Neurophysiology of a Stroke - Assignment Example

Neurophysiology: A Case Study of a Patient with Stroke Introduction Stoke is an abrupt forfeiture of neurological function occurring because of focal disturbance of an individual’s cerebral flow of blood due to hemorrhage or ischemia. Stroke can lead to perpetual neurological damage depending on the time the cerebral disturbance lasted. Individuals who go through short cerebral blood flow disturbance experience a transient stroke or ischemic attack (TIA). Transient ischemic attacks do not cause permanent loss of neurological function but may increase the risk of a subsequent attack within the next three months or 90 days (Lindley 2008). Stroke is known to be one of the worst causes of disability and death all over the world. Ischemic stroke contributes to more than 87 percent of all the strokes (Amarenco et al. 2012). Stroke easily leads older people to death within a very short time; research shows that 8 to 12 percent of adults aged between 45 and 64 years die within 30 days of transient ischemic attack. George’s case is a perfect description of an adult who has suffered a stroke that has lasted for more than one hour without medical attention. The amount of time that the patient lasted without medical attention may have been more than one hour since the only person who could have helped him had been away for most part of the day. Various things occur to patients who suffer ischemic stroke within the first hour leading to neurological problems and even death. During the first hour, a section of the brain usually faces threats of death. The infarct core might be highly ischemic and may certainly die, but tissue with a shortfall of blood provision is also poised on a knife-edge between recovery and death. At this state, metabolic factors and hemodynamics are essential (Bath & Lees 2000). Clinical Features Clinical symptoms exhibited by George are due to a stroke that he has undergone. It is more likely that he suffered from ischemia, which causes more than 85% of strokes, or hemorrhage, which accounts for the remaining 15%, after diagnosis rules out subarachnoid hemorrhage. Hemorrhage leads to direct neuronal injury and adjacent ischemia due to the pressure effect it develops. Primary ischemia occurs because of an embolism or atherothrombotic occlusion. The normal sources of embolism in an individual are the left atrium in cases where there is atrial fibrillation or left ventricle in cases where there is heart failure or myocardial infarction. Occlusion of vessels occurs because of atherosclerosis, in the internal parts of the carotid artery, which is simply next to the carotid bifurcation, or from diseases that affect vessels deep in the brain. Ischemia usually leads to direct injury because it halts nutritional support and oxygenation and initiates a cascade of neurochemical events that cause damages in various parts of a patient’s body. George’s case might have been reversed if he had been subjected to reperfusion quickly, and doctors would have interrupted the chemical injury through various drugs or neuroprotective agents (Bath & Lees 2000). Hemiparesis George experiences hemiparesis, or paralysis of one side, specifically the left side, just like many patients who suffer a stroke do. George, like any other hemiparetic stroke patient, suffers from balance abnormalities. Balance problems heighten the risk of falling, leading to high social and economic costs. Various mechanisms involved determine the individual causes of impairment in balance as well as distractibility. Decreased range of movement, muscle strength, unusual muscle tone, sensory organization, motor coordination, multisensory integration, cognition, call all contribute to disturbances in the balance at various levels. In addition to that, positron emission tomography (PET) studies show that stroke patients undergo extensive reorganization of their entire motor system in such a way that their balance and movement changes in terms of functioning, Over the recent past, various studies have contributed to increased understanding regarding the causes of motor reorganization and imbalance in stroke patients. One study shows that extensive reorganization of the stoke patient’s motor system results from striato capsular infarct, such as recruitment of extra motor and sensory structures not usually involved in motor control (Michaelsen & Levin 2004). On the other hand, other studies show that individuals with cortical infarcts imply the presence of motor reorganization similar to cortical maps present in animals. Individuals with motor reorganization, however, are able to recover the incidence of stroke to perform simple actions such as moving or tapping the index finger and successive finger-to-thumb antagonism (Cirstea & Levin 2000). Further studies show that the motor problems increase the risk of falling of stroke patients compared to other adults of the same age. The risk of falling is even higher when stroke patients attempt to rise from a sitting position as well as other transition movements (Sala et al. 2002). Sitting-to-standing movement issues in people with stroke are characterized by higher loading on the limb that is not impacted as well as a displacement of center of pressure (COP) on the larger frontal plane as shown by studies. Impaired balance and weight-bearing lopsidedness may lead to heightened risk of falling in individuals affected with stroke. Consequently, enhanced balance and weight-bearing symmetry are rehabilitation goals among individuals affected with stroke. Trunk Restrain in Stroke Patients The difference between trunk movements of healthy individuals and sick patients is significant. When health people reach for things situated within arm-reaching zones, a smooth coordination between shoulder and elbow movements takes place while the trunk remains motionless. An indispensable requirement for controlled reaching is the harmonization of the action of moving the arm further from the body while inducing appropriate muscles to make the scapula and trunk stable. On the other hand, reaching for far objects requires the trunk to undertake an active role in moving the arm. The adoption of extra degrees of freedom of the trunk and the girdle of the shoulder takes place in a stereotypic manner (Michaelsen & Levin 2004). The application of the trunk region becomes part of the general strategy for reaching. The body recruits the trunk before it recruits the joints of the arm in such a manner that the trunk begins to move before hand movements commence and continue even after the movements of the hands have ended. The restrictions of reaching between two target regions may or may not involve the trunk area. The restrictions take place for target regions that range from 80 to 90 percent of the length of the arm and may be associated to the ease while grasping (Spinazzola et al. 2003). Previous researches in stroke patients or hemiparetic individuals have elucidated excessive shoulder girdle or trunk movement in reaching-to-grasp or pointing movements for targets in far places (Oliveira 2008). Levin and colleagues suggested this heightened recruitment as an appropriate mechanism of compensation through which the patient’s arm stretches further due to the action of the central nervous system when management of the arm’s joints for active ranges are under limitations (Michaelsen et al. 2001). Other studies posit that hemiparetic patients have their shoulder-elbow coordination disrupted. As opposed to healthy individuals, hemiparetic patients have their reaching characterized with absence of smoothness, as shown by both spatial and temporal segmentation. George’s loss of coordination and inability to reach objects located in distant places. In addition to that, these deficits explain his inability to move or rotate smoothly while in sleeping positions (Spinazzola et al. 2003). Over the recent past, studies connecting the left hemisphere of the brain and trunk apraxia have elucidated previously trivial relations. Scientists have concluded that postural imbalance or apraxia could cause impairments in trunk movement. Research shows that posture control and praxis have connections with the right and left hemisphere (Petreska et al. 2007). The novel relations between trunk apraxia and failure of the left hand side hemisphere of the brain explain why George cannot maintain sitting posture for a long time or cannot rotate while in bed. George presents postural instability reactions that limit him from maintaining the same position while sitting by pressing his thighs onto the chair and moving the pelvis region backward. His inability to rotate in bed is due to his loss of motion range and the impact of the disease on his trunk region (Harley et al. 2006). It will be essential to train the patient to sit properly and to be able to maintain the right posture so as to improve standing up functions (Nayak & Karthikbabu 2011). Cognitive functions Cognitive deficits usually cause failures in stroke rehabilitation and poor outcome of patients with stroke. Cognitive disability includes reduced recovery pace, poor efficiency, decreased effectiveness in undertaking routine activities required of each day and failure to adapt to new situations or problematic issues (Mok et al. 2004). Others studies also include disturbances of attention, problems with language syntax, and delayed executive and recall dysfunction impacting the ability to assess, interpret, organize, and implement complex information as part of the symptoms of cognitive deficit. The susceptibility of dementia and vascular cognitive deficiencies as well as the rate at which individuals experience cognitive decline depends on the management of underlying susceptibility factors for stroke. Vascular cognitive inabilities as well as dementia do get worse if patients are not given medical attention (Gorelick et al. 2011). George is undergoing cognitive deficiency due to the stroke incident that took place while the wife was away, and the impact is also causing memory related issues or dementia. The patient’s cognitive deficiencies in George’s case are evident from the fact that he forgets things quickly (MCC 2006). In addition to that, George weeps frequently, which is part of the cognitive impairment problem. Crying is a sign of impulsiveness that results after the impairment of impulse control mechanisms in patients suffering from the effects of stroke. Other symptoms of impulsiveness other than weeping include inabilities in walking, driving, cooking, etc., which usually contribute to post-stroke stress. Impulsiveness occurs mostly to patients who have undergone a right brain or frontal lobe stroke (Scheffer et al. 2011). Short-term and Long-term Goals Setting both short term and long term goals are important parts of the path to recovery from stroke. Goals help stroke patients to accomplish more. Caregivers ought to ensure that individuals suffering from stroke have short term goals and assist them to pick long term goals that will aid in developing action plans. In the process of setting goals, caregivers or nurses ought to timetable the goals, involve the patients, and where applicable, involve the carer or family member. Goals ought to be SMART: specific, measurable, attainable, realistic, and timely. The ability of the brain to recover after a stroke is tremendous, but it can only do this with relevant therapy and training. Nursing plan with short term and long term goals for George Name: Mr. George Age: 65 Date of Admission: May 2014 Diagnosis on Admission: Cerebral Vascular Accident (CVA)/ stroke with lift-sided weakness. Nursing Diagnosis: Impaired ability to maintain sitting posture, inability roll in bed, low mobility, problems grasping far objects, cognitive problems, Situational Low Self-Esteem, and High Risk for Injury Long term goals: Independent movement using quad cane or walker, assessment of personal safety, positive self-regard Date Issue Goal Achievement date Nursing orders 1/May 2014 1. Reduced physical flexibility related to lift-sided weakness as demonstrated by diminished muscle strength and muscle tone throughout the trunk and left hand and left side, inability to roll in bed, overusing right hand, and inability to sit for long periods. George will rotate himself in bed and maintain correct posture while seated at all times. 14/May/2014 1. Perform Passive Range of Motion (ROM) three times a day on the left arm as well as leg. 2. Physical therapy two times per day. 3. Apply support to the trunk when attempting to turn. 4. Assist left arm to move from one position to another severally every day. 5. Stretch muscles that have become tight to a point of small amounts of discomfort and maintain position for one minute. 6. Reach for far objects three times a day. 7. Daily training of sitting and maintenance of correct posture. 15/May/2014 2. Risk for Injury because of motor deficit George will transfer from his bed to his wheelchair without causing injury to himself 30/May/2014 1. Train patient on trunk control and sitting posture to assist in standing from bed or chair. 2. Maintain the use of side rails and trapeze on the patient’s bed 3. Provide patient with a shoe on the right foot as well as with a brace on the left one before performing transfer. 4. Suspend for five minutes before trying to stand. 5. Lock all the wheels of the wheelchair before commencing the exercise. 6. Obtain the assistance of another therapist. 7. Provide blockage for the right foot to prevent slippage during rotation. 8. Keep signal light on one side within access at all times. 14/May/2014 3. Situational Low self-esteem manifested by weeping that the patient claims to have no control over George will increase self-esteem by highlighting one or more instances of self-care and enhanced mobility 12/18 1. Allow George to express feeling without interrupting or disagreeing. 2. Reinforce idea that the right side of the body is perfectly well. 3. Help set and attain one realistic goal every day. Explanation of Therapy Choice George’s condition is set to improve with the above treatment plan, short-term goals, and long-term goal. The participation of the patient in the treatment plan is of essence as it improves the general outcome. While physical therapy does not offer full recovery after the event of a stroke, it does go a long way in improving the quality of life that the patient will lead after stroke. Further, proper goal setting and therapy can improve abilities and reduce the disabilities in a stroke patient. Passive ranges of motion therapeutic exercises are essential in George’s case, as they will assist in enhancing his mobility and coordination of movements. In a study, researchers showed that patients improve their joint range provided they maintain standardized protocols during training. The researchers showed that standard PROM protocols led to increased inter-observer reliability for stroke patients’ arms. Although the results depicted small differences, it is an indication that continued therapy could lead to results that are more positive. The results of this study are essential in interpreting hemiplegic arm passive random movement measurements (Jong et al. 2012). The therapy can thus be helpful for George in assisting him to increase his ability to reach for objects that require coordination of the shoulder blade and the entire arm or even trunk. Arm kinematics also stands as beneficial to George’s case, as he attempts to increase his ability to use his left side’s arm. Research has been able to show that a single reach-to-grasp repetitive session with the reach of a patient’s arm with restrictions to compensatory movements of the trunk led to better advantages in elbow extension, reduction of trunk involvement, and enhanced temporal harmonization of interjoint. The results appeared to be better than those of instructed practice as a single intervention were. Interestingly, arm kinematics led to sustained effects in stroke patients even after 24 hours (Michaelsen & Levin 2004). The application of this principle in the patient’s treatment plan is, therefore, highly beneficial given that the patient’s ability to reach for objects appears to be limited. Wade and colleagues pointed out the importance of improving cognitive development in enhancing the sitting posture of patients (Harley et al. 2006). Further, Dean (2007) also offers valuable pointers for therapeutic actions that may improve the maintenance of sitting posture in stroke patients. The study suggests that a two-week sitting training schedule could lead to improved ability for stroke patients to sit. The training also enhances the quality of sitting for the patients (Dean et al. 2007). This experiment, done among various stoke patients with sitting problems, is beneficial and implies that sufficient training in sitting could assist post-stroke patients lead a better life that involves sitting without support. Conclusion Stroke, a dangerous disease that occurs because of nutrient and oxygen deficiency in the brain, can occur to individuals with other cardiovascular issues. In the event that blood supply is cut off from the brain, one of the few forms of stroke can occur. Prolonged periods of oxygen and nutrient supply lead to transient ischemic attack. Most often, patients who experience stroke attacks that last for more than one hour without being attended to risk developing lifetime conditions such as paralysis of one side and motor deficiency. However, the brain is apt to learn, and proper utilization of therapeutic techniques can assist in helping stroke patients reduce disability and increase ability. Reference List Amarenco, P., Labreuche, J. & Lavallée, P.C., 2012. Patients With Transient Ischemic Attack With ABCD2 Read More