Clinical Assessment of TIA and CVA in Emergency Nursing - Essay Example

Assessment 3 - Learning Plan Outcome Report Introduction In my previous assignment, I undertook an assessment of learning in the area of emergency nursing. From the workshop, academic learning, and practice, my objective was to develop an understanding of the necessary skills for assessment of the patients who presented to the Emergency Department with transient ischemic attack (TIA) or cerebrovascular accident (CVA). Based on my learning, I am required to develop a fact sheet for undergraduate nursing for undergraduate nursing students. Before going ahead to develop the product in this assignment, a brief overview of my learning in my previous assignment may be pertinent for reference. Patient assessment skills in the area of emergency nursing are important for several reasons (Sbaih, 2001). The most important of them is gradually increasing patient loads and increased waiting time. Nurses may segregate patients needing immediate attendance by being able to identify the patients with serious problems. This also fulfils two graduate qualities of the nurses, which are ability to apply knowledge in real situations and ability to identify the methodological and substantive limitations of the field and to apply a disciplined mode of enquiry in practice. To be able to apply nursing assessment skills in the patients with TIA needs ability to execute a detailed central nervous system examination to know whether the patient is progressing towards CVA. This is a changing situation in the patient's clinical status which can be determined through a thorough clinical examination. This clinical information must be located, evaluated, managed, and used in the clinical context of the patient's condition. It is evident that the clinical skill of the nurse in this context will be limited, and an accurate assessment of learning will imbibe this point (Schriver et al., 2003). This means this would also involve the capacity to evaluate current knowledge. In the real clinical scenario of the Emergency Department, this means an independent demonstration of the skill, and therefore, it means taking the responsibility for learning development. In order to reach a diagnosis which would classify the urgency of the patient means responding confidently to changing clinical scenarios in a flexible and adaptable manner, and a critical thinking approach would develop through this which would also promote sustenance of intellectual interest for further learning (Hageness et al., 2003) Product Information Fact Sheet on Clinical Assessment of TIA and CVA in the Emergency Nursing Q1. What is TIA Ans 1. TIA or transient ischemic attack is a state of transient deficiency of cerebrovascular blood supply leading to alterations in vision or speech, dizziness, weakness, a sudden fall, or a temporary paralysis on one side of the body. Usually, this is reversible, but calls for a detailed neurological examination to rule out any permanent neurological deficits (American Association of Neuroscience Nurses, 2004). Q2. What is CVA Ans 2. CVA or cerebrovascular accident is also known as stroke or brain attack. By definition, it is occurrence and persistence of neurologic dysfunction for more than 24 hours as a result of disruption of blood supply to the brain in an irreversible manner (American Association of Neuroscience Nurses, 2004). Q3. How does CVA occur Ans 3. Most of the CVAs are ischemic. About 30% of these patients may have hemorrhage within the brain to be attended, supported, admitted, and managed immediately for higher mortality and morbidity. Thus, in the emergency nursing area, it is important to identify the categories of these patients so appropriate management can be provided (Hickey, 2004). Q4. What are the other associated conditions in these patients Ans 4. TIA or CVA originates from diseases of the blood vessels. In some patients the associated heart disease is the cause of TIA or CVA. Hypertension is commonly associated with most of these cases. While assessing a patient with CVA, it is to be remembered that many patients may also be diabetic. Appropriate and timely assessment and management of a patient with TIA may prevent CVA, and similar treatment in CVA may prevent long-term disability and even death (Hickey, 2004). Q5. Briefly enumerate the pathophysiology of CVA. Ans 5. The commonest final common cause of TIA or CVA is partial or complete occlusion of blood supply to the brain. In this regard, thrombus most commonly occurs in an arterial plaque. This is usually a slowly developing process. On the contrary embolus is due to a moving clot which travels from some other place in the vascular system and abruptly blocks an artery in the brain. The basic difference between a TIA and CVA is the extent of compromise and duration of persistence of that compromise (Diepenbrock, 2004). Q6. What is hemorrhagic stroke Ans 6. Bleeding within the brain tissue from a ruptured blood vessel or leak leading to compression and edema of the brain tissue and spasm of the adjacent blood vessels may also lead to presentation of a CVA (Diepenbrock, 2004). Q7. What in the history of these patients may predispose to hemorrhagic stroke Ans 7. There can be several such causes. These are hypertension; trauma to the head; vessel degeneration from hypertension, diabetes, or cocaine use; congenital weakness of a part of the vessel wall; and congenital malformation of the arteries and veins. Sudden onset of CVA in an active person, otherwise apparently normal individuals raises suspicion of hemorrhagic stroke (Diepenbrock, 2004). Q8. Are the clinical manifestations same in all patients with CVA Ans 8. No. The clinical manifestations of CVA may vary depending on the affected vessel territory. Symptoms are usually multiple. In some patients, headache may be complained, which may indicate upcoming cerebral hemorrhage (Hickey, 2004). Q9. What are the main arterial territories in the brain Ans 9. The main arterial territories in the brain are anterior cerebral, middle cerebral, posterior cerebral, and basilar and vertebral (Lower, 2002). Q10. What are the signs and symptoms of anterior cerebral artery CVA Ans 10. Paralysis of contralateral foot or leg; impaired gait; paresis of contralateral arm; contralateral sensory loss over toes, foot, and leg; problems making decisions or performing acts voluntarily (Lower, 2002). Q11. What are the signs and symptoms of middle cerebral artery CVA Ans 11. Contralateral hemiplegia involving face and arm; contralateral sensory impairment; aphasia; homonymous hemiplegia; altered consciousness leading even to confusion to coma; inability to turn eyes toward paralyzed side (Lower, 2002). Q12. What are the signs and symptoms of middle cerebral artery CVA Ans 12. Homonymous hemianopia and other visual defects are main manifestationsIf the thalamus is involved (Victor & Ropper, 2001), it manifests as loss of all sensory modalities; spontaneous pain; intentional tremor; mild hemiparesis; aphasia (Lower, 2002). Q13. What are the signs and symptoms when basilar and vertebral artery CVA Ans 13. Visual disturbance such as diplopia, dystaxia, vertigo, dysphagia, and dysphonia (Lower, 2002). Q14. What are the main signs to be looked for in the emergency assessment of a patient with CVA Ans 14. Numbness, weakness, paralysis in one side of the body; difficulty swallowing; expressive, receptive, and global aphasia; visual difficulties; psychological and cognitive effects; and possibility of deficits in self care (Victor & Ropper, 2001). Q15. What other systems must be examined Ans 15. The respiratory system including the airways and cardiovascular system must be examined including a record of the vital signs (Smetana, 2000). Q16. How paralysis is assessed Ans 16. The paralysis is assessed through assessment of voluntary and involuntary movements, tone of muscles, examination of deep tendon reflexes, and power of the muscles (Smetana, 2000). Q17. What other central nervous system functions are assessed Ans 17. A complete assessment must examine mental status, plantar reflex, cranial nerve functions, sensations, and proprioception (Smetana, 2000). Critique of Product Neurological assessment is a vast area of clinical skill and expertise. It needs not only knowledge about the anatomy and physiology of the brain, but also the baseline condition of the patient on which CVA or TIA developed. Usually the neurological clinical examination is time consuming and vast and needs considerable practice and expertise on the part of the nurse to be able to quickly assess the patient in a busy area such as Emergency Nursing. As will be evident from the product, it is difficult to accomplish these skills in one go (LaMonte, 2008). However, in the emergency, it may be the fact that a complete assessment of such a patient would need collaboration with the Emergency Department physicians. However, to begin with such knowledge helped me to work in a self-directed way. It is very clear that if urgency is felt through initial assessment, initial formation of the diagnosis by the nurse becomes of utmost importance to persuade others through logical and rational argument about the findings and their interpretations (Jones et al., 2006). Negotiation then becomes an important art so a collaborative work with different groups may be initiated through positive relationships, where the nurse can execute the responsibility through organised planning. In this assignment, the ability of the nurse to implement clinical examination skills also indicate her efficiency in initiating a safe care pathway, which is also cost-effective for the hospital where she belongs (Gonzaga-Camfield, 1999). This assignment also demonstrates written and visual literacy. When this product is presented to the other graduate nurses, their need has been kept in mind, and this builds up an important communication for other colleagues. In my opinion, this assignment also displays my abilities of global thinking in the context of emergency nursing and my learning objectives. The evidence base of this assignment also highlights implementation of global standards in practice (ANMC, 2004b). From this critical approach, it was clear to be what could be my learning objectives. The first was the need to acquire the skills of detailed neurological examination and interpretation. The second was to be able to perform a clinical assessment of a patient presenting in to the emergency department with TIA and CVA. In doing so, I must be able to use evidence from literature and apply them in practice, which could fulfill another graduate quality, namely, to gather, evaluate, and deploy relevant information to assist problem solving (ANMC, 2004a). Finding evidence from literature to change or to support practice would mean that I would be able to define researchable questions in the discipline. Therefore, the solutions of the clinical problems encountered in the practice may be solved creatively through evidence in research, and I would have to initiate the process of formulation of a range of strategic solutions to the problems conceptualised (ANMC 2004b) Workshop Reflective Critique I have evaluated my situation and my learning on the backdrop of my placement as an emergency nurse in the real clinical situation. The workshop was invaluable from that angle. From that experience, I knew the basic background pathophysiology of these conditions. As a result, it was easier for me to understand the implications of different findings in such patients (Johnston et al., 2000). Although I was inexperienced in emergency nursing practice and was feeling awkward about doing a nursing assessment due to lack of experience, I think my strength was skills of communication, which is very important in the emergency department. In the workshop, the modules we went through were triage and assessment of emergency patients, primary and secondary assessment of a pediatric trauma patient, and patient preparation and assessment for retrieval. My learning objectives were learning the skill of assessment of a patient with TIA or CVA. These modules were relevant to that objective. Specially, the assessment part taught me how to assess these patients. Before even assessment, stabilisation of the patient was important in all these clinical contexts. The ABCDE assessment applied to all, and I understood how to support the respiratory system by depressing the chin and forcing open the jaw. The other thing I learned was assessment and monitoring of vital signs and recording them. The initial action is assessment, and a systematic and methodical assessment process through primary and secondary surveys enable the nurse to identify and prioritize the needs of such patients (ANMC 2004a). The primary assessment consists of a rapid assessment of airway, breathing, circulation, and neurologic disabilities, mainly in order to diagnose preliminarily any life-threatening problem. In specific examination she will undertake a methodical examination of all the systems and record all findings. I should be able to recognise that I have responsibility to prevent harm. Moreover, the nursing interventions provided by me must be through comprehensive and accurate assessment. If my clinical skills and knowledge is deficient in some areas, there is a high probability that the interventions would be inaccurate. Moreover, I must maintain a current knowledge base (Brown et al., 2004). Conclusion In this assignment, based on my placement in emergency nursing and workshop, as it has been demonstrated, I could develop a product which can be an important indicator of my graduate nursing skills. Neurological examination skills are important emergency nursing skills which demonstrate not only personal skills, but also skills in collaborative care, which can offer better care to these patients presenting in to the emergency department. In all categories of patients, there are certain basic assessments that need to be skillfully performed so the patient safety is ensured. The triage is an important area, where the most critical patients can be immediately attended so delay in treatment does not happen. Moreover, the knowledge about retrieval can help the patient to be retrieved safely from the ambulance. On the whole, this module of self-directed learning can be very helpful for the student nurses. Reference List American Association of Neuroscience Nurses (2004). Core curriculum for neuroscience nursing (4th ed.). Chicago: AANN. ANMC (2004a) Competency Standard. ANMC ANMC (2004b). Graduate Qualities, ANMC. Brown, DL., Lisabeth, LD., Garcia, NM., Smith, MA., and Morgenstern, LB., (2004). Emergency department evaluation of ischemic stroke and TIA: The BASIC Project. Neurology; 63: 2250 - 2254. Diepenbrock, N.H. (2004). Quick reference to critical care (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. 12-23. Gonzaga-Camfield, R., (1999). Developing an emergency department team for treatment of stroke with recombinant tissue plasminogen activator. Crit Care Nurs Clin North Am; 11(2): 261-8. Hageness, SM., Kreitzer, MJ., and Kinney, ME., (2002). Complementary, integrative, and holistic care in emergency nursing. Nurs Clin North Am; 37(1): 123-33, viii. Hickey, J.V. (2004). The clinical practice of neurologic and neurosurgical nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.34-76. Johnston, SC., Gress, DR., Browner, WS., and Sidney, S., (2000). Short-term Prognosis After Emergency Department Diagnosis of TIA. JAMA; 284: 2901 - 2906. Jones, D., Baldwin, I., McIntyre, T., Story, D., Mercer, I., Miglic, A., Goldsmith, D., and Bellomo, R., (2006). Nurses' attitudes to a medical emergency team service in a teaching hospital. Qual. Saf. Health Care; 15: 427 - 432. LaMonte, MP., (2008). Ensuring emergency medicine performance standards for stroke and transient ischemic attack care. Emerg Med Clin North Am; 26(3): 703-13 Lower, J. (2002). Facing neuro assessment fearlessly. Nursing 2002, 32(2), 58-64. Sbaih, LC., (2001). Shaping the future: reforming routine emergency nursing work. Accid Emerg Nurs; 9(4): 266-73. Schriver, JA., Talmadge, R., Chuong, R., and Hedges, JR., (2003). Emergency nursing: historical, current, and future roles. J Emerg Nurs; 29(5): 431-9. Smetana, G. (2000). The diagnostic value of historical features in primary headache syndromes: A comprehensive review. Archives of Internal Medicine, 160(18), 2729-2737. Victor, M., & Ropper, A. (2001). Principles of neurology (7th ed.). New York: McGraw-Hill. 7-56 Read More