Theory and Construction of a Care Plan for Stroke Rehabilitation

For this assignment I will be looking at the care planning process for an elderly stroke patient. The theory behind care plans how they are constructed and are used in rehabilitation and ongoing care I will also look briefly into my client’s condition.

For this placement I was based on an elderly female rehabilitation ward. Patients were admitted from a range of places, but mainly from acute elderly care wards. Patients were transferred to the ward for specialised rehabilitation, to a stage where they could be discharged, either to their own home or into residential care. The conditions patients were admitted with were quite varied, ranging from severe MS and CVA patients, to confusion and falls at home.

The client this assignment will be based on is an 82 year old lady whom for the sake of confidentiality I will call “Mary”. She was admitted to an elderly medical ward after being found on the floor of her flat by the police. She was diagnosed with right sided stroke which had caused Paralysis of the entire left side of her body, which was causing several related problems. She was also diagnosed with an irregular heart rhythm (atrial fibrillation) which was the probable source for the clot that caused the cerebral ischemia. To prevent further clotting she was placed on Warfarin (an anticoagulant). Mary also suffered from osteoarthritis which she was taking pain killers.

She stayed on a medical ward for about 3 weeks where she was fully cared for with little rehab. She was then transferred to the rehabilitation ward.

Rehabilitation is the processes of helping an individual achieve the highest level of function, independence, and quality of life, it does not reverse or undo the damage caused by disease or trauma, but helps restore the individual to optimal health, functioning, and well-being. Rehabilitate (from the Latin “habilitas”) means to make able. The interaction of disease, disability, and the environment creates a set of variables unique to every patient, and any rehabilitation care plan must therefore be individually tailored to their needs.

The type of stroke Mary had suffered from was an Ischemic stroke meaning a blood clot caused a blockage in an artery leading to the brain. As the brain does not get enough oxygen rich blood, the oxygen starved brain cells can die within minutes. The condition must be treated immediately. Rapid response to stroke can result in little apparent damage, but a stroke left untreated for too long can result in neurological tissue damage (e.g., permanent loss of speech or paralysis) or death.

Strategies for stroke rehabilitation should be started as soon as possible, preferably in the acute setting and then continued in a rehab setting or at home.

Physical therapy is focused on regaining gross motor deficits (transferring, walking, stairs, etc.). Occupational therapy focuses on fine motor functions and focal deficits, brain functions such as calculations, and daily activities such as bathing, dressing, and kitchen activities. Speech therapy targets assessment and recovery of two important functions: speech functions (such as linguistics and articulation) and swallowing ability.

Every ward uses a model of nursing on which to base its care planning.

A care plan is a written, complete, plan of action that states the health care needs of a patient and the kind of services and supports that are needed to meet those needs. Care plans are almost exclusively based around models of nursing.

Different nursing models make different assumptions about people and their health related needs. Some see people in a way similar to the medical model as interrelated sets of anatomical parts and

Physiological systems like Henderson’s Model of Nursing. (Henderson & Cushman 1991). Others suggest that it is not very helpful to ‘fragment’ people in this way, preferring to see individuals more holistically as ‘whole beings’

A model can also help to determine the kinds of intervention best suited to the patient’s needs and can contribute to the decision of who should intervene. In this way, decisions informed by the thoughtful application of a recognised nursing model can go a long way towards meeting the demands of accountability. As indicated in the NMC Guidelines for Professional Practice: “If you delegate work to someone who is not registered with the NMC/UKCC, your accountability is to make sure that the person who does the work is able to do it and that appropriate levels of supervision or support are in place.” (NMC/UKCC, 1997)

The model of nursing used on my ward was Roper, Logan and Tierney’s Activities of living (Roper et al 1996) which was adapted to focus upon the process of rehabilitation. It was this model that was used to structure Mary’s care plan because it looks at the person holistically which is important in rehabilitation as stroke victims can suffer from numerous different problems.

The starting point for the Roper, Logan and Tierney model of nursing is the hierarchy of human needs identified by the psychologist Abraham Maslow (Maslow 1954. cited by Walsh et al 2001). This arranges human needs from the most basic to the most sophisticated. In this theory, unless basic physiological and safety needs such as the need for food, water and air are met, people cannot go on to express themselves in intellectual and creative endeavours.

This early list of behaviours was later refined to specify 12 activities of living, these being central to the model later versions. Each activity of living specifies a distinct type of human behaviour related to meeting a particular need. Some activities of living have a biological basis, like drinking and breathing. Others are more socially and culturally determined: activities of living relating to personal dress, cleanliness, work/play and sexuality are more of this kind.

From the Roper, Logan and Tierney model the trust have standardised a way of admitting and assessing each patient in the form of a collection of assessment and planning documents, an integrated care pathway (ICP). ICP’s are used as a multidisciplinary outline of anticipated care for patients with similar diagnosis. ICP documents specify the interventions required for the patient to progress along the pathway and place them against a timeframe measured in terms of hours, days and weeks (goals achieved)

ICP’s are important because by providing explicit standards they can improve multidisciplinary (and multi agency) communication and collaborate, empower and inform patients, careers and help meet the requirements of clinical governance (Middleton et al 2001)

To gain an initial insight into Mary’s condition we looked at the transfer documents, her notes, the care plan and continuation sheet from the last ward. Mike Walsh states (Walsh et al 2001) it is not always possible to complete a full assessment on first arrival as not all the information or assessment equipment may be available. Once Mary had settled in, the senior nurse and I sat down with her to start the nursing cardex admission pack, which on our ward was a standardised package set out by the trust to meet all the clinical governance standards. This pack contains all the relevant documentation to assess the patient and construct a standardised package of care based around Roper, Logan and Tierney activities of daily living, which at the same time is individual to each patient. This helps to reduce unnecessary variations in patient care and outcomes and incorporates the local and national guidelines to everyday practice. (NMC/UKCC 1997)

This information was compiled with Mary present to help her to decide how her care plan should be constructed. This was difficult as Mary was suffering from mild dysphasia so it required a lot of communication skills to both understand what Mary was saying and to communicate information to her in such a way as to not require complex long answers. According to Walsh (Walsh et al 2001) patient assessment is often poorly carried out. It is frequently lumped together with admission, to the point now that many wards talk of admitting rather than assessing a new patient. This is something that was being tackled on the ward by completing the admission/assessment process with Mary present.

From the information gathered we were able to form an initial plan of care. These plans are a continuing process; each part of Mary’s care plan has a progress and evaluation sheet to see if it is achieving its goals, this assessment is ongoing. Each individual ICP document requires different assessment skills and tools, to determine the level of competence.

Once all these assessment documents were completed we could decide which members of the MDT to refer her to. We then start putting together an initial care plan with the core care plan documents (See appendix 1). Other nursing problems that require identification during assessment are those which derive from the treatments prescribed by medical and other health professionals. For these there where care plan sheets covering specialised interventions, like, one for the correct care of a sub-cut venflon or maintaining blood glucose levels.

In early RLT models it is clearly stated that it may not always be necessary to consider each activity of living in patient assessment, (Aggleton and Chalmers 2000).

Each core care plan document sets down a plan of care and assessment for each individual activity of living from this base assessment it is possible to monitor, maintain and adjust the level of care needed. (See appendix 1 for the core care plans.)

During Mary’s assessment it became apparent that several deferent care plans would be needed to adequately meet the rehabilitation needs for the 12 activities of daily living. I will give a brief outline of all the care given and go into detail where necessary.

Florence Nightingale highlighted the importance of ensuring that patients were safe when she stated in her, Notes on nursing, that nursing should ‘Do the patient no harm’. (Nightingale 1860. cited by Mallik et al 1998).

Hemiplegia is often caused by stroke, so the care of paralysed limbs and avoiding the hazards of immobility are important. Similarly, the patient with a decreased level of consciousness will require their safety needs met. This includes an accurate assessment of conscious level also raised intracranial pressure could pose a number of dangers for the patient. Patient safety and comfort are greatly enhanced when consideration is given to the patient’s ability to communicate.

As Mary had complete paralysis of her left side her safety was an important issue when it came to transferring it was necessary to use the hoist for any mobilisation. This was not only to protect Mary but the nursing staff as well. As Mary had high levels of consciousness with a continually high Mental Test Score (MTS) she was aware off all the safety precautions needed.

Speech impairment or loss can be a frightening experience for the patient. Early referral to a speech therapist is important in order that an expert assessment can be performed and a strategy identified. It is crucial to ascertain the type and nature of the speech deficit, e.g. whether the patient’s difficulties are related to expression or comprehension. The nurse should encourage the patient to perform the prescribed exercises.

Powerful emotions are often displayed by the patient following stroke. Many patients display anger or frustration with the frightening situation in which they find themselves. They can be vented onto the nurse and can manifest itself as lack of cooperation. Patients who are unable to communicate their feelings verbally may feel trapped inside a body that refuses to do what they want (Roper et al 1996). The patient needs to be repeatedly reminded of what has happened to her and why she feels the way she does, in order to try to reassure her.

Mary had mild Dysphasia but no hearing problems, approximately one third of all stroke patients suffer from some form of dysphasia (Alexander et al 2000). The speech therapist prescribed a number of vocal exercises which Mary was to do as often as possible. To help Mary feel more comfortable and relaxed we took are time to listen to her and encouraged her to express her needs in time she showed steady improvement, recovering to almost normal speech.

After a stroke patient’s fluid intake should be via an intravenous infusion and the nurse is responsible for maintaining this at the correct rate. This helps to maintain arterial blood pressure, which encourages adequate cerebral perfusion and, in turn, prevents cerebral ischemia. An accurate record of fluid balance should be maintained.

For Mary this was started on the previous ward and she had already been introduces onto an oral diet because her swallowing and cough reflexes were adequate. The patient may need help with feeding, or can be given adapted eating utensils which allow her to feed herself. Being spoon-fed can be embarrassing and sensitivity is required on the nurse’s part to preserve the patient’s dignity and self-esteem. The nurse should determine what the patient is capable of; for example, paralysis may prevent her from cutting up her own food but not stop her from feeding herself. The patient with a facial paralysis should be instructed to chew food on the unaffected side only. If the patient experiences swallowing difficulties the increased oral hygiene is needed.

The “Hospital Nutritional Assessment Chart” not only assesses the patient’s nutritional needs, but her ability to chew and swallow and ability to feed herself by a number of observational check boxes. From this assessment it became obvious that Mary was having difficulties swallowing and was unable to feed herself competently. On her last ward she had been fed so made no attempt to feed her self. After the full assessment by the dietician Mary was continued on a stage 2 diet (liquidised meals to a drop yogurt consistency) and runny honey fluids, the purpose of the liquid foods is to promote a swallow reflex as un-thickened fluids can run down the throat to fast for the reflex to cope and enter the trachea and more solid foods can get logged dew to the weekend swallow action. After assessment by the occupational therapist with the help of a plate ring and tack-pad to prevent the food coming of the plat and the plate moving. Mary was prompted to feed her self after the initial stages Mary found this much more enjoyable than being fed.

Continence in stroke patients can be both a physical and physiological problem. Combined with poor mobility incontinence can easily lead to skin problems (broken spots leading to pressure sores) which then can get infected by continued soiling. It is the duty of the nurse to keep continued observations of a patient to prevent significant discomfort. The use of a catheter initially is of great help during the initial stages of rehabilitation on admission Mary was incontinent of faeces and already catheterised. Since the stroke Mary seem to have no control over her elimination and was even unaware that she had been. So she was placed on a fluid balance chart to record any abnormalities in her urinary output and a stool chart to try to establish a pattern, to lessen her discomfort. As her condition slowly improved Mary started to become aware of when she was going and slowly progressed to the point when she could control herself eventually even the catheter was removed at her request.

Personal cleansing and dressing can be a major issue for all stroke patients as in nearly all cases some degree of re-education is needed in some cases it may never be possible for the patient to dress themselves again. In many cases a course of passive exercise is used to move the effected limbs in the correct motions to dress and wash. What this does is reconnect the nuro-connections between movement and brain activity (Alexander et al 2000).

After the occupational therapist had seen Mary, she implemented a plan of washing her lower half in bed and then sitting her out where she was given all the implements to wash herself she was helped to wash herself with her right hand and then placing the sponge in her left hand the nurse would use Mary’s hand to gently wash her again, this was to help promote muscle memory and try to regain some movement in the paralysed side. This led to Mary being able to wash and dress her top half unaided. Unfortunately no progress was seen with the left side which was completely paralysed. Mobility was a problem for her, she attended physiotherapy sessions 5 days a week and was encouraged to do as much for herself as possible. Over the weeks her strength and mobility increased in her right side. Her bed mobility was restricted at first a draw sheet and full assistance of 4 was needed to sit her up comfortably, but as her strength returned with the aid of a bed hook she could sit herself up. Due to the paralysis Mary’s sitting balance was not too good so the physiotherapist prescribed a specialised stroke chair with side supports.

Every week there was a multi disciplinary team meeting (MDT) involving all the relevant services and team member required for the full care of patients. This was in accordance with the new government guidelines in the white Paper “Saving Lives: Our Healthier Nation”. It emphasises the value of cross departmental working and greater ‘partnership’ between local authorities, health authorities, the private sector and the voluntary sector (DoH, 1999).

These meeting where held on a Tuesday, Mary was admitted on a Thursday it was nearly a week before Mary had her first MDT. All the people relevant to Mary’s case were present and discussed how her care was going and whether she had made any progress or decline, and what the next course of action should be, what changes to the care plan were needed. At the first meeting it was noted that sometimes Mary had been fed, although the occupational therapist had documented that it was important that Mary, feed herself to improve her independence. So an additional note was added to the care plan.

Family and friends are usually involved but Mary had no family and her husband had been dead for many years. It seemed very sad how isolated that she had become as during the admission it was noted that her primary contact was a solicitor. During Mary’s care she always scored highly on the Geriatric depression scale [GDS] as she seemed to quite like being in hospital with people to talk to and interact with her. This was unusual as Kalra states that depression in both the patient and his or her family members is common after having a stroke. (Kalra and Crome 1993)

With gradual changes to the care plan Mary showed steady improvement over the first few weeks but at one of the MDT meetings it was suggested that Mary might have reached a plateau in her improvement. Over the next few meetings it was discussed in more detail and it was agreed that we had come as far as we could with ward base rehabilitation, so the social worker was brought into the meetings to sort out the possibilities of care in the community in accordance with Mary’s wishes.

In conclusion for patients to get the most from hospital stays, different models of nursing are used, the care plans worked out from these models of nursing are continually updated and all of the relevant professionals are involved to ensure continuity of care.

References

*Aggleton P, Chalmers H. (2000). Nursing Models and Nursing Practice. 2nd Edition. Hampshire: Palgrave.

*Andrews H A, Roy C. (1991). The nursing process according to the Roy adaptation model. .’ In Roy and Andrews (1991). The Roy Adaptation Model: The Definitive Statement. Norwalk, CT, Appleton & Lange.

*Alexander M F, Fawcett J N, Runciman. (2000). Nursing Practice, Hospital & Home: The Adult. 2nd Edition. Spain: Churchill & Livingstone.

*Department of Health. (1999). Saving Lives: Our Healthier Nation. London, Stationery Office.

*Henderson, V. Cushman M. (1991). Nature of Nursing: A Definition and implications. 2nd Edition. New York: National League for Nursing

*Kalra L, Crome P, 1993. The role of prognostic scores in targeting stroke rehabilitation in elderly patients. [website] Available from: < www.ncbi.nlm.nih.gov/entrez/> [Accessed: 5:12:2002]

*Mallik M, Hall C, Howard D. (1998). Nursing Knowledge & Practice: A Decision Making Approach. London: Bailliere Tindall

*Middleton S, Barnett J, Reeves D, 2001. What is an integrated care pathway? [web site] Available from: < www.evidence-based-medicine-co.uk> [Accessed: 5:12:2002]

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*Roper N, Logan W, Tierney A. (1996). The Elements of Nursing. 4th Edition. Edinburgh: Churchill Livingstone.

*United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1997) Guidelines for Professional Practice. London, NMC.

*Walsh M, Duxbury J, Rowswell M. Models and critical pathways in clinical nursing: Conceptual Frameworks for Care Planning. 2nd Edition. Edinburgh: Bailliere Tindall.

*Wester P, Radberg J, Lundgren B & Markku P. (1999). Factors Associated With Delayed Admission to Hospital and In-Hospital Delays. Stroke. Volume: 30. (40-48)