Case Study Based on Stroke Victim

In this paper I will be discussing a patient who at 49 years of age became incapacitated by a left sided cerebrovascular accident (CVA) following a motor vehicle accident. To keep her identity completely confidential, I will be referring to her as Mary. I will not refer to any medical staff or buildings by name for this same reason. Mary had two seizures while in hospital recovering from the motor vehicle accident (MVA). Mary’s recovery was progressing normally but was compromised by a CVA following the seizures which left Mary with a permanent disability. Mary can not walk at all. She can stand with assistance for clothing adjustments. Mary can not talk properly, she responds with “yes”, “no” or “oh no”. Mary is cognitively disabled, although slightly, it can be difficult to tell when Mary is answering the questions or just responding to being spoken to.

Prior to the MVA and CVA, Mary had some health problems that include a long history of hypertension, asthma, an aortic valve replacement, diagnosed major depression, anxiety and epilepsy. The cerebrovascular accident has left Mary unable to perform any activities of daily living so has been forced to reside in a nursing home. Mary is surrounded by elderly patients primarily affected by dementia, leaving her susceptible to other possible problems such as depressive episodes, (although she is on medication for depression), boredom, or possible withdrawal just to name a few (Newcombe, 2005).

This paper will discuss how the nursing staff uses the nursing process to encourage Mary to be involved in activities and her surroundings and how they try to cater for a much younger patient living in the nursing home (Seaback, 2001). I will address areas such as medical and pharmacological management, mobility, and some of the other needs that Mary finds are now compromised, for example, spiritual, sexual, social, and cultural and the difficulties in general family contact.

Epidemiology & Aetiology

Stroke is the third leading cause of death in the United States (McCance & Heuther, 2002), and in Australia (National Stroke Foundation, 2004), after heart disease and cancer, and is the most common cause of Neurologic disability (Springhouse, 1998). The majority of stroke victims are over 65 years of age. Strokes can be hereditary, and seem to be more common in women ( McCance & Heuther, 2002). Stroke is slightly more common in African Americans that Caucasians, affecting African Americans with greater impairment and are twice as likely to die from a stroke as Caucasian people seem to be. This is also the case in Australia according to the Bureau of Statistics, (2005), Aboriginal people are 10 to 20 times more likely to be affected by stroke and heart disease than non-Aboriginal people. The risk factors include modifiable risk factors, which are things like lack of exercise, being overweight, cigarette smoking, alcohol abuse, hypertension, and contraceptive pill, basically the things that we can be changes through lifestyle changes or medical treatment.

Non-modifiable riskfactors include age, gender, race and family history of cerebrovascular disease (Brown & Edwards, 2005). The most common cause of CVA in the elderly is thrombosis, resulting from obstruction in the extracerebral vessels or less frequently the intracerebral vessels (Springhouse, 1998). The second most common is the embolism. An occlusion caused by a fragmented clot, and can occur at any age and occurs suddenly, and thirdly, is a CVA caused by hemorrhage, this also can occur at any age and suddenly (Springhouse, 1998). Mary had been exposed to many of the common risk factors, hypertension, contraceptive pill, smoking, alcohol, aortic valve replacement, and being over weight (Brown & Edwards, 2005).

Awareness of the risk factors and being in control of modifiable risk factors is the most effective way of decreasing the likelihood of becoming victim of a stroke.

Pathophysiology

Stroke is medically defined as a clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and at times global, loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent causes other than of vascular origin (Nursing Standard, 2004). A transient ischaemic attack (TIA) differs from stroke in that symptoms last less than 24 hours. A TIA should never be ignored, as it is a warning that the person has a high risk of developing stroke. Anything that causes a TIA has the potential to cause an ischaemic stroke. People experiencing TIA should see their doctor and most definitely not ignore symptoms simply because they are transient (Nursing Standard, 2004). Mary had no known medical history of TIA. She could not fully understand the question to respond correctly to enable medical staff to ascertain if there had or had not been any prior incidence.

A cerebral infarction occurs when any area of the brain looses blood supply because of vascular occlusion (McCance & Heuther, 2002). The damage can be either reversible or irreversible, in Mary’s case, irreversible. Cerebral infarctions are either ischemic or hemorrhagic. Ischemic stroke occurs when blood flow to the brain is inadequate and cause brain injury (McCance & Heuther, 2002) and accounts for 85% of all strokes (Brown & Edwards, 2005). Ischemic stroke is divided into two categories, thrombilitic and embolitic. Mary was most probably affected by an embolitic stroke, because it occurs when an embolus lodges in and blocks the cerebral artery (Brown & Edwards, 2005), or a clot that originates somewhere other than the brain.

This type of stroke occurs when a piece of clot breaks loose and is carried by the blood stream to the brain. As it travels into smaller vessels, it reaches a point where it can no longer travel and blocks the vessel, cutting off the blood supply. This type of stroke is associated with prosthetic valve replacement. Still referenced incorrectly Conditions associated with this are arterial fibrillation, myocardial infarction, infective endocarditis, rheumatic heart disease, valvular prostheses, and arterial septal defects (Brown & Edwards, 2005). Hemorrhagic stroke occurs when bleeding into the infarcted area due to restoration of blood flow occurs (McCance & Heuther, 2002). When blood is interrupted and the brain is deprived of oxygen and nutrients, the cells in the affected area are damaged causing problems to motor functions controlled by that area of the brain (McCance &Heuther, 2002).

Medical/Surgical Treatment

Stroke is a medical emergency and has to be treated as such to allow for optimal recovery of the patient (Stroke Foundation, 2004). Correct diagnosis and referral to a stroke team reduces the risk of complications during recovery (Stroke Foundation, 2004). CT scan should be used to determine if a stroke has occurred and what type of stroke, and again if the patient experiences any deterioration. Discharge planning is put in to process early to ensure the correct decisions surrounding rehabilitation are made. The medical team would keep the family well informed. Some risks such as aspiration, deep vein thrombosis (D.V.T), pressure sores, pneumonia and recurrent stroke are monitored closely, to reduce the risk of them occurring (Stroke Foundation, 2004).

Mary was admitted to the nursing home after the CVA with a peg tube for feeding because she was having some difficulty swallowing. Mary also initially was non-compliant to speech therapists assessing her swallowing reflexes so this resulted in her keeping the peg tubing in longer than needed. Once Mary realized that she could have the tube removed if assessed to be safely swallowing she happily complied with the speech pathologists and the tube was removed. Mary is restricted to a soft diet but has no difficulties at all with her food.

You haven’t added anything to this section about specific treatment for CVA – ie what does the latest evidence show re things like anticoagulation therapy, thrombolytics etc

Mary’s medications consist of

* Epilim for epilepsy

The generic name for Epilim is Vigabatrin. It is primarily used for the treatment of epilepsy. Some common adverse effects include fatigue, headache, memory loss, insomnia, dizziness, nervousness, weight gain, depression, confusion. Allergic reactions to this drug are rare. It works by inhibiting the gamma-aminobutyric acid transaminase, GABA, which results in increased brain concentrations of GABA. (Reference)

* Pravachol secondary prevention of myocardial infarction

The generic name for Pravachol is Pravastatin. This drug is also used in conjunction with diet to control cholesterol. There is an increased risk of renal impairment, and regular monitoring of renal function is necessary. Some of the common adverse effects include mild Gastrointestinal (GI) problems, headache, insomnia, dizziness, elevated transaminase concentration. Some rare effects include myopothy, hepatitis, liver failure, vision impairment, and anaphylaxis.(Reference)

* Seritide for asthma control

The generic name for Seritide is Salmeterol with Fluticasone. Some adverse effects are mouth ulcers, headache, and tremor. This drug works by relaxing the bronchial smooth muscle by stimulating beta2 adrenoceptors(Reference)

* Warfarin to prevent thromboembolism as Mary has had a aortic valve replacement prior to the CVA

Warfarin inhibits the synthesis of vitamin K-dependant clotting factors. It is used for prevention and treatment of venous thromboembolism, thromboembolism for patients with prosthetic heart valves; it is used for prevention of stroke in patients with previous history of myocardial infarction. Bleeding is a common adverse effect. Rare effects are skin necrosis, purple discoloration of toes, allergic reactions, fever, rash, vomiting, diarrhea, hepatic dysfunction. When a patient is taking Warfarin, constant monitoring if INR levels are necessary to indicate if levels are in a therapeutic range. (Reference)

* Coversyl plus for hypertension

The generic name for Coversyl plus is Indapamide. It is indicated for hypertension. Too brief – needed to be expanded

* Efexor XR for treatment of major depression

Efexor XR has the generic name of Venlafaxine. It is indicated for major depression, and generalized anxiety disorder. Hypertension can be exacerbated by this medication. Common adverse effects are nausea, vomiting, anorexia, headache, sweating, anxiety, rash, dizziness, fatigue, hypertension, tremor and orthostatic hypotension. Some less common side effects are sexual dysfunction, dry mouth, insomnia, constipation, palpitations, seizures and hepatitis. (reference)

* Coloxyl & Senna to avoid constipation

Docusate is the generic name for Coloxyl. Coloxyl is a laxative, or a stool softener. It works by assisting with the mixture of water into the faeces. Its infrequent adverse effects include abdominal cramping, colic, diarrhea, rash, excessive loss of water and electrolytes. Senna is also a laxative. The adverse effects are also abdominal cramping, and diarrhea. (Reference)

* Panamax / panadiene forte PRN for pain relief

Paracetamol is the generic name for Panamax. It is indicated for mild to moderate pain, fever, migraine and tension headache. Paracetamol can interact with Warfarin, and it is suggested that 3.5-7.0g of paracetamol can elevate INR levels. Panadiene is paracetamol with codeine. Constipation is a common side effect of codeine. (Reference)

* Diazepam elixor for control of seizures

Diazepam elixor is a benzodiazepine. It is indicated for treatment of acute seizures, drug and alcohol withdrawal seizures, and muscle spasm. Some common adverse effects are drowsiness, hyper salivation, aggression, irritability, and hyperactivity. Alcohol should be avoided with this drug because it can increase CNS depression. (Reference)

* Ventolin nebs. PRN for asthma relief

Ventolin’s generic name is Subutamol. It is indicated for the treatment of acute asthma, symptomatic relief and protection against exercise educed asthma. It is a bronchodilator. Its mode of action is it relaxes the bronchial smooth muscle by stimulating beta2 adrenoceptors. Common side effects include tremor, palpitations and headache. Less common are tachycardia, insomnia, hyperactivity in children and agitation (AMH 2004). Is this your reference for all information re drugs? – if so you need to add this reference at the end of each section OR mention at the beginning of the section explaining drugs that you obtained all information from this source

Social, Cultural, historical and primary Health Care Issues

Mary is in the middle adulthood developmental stage according to the developmental theories (Crisp & Taylor, 2003). This indicates that generally, without her disability, she would be having increased feelings of satisfaction, decreased negativism, and would be having a concern for her health. The fact that she has had such a major disability affect her at this stage also affects how she has coped. She has coped relatively well by staying close to her family, drawing on their love, leaning on her friends and family for support while she was adjusting and taking one day at a time..

Mary’s social life largely revolved around her family and friends before the stroke. After her initial withdrawal she has remained very tightly networked with the same people. They take her out for short functions, they spend time at the nursing home, and they take her home for the afternoon simply just to watch television. Mary has also developed a relationship with the nursing team at the nursing home but can be reliant on them so care is taken to enhance her independence where possible. Nursing staff set Mary up with her chosen activity, whether it is an ADL or a planned activity and make sure she has every thing she needs and the reassurance of knowing a nurse is close by to assist if needed, and then encourage Mary to attend the activity herself.

The divisional therapy staff gives Mary a choice of activities within her capability so she won’t need a lot of help from staff and this helps to avoid Mary becoming agitated or frustrated. If staff can see Mary is having difficulties then they ask Mary if she would like help or if she would like to join a different activity. Mary particularly enjoys craft. She can take her time and enjoys seeing how the staff and residents all have difficulties in some areas with craft. This makes Mary smile and laugh. Some good additions here Janeen.

Mary is not religious at all but chooses to join the facilities church service occasionally. Nursing staff encourage and support Mary if she wishes to join in but do not push the issue if she indicates she is not interested on that day. When Mary does choose to join in with church services she is sometimes joined by her family or friends.

Mary has a lot of health care issues; most are prior to the stroke so she has dealt with issues surrounding them. Health is a complete state of mental and social wellbeing, not just the state of physical health (Health Promotion, 2005), so Mary’s health will suffer if her emotional health needs are not adequately met.

Nursing Care

Patient Problems Nursing Action Goal

* pain and discomfort due to communication deficit

* pain and discomfort due to mobility deficit

* high risk of major depressive episode due to disability, boredom, pain, lack of stimulation, loss of independence,

* Self care deficit due to left sided partial paralysis

Poor mouth hygiene due to poor mobility and self care deficit

Anxiety related to disability

Skin problems, pressure areas, due to poor mobility, lack of sensation

High risk of constipation due to lack of mobility

High risk of urinary tract infections due to self care deficit

Emotional dependence due to high care needs from nursing staff

Aggression or agitation due to unmet pain levels, communication deficit, frustration

Joint contracturesdue to poor mobility

High risk of unintentional self harm, due to lack of sensation in right hand and foot

Risk of obesity due to poor mobility

High risk of boredom due to limited resources in nursing home

Risk of becoming withdrawn due to lack of independence, communication deficit, mobility deficit, lack of resources in nursing home, unwillingness to accept change of body image

Mary’s emotional wellbeing will largely determine her overall health. If she is happy, free from pain and discomfort then she is more likely to join in with daily activities in the facility (National Stroke Foundation, 2004). Nursing staff can assist Mary to stay pain free and comfortable by observing Mary for non-verbal cues such as withdrawal, irritation or agitation, aggression, facial grimace, and by keeping Mary’s routine as constant as possible. Keeping Mary as independent as possible by encouraging her to do what she can while attending hygiene keeps Mary from becoming overwhelmed by her disability which in turn keeps her in good spirits, but also assisting Mary to look and feel nice where necessary.

Mary self initiates toileting needs and moves around the building in a wheelchair but is still reliant on staff to assist her. If the nursing staff do not attend Mary promptly she will try to transfer herself to the toilet and then is at risk of falling. Mary understands this and waits sometimes but in order to avoid falls staff must be aware of Mary’s location at all times. This can be difficult at times as Mary moves around from room to room, but generally seeks out a room with other people in it. Prompt attention will assist Mary with elimination needs also and help to prevent constipation or incontinence. Mostly all of Mary’s needs will be equally important because if one is not met them something else will occur causing a different problem for Mary or nursing staff to deal with.

Patient Aims

To keep Mary as independent as possible while still providing the care Mary needs to meet daily living needs, and to keep Mary well, mentally and physically. If Mary becomes unwell mentally it will ultimately affect her physical health and vise/versa. Mary’s family network is very important to her so the nursing team includes them in any decision making and any facility functions at any time possible. The nursing team encourages Mary’s family to meet regularly with the nursing staff to discuss their concerns and expectations surrounding Mary’s care.

Nursing Actions

Keep Mary free from pain and discomfort by using appropriate medication, observing for non verbal cues such as facial expressions, irritation, agitation, aggression.

Keep Mary’s mental health stable by involving Mary in decision making where possible, activities where possible, encourage Mary to go out with family and friends.

Enable Mary to meet hygiene needs by assisting where necessary but not where unnecessary by assisting rather than doing.

Keep Mary from becoming emotionally dependant on nursing staff by encouraging Mary to be involved in her care, doing what she can do for herself

Keep Mary as active as possible by encouraging and assisting with active and passive exercises,

Encourage Mary to make her own choices

Regular assessment of skin for any signs of change

Encourage and assist Mary to make the correct nutritional choices for her to avoid obesity, bladder and bowel problems

By keeping Mary’s physical and mental self as healthy as possible the nursing care team will hopefully eliminate any other possible nursing problems that will cause Mary discomfort, distress or more disability and ultimately save the health care facility time and money.

Brief discussion on the overall nursing care for the patient

Initially when Mary was hospitalized after the MVA and she had suffered a stroke she experienced anxiety partly because of the loss of movement and the complex nursing and medical interventions. Although the health care workers where there to assist Mary, she did not know any of them, and was in unfamiliar surroundings, with these difficulties as well as all of the other patients receiving care within close proximity had an impact on Mary’s anxiety levels (Hafsteinsdottir & Grypdonck, 1997). Now that Mary is in more of a home environment she is more relaxed and comfortable with her surroundings. She now has developed nurse/patient relationships with the Nursing Staff in the Nursing Home. Mary is at risk of developing a dependence on the nursing team and care is taken so this does not get out of control for Mary.

The overall nursing care for Mary will change periodically so the nursing team will evaluate Mary’s care plan monthly but will also modify it in the interim if needed. Mary is a considerable many years younger that the usual resident in a nursing home so nurses are careful not to treat her as an elderly resident. Although the majority of the care does not change, the cognitive behavior of a 50 year old and a 70 year old are different according to the theories surrounding lifespan developement (Crisp & Taylor, 2003). The nursing team is aware of this and treats all residents accordingly.

Conclusion

We all need to take our control of our health and change any of the modifiable risk factors that we possibly can to make ourselves healthier in the long run. Whether or not we have any of the non-modifiable risk factors, we may still be susceptible and not be aware. A stroke will change a person’s life dramatically. Although Mary was dealing with many medical problems before the stroke, one day she is totally independent driving her car, doing her shopping and the next day she is totally dependant on nursing care at a nursing home. The care for Mary is long term and the nursing home is now her permanent home.

Mary has had to make enormous adjustments although, mentally she has been affected by the stroke, and she is very aware and does not appear to have any Neurologic deficit at all to the general public. The nursing care of any nursing home resident should be individual, and if a younger person becomes disabled and ultimately ends up in a nursing home as a permanent resident, they should also be cared for on a individual basis but unfortunately the care in some nursing homes is changing as nurses are being replaced by care workers who do not have the same training and a combination of this and time constraints turn nursing care into task driven care.

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