Nursing Care for Long-Term Condition - Case Study Example

Nursing Care for Long Term Condition (Stroke) Sample Case: Mrs. X lives most of her younger life in Brighton she moved to Kent 30 years ago near her son. She is 68 years old and used to work as bank clerk Mrs. X suffers from cerebral vascular accident (stroke) five years ago. She experiences some difficulty with her speech. Rationale for Selection: Mrs. X is of an adult belonging to an age bracket where occurrence of stroke is not uncommon. She is suffering from a single disability, that of speech resulting from the stroke. Therefore, a study of her care management can be more focused and simple. Definition of Stroke: Stroke is a focal neurological deficit lasting longer than 24 hours and is the result of a vascular lesion. A completed stroke is when neurological deficit has reached its maximum (usually within six hours). (Ballinger et al. 2000) Epidemiology: It has been found that stroke is the third most common cause leading to death in the UK and the most common cause of physical disability among adults. (Ebrahim 1990) Immediate mortality is high and almost 20% of stroke patients die within 30 days. For those who survive, the recovery of neurological impairment takes place over a variable time span. About 30% of survivors will be fully independent within three weeks, rising to nearly 50% by six months. (Scottish Intercollegiate Guidelines Network 2001 - 2008) Mrs. X in this study had an attack when she was 63 years of age. Atrial fibrillation can be one of the causes leading to stroke. The prevalence of atrial fibrillation (AF) is highly age related and is a major cause of stroke and premature death and disability. The risk of stroke and systemic thromboembolism is highest in the elderly, particularly older women. (Ford et al. 2007) Stroke is also related to stress factors which may be induced by environment, loneliness, lifestyle changes, relationships and a number of other factors. Mrs. X had enjoyed a busy life working as a clerk in a bank. Her lifestyle changed considerably after her retirement. The loneliness brought about by a change in her environment could be one of the causes leading to her illness. Her lifestyle has changed in response to her changed environment and her financial needs and capabilities. (European Stroke Organization 2008) Pathogenesis: The two major mechanisms which cause brain damage in stroke are ischemia and haemorrhage. Almost 80% of all strokes are ischemic strokes. In ischemic strokes, decreased or absent blood circulation deprives neurons of necessary substrates. The effect of this is fairly rapid since the brain does not store glucose which is the chief energy substrate and is incapable of anaerobic metabolism. (Merck Manuals 1995 - 2009) About 10% to 15% of strokes are caused by non-traumatic intracerebral haemorrhage. Intracerebral haemorrhage originates from deep penetrating vessels and causes injury to brain tissue by disrupting connecting pathways and causing localized pressure injury. In both kinds of stroke destructive biochemical substances, released from a variety of sources, play an important role in tissue destruction. (Foundation for Education and Research in Neurological Emergencies 2009) The causes for a cerebral infarction may be: Thrombosis at the site of an atheromatous plaque in a major cerebral vessel. Emboli arising from atheromatous plaques in the carotid/vertebrobasilar arteries, or from cardiac mural thrombi or from the left atrium in atrial fibrillation Rarely cerebral infarction is the result of severe hypotension. (Ballinger et al. 2000) At the basic level, vascular compromise leading to stroke evolves over time. The progression and extent of ischemic injury is influenced by many factors such as: Rate of onset and duration: The brain is able to better tolerate an ischemic attack of short duration or of slow onset. Collateral circulation: A good collateral circulation in the impacted area often results is a better recovery. (American Heart Association 2009) Health of systemic circulation: A constant cerebral perfusion pressure depends on adequate systemic blood pressure. Systemic hypotension can cause global cerebral ischemia. Hematological factors: A hypercoagulable state increases the progression and extent of microscopic thrombi, exacerbating vascular occlusion. Temperature: Elevated body temperature is associated with greater cerebral ischemic injury. Glucose metabolism: hyper-hypoglycemia can adversely affect the size of an infarct. (Foundation for Education and Research in Neurological Emergencies 2009) Some of the motor impairments associated with stroke include paralysis of limbs, nerve palsy, cortical blindness, facial paralysis, speech impairment etc. (Harrison et al. 2002) When preparing a nursing framework for a patient like Mrs. X in our discussion it is important to understand several aspects related to her present condition. The Roper-Logan-Tierney mode of nursing can help us access what activities of daily living Mrs. X is able to accomplish and her degree of independence in achieving these activities. (Roper et al. 2000) We can understand the degree and amount of help the patient needs by assessing her needs on the basis of the following conditions: Bowels Incontinent (or needs to be given enemas) Occasional accidents (once a week) Continent Bladder Incontinent or using catheter but unable to manage Occasional accidents (once in 24 hours) Continent (for more than seven days) Grooming Needs help with personal care Independent with implements provided Toilet Use Dependent Needs some help but can do a few things alone Independent (on and off, wiping, dressing) Feeding Unable Needs some help but can do a few things alone Independent (food provided within reach) Transfer Unable to get from bed to bathroom Major help needed (physical, 1 to 2 people), can sit Minor help needed (verbal or physical) Independent Mobility Immobile Wheel chair independent, including corners Walks with help of one person (verbal or physical) Independent (Turnbull et al. 1985) Dressing Dependent Needs help but can do about half unaided Independent (including buttons, zips, laces etc.) Stairs Unable Needs help (verbal, physical, carrying aid) Independent up and down Bath/Shower Dependent Independent (must get in and out unaided and wash self). (Campos et al. 2008) The aim of the above assessment is to understand the degree of independence from any help. (Longmore et al. 2006) It is supposed that Mrs. X enjoys a good degree of independence, having survived the stroke five years back, but still suffers from a degree of speech impairment or aphasia. (Medline Plus 2008) It needs to be appreciated that dysphagia or difficulty in swallowing and communication impairment are common consequences of stroke. Stroke survivors with either or both of these impairments are likely to have poorer long-term outcomes than those who do not have them. Speech-language pathologists (SLP) play a significant role in the screening, formal assessment, management, and rehabilitation of stroke survivors who present with dysphagia and/or communication impairment. (Dilworth 2008) Aphasia particularly refers to the loss of communication skills previously learned. This commonly occurs following strokes or in people with brain tumors or degenerative diseases that affect the language areas of the brain. (Health Central 2005 - 2009) It is in essence an acquired impairment of the cognitive system for comprehending and formulating language, leaving other cognitive capacities relatively intact. It can also co-exist with other cognitive deficits. (Scottish Intercollegiate Guidelines Network 2001 - 2008) Loss in communication or aphasia can also precipitate due to depression. This needs to be taken into concern in the current context since Mrs. X has retired and is living by herself and has suffered an incident of stroke. However it needs to be remembered that she lives close to her son so the degree of depression she suffers may be less. The role of a speech and language therapist (SLT) can be invaluable in the treatment of aphasia. His role involves assessment and differentiation of aphasia from other communication related difficulties, advice and education about maximising the degree communication, counselling, providing augmentative or alternative communication and direct intervention. (eMedicine 1994 - 2009) The SLT must work in close interaction with the nurse and the patient's relatives, here her son, to help the patient recover her speech abilities quickly. (New Zealand Speech language Therapists' Association 2007 - 2009) Communication devices and interventions can be used by a nurse to bring about an effective change in her patient's condition after receiving adequate training from the SLT. There are in effect strategies to enhance the communication skills of the patient and promote effective communication and recovery. Since Mrs. X does not have a record of any other motor impairment she may use a range of communication supports which mayinclude: Using pen and paper to write down what she wishes to communicate Use a letter pointing board instead of writing. If she is unable to form full words then she may also use the first letter or a few letters of the word that she is able to remember The use of electronic communication devices Slow speech Amplification Using iconic gestures Introducing the topic of discussion to the patient and discussing it so that the patient is able to understand what is required of her Talking one to one As a nurse, it is important to make sure that there are as few distractions as possible while she is communicating with Mrs. X so that she is able to concentrate on what is being said to her. It is also important to have a one to one discussion and to observe the patient carefully so that the nurse is able to understand her needs and help her. It is important to remember that treating a patient as someone who is suffering from a physical impairment may have a negative effect on her psychological condition. Therefore, it is important that she feels happy in your presence. Show her pictures on magazines, read slowly to her, tell her about sports results or bring her updates about any special activity she may be interested in. (PsychCentral 1992 - 2009) She must speak slowly so that the patient is able to follow her. Lip reading is a very important part here. Also, a great deal of patience is required to nurse a patient suffering from aphasia. It is important to record the degree of progress Mrs. X is making on a daily basis so that effective follow-up is possible. A vital part of Mrs. X's recovery is her social rehabilitation. Encourage her friends to come and meet her, accompany her to neighbour's houses and try to help her participate in discussions and other activities as much as possible. Her speech disability should not be a reason for her to be left out of other activities. It must be remembered that she had once enjoyed a full life and would not like to give it up. It is necessary as her nurse to also educate her friends and relatives who come to visit her about her condition and discuss with them to identify means of how they can best help her recover. References 1. Ballinger, Anne and Patchett, Stephen (2000). Clinical Medicine. Philadelphia: Saunders. 2. Ebrahim, Shah (1990). Clinical Epidemiology of Stroke. Ann Arbor: University of Michigan Press. 3. Speech Disorder (2000 - 2009). Strokes [online]. Available from [10 January 2009]. 4. Scottish Intercollegiate Guidelines Network (2001 - 2008). Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complication, and Discharge Planning: A national clinical guideline [online]. Available from < http://www.sign.ac.uk/pdf/sign64.pdf> [10 January 2009]. 5. Ford, Gary A.; Choy, Anna Maria; Deedwania, Prakash; Karalis, Dean G.; Lindholm, Carl - Johann; Puta, Wladyslaw; Frison, Lars and Olson, Bertill S. (2007). "Direct Thrombin Inhibition and Stroke Prevention in Elderly Patients With Atrial Fibrillation: Experience From the SPORTIF III and V Trials". Stroke [online]. Available from [10 January 2009]. 6. The Merck Manuals (1995 - 2009). Ischemic Stroke [online]. Available from [10 January 2009]. 7. Foundation for Education and Research in Neurological Emergencies (2009). Stroke Pathophysiology [online]. Available from [10 January 2009]. 8. American Heart Association (2009). Collateral Circulation [online] Available from [10 January 2009]. 9. Harrison, T.R.; Braunwald, E.; Kasper, D.; Fauci, Anthony S.; Longo, D. L.; Hauser, Stephen L. and Jameson, J. L. (2002). Harrison's Manual of Medicine. Columbus: McGraw Hill. 10. Roper, N.; Logan, W. W. and Tierney, A.J. (2000). The Roper-Logan-Tierney Model of Nursing. London: Elsevier Health Sciences. 11. Longmore, M. and Wilkinson, I. (2006) Oxford Handbook of Clinical Medicine,Oxford: Oxford University Press. 12. Medline Plus (2008). Aphasia [online]. Available from [10 January 2009]. 13. Dilworth, Cindy. (2008). "The role of the speech language pathologist in acute stroke". Annals of Indian Academy of Neurology. 11 (5): 108 - 118. 14. Health Central (2005 - 2009). Speech Impairment (adult) [online]. Available from [10 January 2009]. 15. eMedicine (1994 - 2009). Acute Stroke Management [online]. Available from [10 January 2009]. 16. New Zealand Speech Language Therapists' Association (2007 - 2009). Speech and Language Difficulties following Stroke [online]. Available from [10 January 2009] 17. PsychCentral (1992 - 2009) Depression Goes Untreated After a Stroke [online]. Available from [10 January 2009]. 18. Turnbull, G. I. and Bell, P. (1985). Maximizing Motility After Stroke: Nursing the Acute Patient. Oxford: Taylor and Francis 19. European Stroke Organization (2008). Epidemiology of Stroke [online]. Available from [10 January 2009] 20. Campos, T.F. et al. (2008) "Regulation of Daily Activities in Stroke". Chronobiology International. 25 (4): 611 - 624. Read More