Pontine Shock and Possible Side Effects - Case Study Example

Pontine Shock and Possible Side Effects Introduction: Blood supply to the components of the brain consisting of the medulla, cerebellum, pons, midbrain, thalamus and occipital cortex occurs through the vertebro arterial system. Atherosclerosis or haemorrhages may cause disruption to this critical blood supply system to different parts of the brain and lead to stroke. Stroke is the result of ischemia to the various neuronal structures of the brain. Nearly eighty-five percent of strokes are ischemic in nature, with the remaining fifteen percent having being hemorrhagic in nature. These strokes consist of several different subtypes. Each of these different subtypes has disparate presentations, causes, prognoses, and management strategies (Felberg & Naidech, 2003). Background: Ischemic strokes are classified generally into three groups. The first are lacunar strokes that are caused by ischemia to the deep arterioles that supply blood to the white matter structures and the thalamus. Occurring as a result of occlusions to the small blood vessels, such strokes offer the best prognosis, when managed efficiently. The second type of stroke is the result of thrombotic occlusion of the major intracranial blood vessels. Prognosis in such strokes is not often promising. The final type of stroke consists of the brainstem stroke. Brain stem stroke can occur either from small vessel or pontine perforation (pontine shock) or compromise of the large vessel (basilar artery). The clinical presentation of brain stem stroke includes variable cranial neuropathy, hemiparesis, and varying levels of consciousness. Differentiating between brain stem stroke as a result of pontine shock or basilar artery compromise is confusing, yet essential for the efficient management of the strike, just as it is necessary to differentiate between brain stem stroke and lacunar stroke (Felberg & Naidech, 2003). In the developed world one of the leading causes of disability and death is stroke. In the United States of America every year approximately 750,000 people are affected by stroke (Crowley, Medel & Dumont, 2008). There is a greater tendency for African Americans to be affected by stroke in the United States of America, and also there is greater prevalence of stroke in men than in women. The likelihood of being affected with stroke increases with advance in age. Patient that present with stroke, normally display clinical findings that include abnormal level of consciousness and hemiparesis or quadriparesis, which usually is asymmetric. Other common signs are pupillary abnormalities and oculomotor weakness. Nearly forty percent of the patients also demonstrate bulbar manifestations in the form of dysphonia, dysathria, and dysphagia. The mortality rate of patients with brain stem stroke irrespective of the underlying cause is very high. Evaluations of mortality rates show that between seventy-five to eighty percent of people affected by brain stem stroke are likely to die from it. The prognosis for the survivors is also not promising, with a major proportion of the survivors suffering from severe persisting disabilities for the rest of their lives (Kaye & Brandsteter, 2006). The mortality rate for pontine stroke is equally high making for poor survival rates and prognosis. Motor deficits are the chief concern people who survive pontine shock and require rehabilitation. However, with the low incidence of pontine shock, there is limited evidence available on rehabilitation plans in the case of pontine shock, with most of the evidence relating to cortical shock rehabilitation (Ruhland & van Kan, 2003). Medical Issues: The initial medical issue with a pontine shock patient is the differential diagnosis of pontine shock and whether the shock is ischemic or hemorrhagic for initiating the right intervention strategies. Moreover there is the need to act fast to prevent the stroke from reaching a point of no return for the patient or the consequences of the shock enhancing the morbidity of the patient on survival (Kaye & Brandsteter, 2006). In the management of pontine shock of ischemic nature, three issues stand to the forefront and these are hemodynamic management, respiratory management and thrombolysis. In hemodynamic management the focus is on minimizing the ischemic injury. The lack of blood flow in pontine shock causes impaired auto regulation. Mechanisms that are part of the auto regulation of the flow of blood are vasoconstriction and vasodilation. In this ischemic condition blood flow becomes dependent on blood pressure. Increase in the mean arterial pressure (MAP), as a consequence there is an impact on perfusion and blood volume. Decrease in MAP has the consequence of vasodilation. Thus it becomes necessary to ascertain the correct pressure status of the patient. In addition more than required treatment of hypertension is counter productive in that it can lead to decrease in the cerebral perfusion pressure and cause exacerbation of the ischemic condition. Hypotension when present also needs to be treated initially with the use of isotonic solutions to try and attain normal intravascular volume. Monitoring of the intravascular volume is an essential requirement to ensure that there is no overload of the intravascular volume (Kaye & Brandsteter, 2006). Under respiratory management in pontine stroke it is critical that an early evaluation of the airway and its management is undertaken. This is due to the commonly encountered impairment of consciousness of the patients. Evaluation of the airway constitutes looking into the respiratory drive, gag reflex, and the capacity to handle secretions during forceful coughs. In patients where the evaluation of airway is poor and in patients with low levels of consciousness as assessed using a coma score endotracheal intubation has to be a serious consideration, so that airway and normal ventilation is maintained (Kaye & Brandsteter, 2006). The utility of thrombolysis and anticoagulant agents in the case of pontine stroke is yet to be established. Evidence from some studies suggest that thrombolysis may be, but the use of thrombolysis in pontine stoke has still to be established and accepted. In the case of anticoagulant agents there is limited and controversial evidence that makes the acceptance of the use of anticoagulants in pontine shock difficult (Kaye & Brandsteter, 2006). Taking into consideration the nature of brain stem strokes including pontine shock that involves fluctuating neurological symptoms, decreased levels of consciousness, hemodynamic instability, active cardiac or respiratory problems and the interventional therapies including thrombolysis, a patient arriving with pontine shock is best admitted into a intensive care unit, which has a specialized stroke team for assessment and management of the patient (Kaye & Brandsteter, 2006). There is emerging evidence that show that stroke patients that are taken care of by specialized stroke units built around a physicians and nursing professional that specialize in stroke care have enjoy the benefits of reduced risk of death and disability by as much as twenty percent (Cassels, 2007). The increased number of survivors as a result of specialized stroke team interventions, stand to benefit from better functional capacities in terns of motor functions, reduced length of stay in hospitals, and early discharge into community settings also (Strasser, et al, 2008). Nursing Issues: The stroke unit is built around physicians and nursing professionals, emphasizing the importance of nursing in the management of stroke victims. In the acute care scenario nursing plays its part in the assessment and implementation of the management of the critical phase of the patient. The role of nursing becomes even more important as the patient passes from the acute care stage to the rehabilitation phase, as a result of the disabilities that arise from motor deficits that are common ion patients, who have survived a pontine shock (Kaye & Brandsteter, 2006). The motor deficits and signs following pontine stroke may consist of contralateral hemiparesis, ipsilateral lower motor neuron facial weakness or sensory loss, quadriplegia, pupillary changes, diplopia, gaze palsies, internuclear opthalmoplegia, dysphagia, vertigo, ataxia, and severe impact on axial and proximal limb musculature (Ruhland & van Kan, 2003). The consequences of pontine stroke may lead to a wide variety of disabilities, depending on the extent of damage that has occurred to the brain. It is these consequences that lead to the greater involvement of nursing in pontine stroke to initiate rehabilitation activities and services. Among the nursing interventions are maintaining the integrity of the skin, establishing a bowel and bladder program, maintaining nutrition, making sure that the patient is safe from injury, assessment of communication ability, swallowing function and capability and performance of the activities related to daily living. Mobility assessment and making ambulation possible is another issue for nursing in pontine stroke. In some cases the impact of pontine stroke may be such that the severity of the deficits may lead to ambulation being impossible. Mobilizing patients out of bed calls for active support of physical and occupational therapy professionals and more so when the ability to move is badly impaired. These activities call for interaction with professionals from other disciplines like, physicians, physical medicine professionals, speech and voice therapists, and nutrition professionals (Kaye & Brandsteter, 2006). Members of the family, who have a role to play in the care of the patient, are usually unaware of pontine stroke, its effects, the care needs of the patient, and the rehabilitation support requirements. Communicating with the family members on the nature of the affliction and educating them on its effects and the treatment, care needs, and support that the patient would require on discharge from hospital to the home environment are all part of nursing issues in the case of patient who has survived a pontine stroke. Discharge Plan from Acute Care to Inpatient Rehabilitation Centre: The discharge plan from acute care to inpatient rehabilitation centre may depend on the severity of the stroke and the deficits that have occurred as a result of the stroke. However key elements in the discharge plan remain the same. Ensuring that the care provided at the new care centre has the capabilities that are required to support the possibility of the extension in the interventions at acute care. For instance tracheostomy may have been performed to maintain airway and the tracheostomy tube may still be in place require knowledge and skills of tracheostomy care or alternatively stoma care. Written instructions on tracheostomy care or stoma care would then have to be provided, with monitoring that the necessary care is being provided. Monitoring of the progress of the stroke management measures initiated in acute care. Clear written instructions on medications to be given to the patient. Written instructions on the measures required to prevent sub acute complications, which include plans to be put in place to prevent deep vein thrombosis and managing comorbidities that be present in the form of diabetes mellitus, hypercholesterolemia, obesity and cardiac conditions. Restoration of neurological functions to the maximum extent possible is essential and this would mean the involvement of occupational, physical, and speech therapists and hence chalking out of a plan for the involvement of these disciplines. Nutritional needs will need the input of a dietician or nutrition specialist. Clear written instructions on nursing care needs. Family member and care givers may require psychological support, which may be provided by nursing or support from psychologists employed (Jauch & Kissela, 2007) Discharge Plan from Inpatient Rehabilitation Centre to Outpatient Rehabilitation: Discharge plans for a stroke patient include the steps to be taken to prevent the recurrence of stroke and the rehabilitation care required. Antiplatelet medications like aspirin to reduce the risk of recurrence of stroke. In case newer anticoagulant agents like clopidogrel are used than steps to monitor for side effects. Medication regimen to take care of possible comorbidities like hypertension, hyperlipidemia, diabetes mellitus, and heart conditions need to be reviewed prior to discharge and changes if required made. Nutritional advice. Review of rehabilitation plan and advice rehabilitation consults with occupational therapist, physical therapist, and speech therapist. Review of daily activity capabilities and written details of support that will need to be provided, including measures to prevent falls. Education of family and care givers on care needs of patient with clear written instructions on care needs (Jauch & Kissela, 2007) Literary References Cassels, C. (2007). Dedicated Units Significantly Reduce Acute Stroke Morbidity, Mortality. Retrieved Aug 23, 2008, from, Medscape Medical News Web Site: http://www.medscape.com/viewarticle/551524 Crowley, W. R., Medel, M. R. & Dumont, S. A. (2008). Evolution of Cerebral Revascularization Techniques. Retrieved Aug 23, 2008, from Neurosurgical Focus, 24(2) E3, Medscape Today Web Site: http://www.medscape.com/viewarticle/572464 Felberg, A. R. & Naidech, M. A. (2003). The 5 Ps of Acute Ischemic Stroke Treatment: Parenchyma, Pipes, Perfusion, Penumbra, and Prevention of Complications. Southern Medical Journal, 96(4), 336-342. Jauch, C. E. & Kissela, B. (2007). Acute Stroke Management. Retrieved Aug 23, 2008, from, emedicine, WebMD Web Site: http://www.emedicine.com/neuro/TOPIC9.HTM Kaye, V. & Brandsteter, E. M. (2006). Vertebrobasilar Stroke. Retrieved Aug 23, 2008, from, Medscape Today Web Site: http://www.emedicine.com/pmr/TOPIC143.HTM Ruhland, L. J. & van Kan, L. E. P. (2003). Medial Pontine Hemorrhagic Stroke. Physical Therapy, 83(6), 552-556. Strasser, D. C. Falconer, J. A., Stevens, A. B. Uomoto, J. M. Herrin, J., Bowen, S. E. & Burridge, A. B. (2008). Team training and stroke rehabilitation outcomes: a cluster randomized trial. Archives of physical medicine and rehabilitation, 89(1), 10-15. Read More