Stroke is Australia’s single greatest killer and a leading cause of disability. Stroke is a serious and deadly condition involving cerebral circulation within the brain and can seriously affect a person maintaining a safe environment, communication and mobility as well as other activities of living. The case of Mr Shaw, a 73 year old male admitted to the stroke unit of his local hospital following a left sided ischaemic stroke is presented in this essay. The ischaemic stroke has left Mr Shaw with right sided hemiparesis, neglect of affected limbs, dysphasia and right sided hemianopia.
The purpose of this essay is to give an overview of the Pathophysiology of ischaemic stroke and Mr Shaw’s symptoms in order to understand what happens in the brain when an ischaemic stroke occurs. The nursing care required for Mr Shaw will also be discussed as well as the rationale behind it. Pathophysiology: Stroke, previously known as cerebrovascular accident (CVA) is defined as ‘a sudden impairment of cerebral circulation in one or more of the blood vessels supplying the brain.
It interrupts or diminishes oxygen supply, causing serious damage or necrosis in brain tissues’ (Pathophysiology made Incredibly Easy 2006). A person suffering a stroke can present one or more of the following symptoms, weakness or numbness or paralysis of the face, arm or leg on either or both sides of the body, difficulty speaking or understanding dizziness, loss of balance or an unexplained fall, loss of vision, sudden blurring or decreased vision in one or both eyes, headache and difficulty swallowing (National Stoke Foundation 2012).
There are two types of stroke, haemorrhagic stroke and ischaemic stroke. In the case of Mr Shaw he has experienced a left sided ischaemic stroke. An ischaemic stroke is ‘a cerebrovascular disorder caused by deprivation of blood flow to an area of the brain, generally as a result of thrombosis, embolism or reduced blood pressure’ (Harris, Nagy & Vardaxis 2010). Ischaemic stokes occur as a result of an obstruction within a blood vessel supplying blood to the brain with the underlying condition for this type of obstruction being the development of fatty deposits lining the vessel walls.
Atherosclerosis is the name given to this condition. These fatty deposits can cause two types of obstruction; cerebral thrombosis or cerebral embolism. Cerebral thrombosis refers to a blood clot that develops at the clogged part of the vessel. Cerebral embolism refers to a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck.
A portion of the blood clot breaks loose and enters the blood stream, travelling through the brains blood vessel until it reaches a blood vessel too small to let it pass through (American Stroke Association 2012). As a result of suffering an ischaemic stroke Mr Shaw has right sided hemiparesis of his arm and leg, neglect of affected limbs, dysphasia and right sided hemianopia. Hemiparesis is muscular weakness of one half of the body (Harris, Nagy & Vardaxis 2010). As Mr Shaw had a left sided ischaemic stroke, the right side of his body has been affected.
Neglect of affected limbs is when a patient does not look at the affected side, leaves food on their plate on the affected side, has a inability to protect the affected side, has an inability to perform self-care and pays consistent inattention to stimuli on the affected side (Comer 2005, p. 106). Another symptom Mr Shaw is experiencing is dysphasia. Dysphasia is defined as, ‘a partial loss of language; usually due to cerebral infarct(s), a cerebrovascular accident (CVA) or traumatic brain injury (TBI) (Harris, Nagy & Vardaxis 2010).
Lastly the symptom of hemianopia is defined as, ‘blindness in half of the normal visual field’ (Harris, Nagy & Vardaxis 2010). With the symptoms that Mr. Shaw is experiencing it is possible to say that the ischaemic stroke has occurred in either the middle cerebral artery or the internal carotid artery as an ischaemic stroke in these areas of the brain produce some not if all of the symptoms that Mr Shaw is experiencing (Pathophysiology made Incredibly Easy 2006, p. 88). Although there is no cure for an ischaemic stroke there are modifiable risk factors that a person can control to reduce their chance of stroke, these include, hypertension (high blood pressure), smoking, diabetes mellitus, hyperlipidaemia (excess of lipids in the plasma), sickle cell disease, obesity, physical inactivity, alcohol or drug abuse and oral contraceptive use (Hennerici, Bogousslavsky & Sacco 2005, p. 12). Nursing care and rationale:
There are many activities of living that a person undertakes that ensure survival, these include, maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. In Mr Shaw’s case, maintaining a safe environment, mobilising and communication will be discussed in detail as they relate most with the symptoms he is experiencing.
Mr Shaw’s Glasgow Coma Scale of 15 is the highest score that a person can obtain which allows nurses to know what care he will require, that he is conscious and responding to stimuli as his eye movement is spontaneous, can obey simple verbal commands and he is orientated to the time, place and person (Roach 2001, p. 232). During the first 24 hours Mr Shaw will also require tests to be done to determine the extent of the damage to his brain caused by his ischaemic stroke.
Some of these tests include; cerebral angiography, digital subtraction angiography, CT scans, PET scans, single-photon emission tomography and an MRI (Pathophysiology made incredibly easy 2006). During the first 24 hours of Mr Shaw being admitted and after gathering information from the Glasgow Coma Scale, the nurse can then take a set of vital observations including, blood pressure, pulse, respiratory rate, temperature and pulse oximetry. This gives the nurse a baseline to work from and can help determine any changes in his condition throughout his care in the stroke unit (Crisp & Taylor 2009).
The activity of living maintaining a safe environment encompasses the human body’s ability to protect itself and the biological mechanisms that it employs to carry this out, the ability that individuals have to make choices and take action to keep safe and free from danger, and the identification and understanding of the dangers and hazards that exist in the surrounding environment and how they pose a threat to individual safety and wellbeing (Holland et al. 2008, p. 46).
As Mr Shaw’s left sided ischaemic stroke has left him with neglect of limbs, right sided hemiparesis of his arm and leg and right sided hemianopia, this affects his ability to maintain a safe environment for himself; certain actions must be carried out by a nurse to ensure Mr Shaw’s safety. The nurse should follow the nursing process and firstly assess for any safety hazards that Mr Shaw may come across as this will remove the potential for injury as he may be unaware of injury threat (Comer 2005).
The nurse should then implement the plan of utilizing side rails, soft restraints or surveillance of positioning of affected side. This protects the neglected limbs from injury (Comer 2005). Providing clear pathways, good lighting, and eliminating small rugs are other actions the nurse can take to ensure that Mr Shaw maintains a safe environment in regards to his neglected limbs and hemiparesis as well as his right sided hemianopia. This will prevent accidental falls for Mr Shaw (Comer 2005).
There are many factors that influence the activity of living maintaining a safe environment, these include, biological, psychological, sociocultural, environmental and politicoeconomic factors. In Mr Shaw’s case, biological factors are having the most significant impact on him maintaining a safe environment as well as environmental factors. Although the nurse is not able to control the biological factors, they are able to control the environmental ones and assist Mr Shaw in his activity of living maintain a safe environment through the actions discussed above.
Mr Shaw’s activity of living communicating is affected by dysphasia that he is experiencing which requires certain nursing actions and care being implemented to ensure Mr Shaw is able to communicate and understand communication. Communication can be written, electronic, oral, face-to-face, verbal and nonverbal and involves expressing oneself, seeing, hearing, feeling, understanding and then expressing back to the person you are talking to (Holland et al. 2008, pp. 102-103). In order for Mr Shaw to be able to communicate effectively a nurse should carry out certain actions.
Firstly the nurse should follow the nursing process and assess or evaluate Mr Shaw’s ability to speak or understand language and then documenting this in Mr Shaw’s notes. By doing this it provides a baseline from which to begin planning interventions. Determining the specific areas of brain injury involvement will also rule out what type of assistance will be required for Mr Shaw (Comer 2005). The nurse should then assess whether Mr Shaw suffers from aphasia or dysarthria. The reason for this is aphasic patients have difficulty using and interpreting language as well as comprehending words, and an inability to speak or make signs.
Dysarthric patients can understand language, but have problems forming or pronouncing words as a result of weakness or paralysis of the oral muscles (Comer 2005, p. 105). Another action the nurse should consider is to avoid talking down to Mr Shaw or make patronizing comments as intellect frequently remains unimpaired after a stroke (Comer 2005, p. 105). When asking Mr Shaw questions the nurse should use yes or no type questions initially, and progress when he is able to answer more specific questions. The reason for his is it provides a method of communication without necessity of response to large volumes of information. As Mr Shaw progresses, the intricacy of questions may increase (Comer 2005, p. 105).
Neglect of affected limbs may also impact on Mr Shaw’s ability to communicate as he may have difficulty controlling certain muscles used for speech. In this case the nurse should provide instructions verbally and in small amounts to Mr Shaw. The nurses should also refer to the affected side frequently while communicating with him as this promotes communication and understanding by Mr Shaw (Comer 2005, p. 07). If verbal communication is too difficult due to dysphasia the nurse may provide a method of communication for the patient such as; a writing board or communication board to which Mr Shaw can point at. This allows Mr Shaw to communicate his needs effectively to the nurse and relieves possible anxiety and stress that he may be experiencing (Comer 2005, p. 105). As Mr Shaw’s dysphasia causes him to have little or no ability to communicate, it is important that the nurse places his buzzer within reach.
This means placing it on his left side as his right sided hemiparesis and hemianopia will not allow him to use it if placed on the right side of the bed. In doing this the nurse is increasing Mr Shaw’s ability to communicate with the nurses. All of the above nursing actions should be conducted within the first 24 hours of his care in order to establish his needs and to ensure that he is able to communicate important and necessary information. Following the nursing process, the nurse should then evaluate Mr Shaw’s speech during the next 48 hours and should consult a speech therapist if Mr Shaw’s speech has not improved.
The reason for consulting a speech therapist is that it may be required to identify cognition, function, and plan interventions for recovery of speech (Comer 2005, p. 105). Lastly the nurse should instruct Mr Shaw and his family on methods he could implement and use for communication. This helps provide ways for Mr Shaw to communicate his needs to his family and can reduce any stress or anxiety that he may be experiencing (Comer 2005, p. 105). Right sided hemianopia, right sided hemiparesis and neglect of affected limbs all impact on Mr Shaw’s ability to perform the activity of living mobilising.
Diminished mobility can have devastating effects on physical wellbeing and can have significant psychological and emotional effects as being in control of movement can be a source of autonomy, pride and dignity (Holland et al. 2008, p. 317). When providing nursing care to Mr Shaw for his mobility it is important for the nurse to firstly conduct a mobility assessment. This will allow the nurse to see what types of movement Mr Shaw can perform, whether he needs assistance when mobilising and if he requires any mobility aids. The mobility assessment should include assessing Mr Shaw’s range of movement (ROM).
This is done to determine the degree of damage or injury to certain joints (Crisp & Taylor 2009, p. 826). Mr Shaw’s gait should then be assessed. Gait is the manner or style of walking and includes rhythm and speed. Assessing his gait will allow the nurse to draw conclusions about his balance, posture and his ability to walk without assistance (Crisp & Taylor 2009, p. 826). Using the mobility assessment the nurse should then implement the required plan to ensure that Mr Shaw is able to mobilise effectively and safely which may include the use of mobility aids.
In the first 24 hours of Mr Shaw’s care it may not be possible for him to have been assessed by a physiotherapist, in this case the nurse would help Mr Shaw walk by standing beside his affected side and supporting him by holding one arm around his waist and the other arm around the inferior aspect of his upper arm so that the nurses hand is supporting his axilla until he is able to be seen by a physiotherapist and receive the required mobility aids (Crisp & Taylor 2009, p. 833).
Other nursing care for his hemiparesis and neglect of limbs can be to instruct him to perform daily exercises of the affected side and the try using the affected limb when possible. This prevents neglect and deterioration of the affected side (Comer 2005, p. 107). To maintain skin integrity it is also important that the nurse helps Mr Shaw turn regularly, this will also ensure that he is comfortable and relaxed which can reduce stress or anxiety that he may be feeling (Crisp & Taylor 2009).
As the hemiparesis, hemianopia and neglect of affected limbs closely relates to how he mobilises, it also affects his ability to perform personal cleansing and dressing activities, so it is necessary for the nurse to help Mr Shaw with his personal cleansing and dressing. When assisting Mr Shaw with his personal cleansing and dressing the nurse should remind him to care for his affected side (Comer 2005, p. 107).
Through exploring the Pathophysiology of ischaemic stroke and the symptoms that Mr Shaw is experiencing a better understanding is gained about ischaemic stroke. This better understanding of what an ischaemic stroke is and the symptoms that Mr Shaw has, allows the nurse to provide the proper and required care for Mr Shaw in regards to the activities of living that are most affected by his stroke, maintaining a safe environment, communication and mobilising.
With the proper care and actions implemented, Mr Shaw will be able to maintain a safe environment, communicate his needs effectively and mobilise safely during his first 72 hours in the stroke unit of his local hospital. Referrals to physiotherapists and occupational therapists will also promote independence for Mr Shaw and will help with his recovery.
Courtney from Study Moose
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