Risk Factors of Stroke - Case Study Example

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Student ID FAN First name Family name Phone number Topic code NURS2003 Topic name Pathophysiology and Pharmacology Tutorial lecturer Assignment number and title Assignment 2—Exploration of A&P and pathophysiology relating to a case Word count Due date 09/06/2015 Date of submission 09/06/2015 Is this a resubmission? Yes  No x Introduction Greta, a 77-year-old female, has been living independently for 38 years. In the last two years. Greta felt it become harder to live independently. Socially, Greta enjoys attending her local Latvian club for their monthly activities until she experienced a trans-ischemic attack (TIA) – 2/12 ago with Hypertension, 3 falls in the last 6/12 months. Before Greta came to emergency department, she was gardening when a feeling of headache and dizzy sudden occurred. Then a warning sing was shown. Greta was diagnosed with a R) cerebral vascular accident (CVA) and atrial fibrillation. She spent 14 days in an acute care hospital until she was medically stable. Greta has mild residual L) sided hemiplegia. Pathophysiology Stroke is a major health problem due to its large contribution to mortality, morbidity, and disability all over the world (Minnerup and Schmidt 2013). Minnerup and Schmidt (2013, p.8), defined it generally as a syndrome of a sudden, focal neurologic deficit resulting from ischemic or hemorrhagic lesions in the brain. For this reason, a stroke is commonly referred to as a cerebrovascular accident (CVA). According to Porth (2011 p. 943), there are two types of strokes, including ischemic and hemorrhagic. Ischemic stroke is the major stroke which accounts for 87% in total stroke. It happens when the blood flow being interrupted in a cerebral vessel. Hemorrhagic stroke occurs when blood goes into brain tissue (Porth 2011 p. 943). Porth (2011) further added that many impairments can be caused by stroke. These impairments include: sensory, motor, perceptual, mental and language functioning. Weakness or paralysis on the side of the body that is opposite of the lesion of the brain is characteristic of motor deficits. The location and extent of damage caused by the lesion determines the severity of the neurologic deficits for the patient (Porth 2011 pp.945- 946). In dealing with the stroke population, considerable attention has to be paid to the geriatric population and the normative information available regarding this age group, since this is the primary population affected by the occurrence of this neurological incident (O’Sullivan & Schmitz 2007, p.254). Stroke may occur at any age, though the prevalence rate appears to be skewed toward the geriatric population. Only 27% of new stroke patients are younger than 65 at onset and the majority of strokes, 43%, occur in individuals that are at least 74 years old (Catalina & Ionita 2005, p. 41). The incidence of stroke seems to double with each decade after age 55 (O’Sullivan & Schmitz 2007, p.250). Demographic data demonstrated that a significant percentage of older stroke patients are female and many have limited family or social support systems (O’Sullivan & Schmitz 2007, p.251). Peter from World stroke organization stated that many factors contribute to an increased incidence of stroke including high blood pressure, heart disease, and diabetes (Peter 2010, p.50). Other factors contributing to a stroke are coronary heart disease, congestive heart disease, and peripheral arterial disease. When these vascular problems are combined with increased age, there is a significant increase in the possibility of a stroke (O’Sullivan & Schmitz 2007, p.253). Further, O’Sullivan and Schmitz (2007, pp.255-56) added that patients with an increased haematocrit level have a reduction of cerebral blood flow causing an increased risk of an occlusive stroke. Risk of embolic stroke is increased due to cardiac disorders such as rheumatic heart valvular disease, endocarditis, arrhythmias, and cardiac surgery, while cigarette smoking greatly increase the risk of precipitating factors include: physical inactivity, obesity, excessive alcohol consumption, and elevated blood cholesterol and lipids. As with any other disease, any combination of these factors can greatly increase the risk of a cerebrovascular accident (O’Sullivan & Schmitz 2007, p.256). With Greta`s Transient ischemic attack (TIA) and hypertension, she was at risk of CVA or stroke. As a result of her stroke and extended bedrest following her 14 day-stay in hospital, Greta maintained both mild residual left-sided hemiplegia. While her global mental status was significantly altered at the time of stroke onset, Greta was cognizant of most events taking place during preceding episodes of hospitalization and reported only mild short-term memory loss and transient confusion at the time of study involvement. Pharmacology Additional to motor weakness resulting from stroke, Greta’s medical history included a variety of other conditions such as atrial fibrillation, TIA, hypertension, 3 falls in the last 6/12 months and appendectomy. Several mechanisms can result in vascular insufficiency resulting in stroke. According to O’Sullivan & Schmitz (2007, p.83), the three most common mechanisms are thrombus, embolus, and hemorrhage secondary to aneurysm or trauma. The formation of thrombi can result from platelet adhesion and aggregation, coagulation of fibrin, and decreased fibrinolysis. O’Sullivan and Schmitz (2007, p.85) further stated that thrombi can also become dislodged and form an embolism. An embolism can be defined as any bit of matter traveling in the circulatory system, not just a free-floating blood clot. Emboli can include thrombi, fat, tissue, air, bacteria, or a foreign body that is traveling in the blood stream. A hemorrhage occurs when the blood vessel ruptures. When any of these mechanisms occur, there is an interruption of blood flow to the area of the brain supplied by the occluded vessel (O ’Sullivan & Schmitz 2007, pp.86-8). The American Association of Neuroscience Nurses (2004) stated that if blood flow is interrupted for even a few minutes, a series of pathoneuro logic events is set into motion. If complete cerebral circulatory arrest occurs, it can result in cellular damage. This damage location has a core area of focal infarction. The area surrounding this core is called the ischemic prenumbra, which consists of viable, but neurologically lethargic cells. The ischemia causes a cascade of chemicals to be released. This chemical cascade causes additional neurologic death that extends into the prenumbra area (O’Sullivan & Schmitz 2007, p.162). O’Sullivan and Schmitz (2007, p.165) added that cerebral edema is accumulation of fluid around the brain and begins soon after the insult and continues until it reaches its maximum in 4 days. This edema is caused by widespread damage of the cell membrane and tissue necrosis. Within 3 weeks of its onset, the oedema subsides (O’Sullivan & Schmitz 2007, p.166). Many impairments can be caused by a CVA. One of these impairments is paralysis. Paralysis can occur as a result of damage to any of the arteries supplying the brain. Flaccidity and lack of voluntary movement is common in the early stages of stroke. This stage is then replaced with spasticity, hyperreflexia, and mass patterns of movements. Following a stroke, functional mobility skills are typically impaired or absent. Patients have problems with rolling, sitting, standing, transferring, and walking. This causes the patient to have decreased mobility or total immobility (Tinker, Biggs, & Manthorpe 2010, pp.960-3). Greta is experiencing the most well-known and thought of consequence of CVA which is motor disturbance with unilateral weakness (hemiplegia).This deficit is frequently comorbid with incoordination, poor motor planning, loss of balance, ataxia and abnormal posture. In addition, survivors of stroke may experience altered level of consciousness, somatosensory deficits, disorders of vision, severe pain and unilateral neglect. The effects of her dysphagia (disruption of swallowing) may interact with one another and greatly diminish both expressive and receptive communicative ability to express needs or psychological states (Tinker, Biggs, & Manthorpe 2010, pp.965). Rehabilitative management Medical management of patients with stroke focuses on the identification and control of the stroke risk factors. Medical management focuses on restoring fluid and electrolyte balances, maintaining adequate airway and pulmonary function, and maintaining sufficient cardiac output. Thus Greta has been discharged home from hospital on the following medications: Aspirin PO 50mg daily Clopidogrel PO 300mg daily and Digoxin 125mg PO daily. Rehabilitative management of stroke patients can be divided into acute and post-acute stroke rehabilitation. Rehabilitation is initiated early in the acute stage of the stroke. This is used to optimize that potential for the patients’ recovery and prevent secondary medical complications that occur during stroke rehabilitation (O’Sullivan &Schmitz 2007, p.300). That is why Greta started her physiotherapy Day 2 admission post CVA. O’Sullivan and Schmitz (2007, p.301) stated that during the first few weeks after a stroke, early stroke recovery is thought to be a result of resolution of the cerebral edema, absorption of the damaged tissue, and improved local circulation. This allows previously effected neurons to regain function. The authors further stated that continuing recovery is thought to be due to central nervous system plasticity (O’Sullivan & Schmitz 2007, pp.302-3). The acute stroke rehabilitation phase can be initiated as soon as the patient is medically stable, usually 72 hours following stroke (O’Sullivan & Schmitz 2007, p.315). Greta`s goals of physiotherapy during this phase (2-3 weeks of rehabilitation) include: maintaining range of motion and prevention of deformity, promotion of awareness, active movement and use of the hemiplegic side, improvement of trunk control, symmetry, and balance, and improvement of functional mobility, initiation of self-care activities, improvement of respiratory and promote function, and monitoring the changes associated with recovery. Conclusion In conclusion, stroke is an acute focal neurologic deficits that injures brain tissue. It is one of the leading causes of death and disability. There are a variety of risk factors and the acute stroke rehabilitation may provide patients a better health outcome. References American Association of Neuroscience Nurses 2004 Guide to the Care of the Patient with Ischemic Stroke, IL, USA Viewed 9 June 2015, < http://www.pennstatehershey.org/c/document_library/get_file?folderId=115233&name=DLFE-2409.pdf> Barker-Collo, S.L. (2007) `Depression and anxiety 3 months post stroke: prevalence and Correlates, Archives of Clinical Neuropsychology, 22(4), pp.519-531. Catalina C. Ionita, MD; Andrew R. Xavier, MD; Jawad F. Kirmani, MD; Subasini  Dash, MD; Afshin A. Divani, PhD; Adnan I. Qureshi, MD 2005, ‘What Proportion of Stroke Is Not Explained by Classic Risk Factors?', Preventive Cardiology, vol.8, no. 4, pp. 41-46. Levin, R. L., Mukherjee, D., and Heller, W. (2006) The cognitive, emotional, and social squeal of stroke: Psychological and ethical concerns in post-stroke adaptation’, Topics in Stroke Rehabilitation, 13 (4), pp.26-35. Minnerup, J, & Schmidt, A, & Albert, W.C, & Kleinschnitz, C (2013). Stroke: Pathophysiolgy and Therapy, Biota Publishing, viewed 9 June 2015, . O’Sullivan, S.B. and Schmitz T.J. (2007) Physical rehabilitation: assessment and treatment (5th ed.). Philadelphia: F. A. Davis Company. Pathophysiolgy and Therapy, Biota  Publishing, viewed 9 June 2015, . Peter, N, 2010. 'Risk Factors of Stroke', p.50. Viewed 9 June 2015, .  Porth，C.M. 2011 Essentials of Pathophysiology, 3rd edn, Lippincott Williams & Wilkins, Philadelphia,USA Tinker, A, Biggs, S & Manthorpe, J. (2010), 'The Mistreatment and Neglect of Older People'. in HM Fillit, L Rockwood & K Woodhouse (eds), Brocklehurst's Textbook of Geriatric Medicine and Gerontology. Saunders (W.B.) Co Ltd (Elsevier Health Sciences), Philadelphia, PA, pp. 959 - 972. Read More