roundworm infections. Curing parasitic infections helps to improve your quality of life. Telfast 120 mg is used in adults and adolescents of 12 years and older to relieve the symptoms that occur with hay fever (seasonal allergic rhinitis) such as sneezing, itchy, runny or blocked nose and itchy, red and watery eyes.

6. Nursing Care Plan NURSING DIAGNOSIS  Ineffective Cerebral Tissue Perfusion May be related to Interruption of blood flow to the brain as evidence by Changes in motor and sensory responses; Page 9 of 13

Case study paper stroke  Impaired Physical Mobility May be related to neuromuscular involvement: weakness as evidence by patient decrease power in all four limbs.  Impaired verbal Communication may be related to impaired cerebral circulation as evidenced by impaired articulation; patient cannot speak.  Deficient knowledge may be related to Cognitive limitation as evidence by Development of preventable complications. PLANNING 1. Demonstrate stable vital signs and absence of signs of increased ICP. 2. Maintain/increase strength and function of affected or compensatory body part. 3. Indicate an understanding of the communication problems. 4. Provide information about disease process, prognosis, & treatment. 5. Verbalize understanding of condition/prognosis and potential complications.

7. Nursing Interventions INTERVENTIONS 1. Closely assess and monitor neurological status frequently and compare with baseline.

RATIONALES 1. Assesses trends in

level

of

consciousness (LOC) and potential for increased

ICP

determining

and

is

location,

useful extent,

in and

progression of damage. 2. Monitor Heart rate and rhythm assess for murmurs.

3. Evaluate pupils, noting size, shape, equality, light reactivity.

2. Changes in rate, especially bradycardia, can occur because of the brain damage.

3. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact.

4. Position with head slightly elevated and in neutral position.

4. Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. Page 10 of 13

Case study paper stroke 5. Maintain bed rest, provide quiet and relaxing

5. Continuous stimulation or activity can

environment, restrict visitors and activities.

increase intracranial pressure (ICP).

6. Change positions at least every 2 hr (supine,

6. Reduces risk of tissue injury.

side lying) and possibly more often if placed on affected side. 7. Position in prone position once or twice a day

7. Helps maintain functional hip extension.

if patient can tolerate.

8. Place pillow under axilla to abduct arm.

8. Prevents adduction of shoulder and flexion of elbow.

9. Assess extent of dysfunction: patient cannot

9. Helps determine area and degree of

understand words nor has trouble speaking or

brain involvement and difficulty patient

making self-understood. Differentiate aphasia

has with any or all steps of the

from dysarthria.

communication process.

10. Speak in normal tones and avoid talking too

10. Patient

is

not

necessarily

hearing

fast. Give patient ample time to respond.

impaired and raising voice may irritate

Avoid pressing for a response.

or anger patient.

11. Consult and refer patient to speech therapist.

11. Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.

12. Discuss plans for meeting self-care needs.

12. Varying levels of assistance may be needed to be planned for based on individual situation.

13. Monitor vital signs.

13. Monitor Alterations

14. Provide safety measures.

14. Prevent falls and injury

8. Evaluation After effective nursing interventions the patient was partially able to: 1. Demonstrate stable vital signs. Page 11 of 13

Case study paper stroke 2. Complications are prevented or minimized. 3. Daily needs are met either by himself or others 4. Maintain usual/improved level of consciousness, cognition, and motor/sensory function. 5. Patient report in information about disease process, prognosis, & treatment.

9. Recommendations The care and services that are provided to the individual after the stroke, should include the following preventive strategies. 1. Lower blood pressure: "High blood pressure is the biggest contributor to the risk of stroke in both men and women," 2. Lose weight: Increase the amount of exercise with activities like walking, golfing, or playing tennis, and by making activity part of every single day. 3. Treat diabetes: Having high blood sugar damages blood vessels over time, making clots more likely to form inside them. 4. Exercise training recommendations and physical activity programs, can serve as important opportunities to implement effective and lasting behavioral and medical interventions that would improve overall health and might prevent the future occurrence of cardiovascular events such as subsequent stroke or myocardial infarction. The patient receives instructions regarding activity level, vaccination information, and instructions about what to do if symptoms worsen. She has been given an appointment for follow-up after discharge (Yusuf, 2018).

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Case study paper stroke References Caplan, L. R. (Ed.). (2016). Caplan's stroke. Cambridge University Press. Mergenthaler, P., Dirnagl, U., & Meisel, A. (2015). Pathophysiology of stroke: lessons from animal models. Metabolic brain disease, 19(3-4), 151-167. National Collaborating Centre for Chronic Conditions (Great Britain). (2018). Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). Royal College of Physicians Silva, G. S., Koroshetz, W. J., González, R. G., & Schwamm, L. H. (2017). Causes of ischemic stroke. In Acute Ischemic Stroke (pp. 25-42). Springer, Berlin, Heidelberg. Tony Rudd Intercollegiate Stroke Working Party. ‘National clinical guideline for stroke’, fith edition. London: RCP,October 2016. Yusuf, S., Diener, H. C., Sacco, R. L., Cotton, D., Ôunpuu, S., Lawton, W. A., ... & Bornstein, N. (2018). Telmisartan to prevent recurrent stroke and cardiovascular events. New England Journal of Medicine, 359(12), 1225-1237

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