Nursing Management of Ischemic Stroke - Case Study Example

Name: Institution Ischemic Stroke: A Case Study The nursing and medication management knowledge is underpinned by proper understanding of the patient’s health condition and the predisposing factors that precipitate the disease in question. The case at hand revolves around a Mrs. Amelia Middleton who was booked at the emergency department upon a distress call by her son reporting that the mother of four had headache, was unable to lift her right arm and has started experiencing difficulties in speaking. An examination on her recorded a BP of 200/110, Pulse 78 and irregular, Respiratory Rate 16, SpO2 98%, Glasgow coma scale 12, Temp 36.8, and blood sugar level of 4.8. Mrs Middleton had a paralysis of the right arm and face, and loss of sensation to touch on the right side of her face and right arm. She appeared to understand what is being said to her but cannot respond verbally. Mrs. Middleton’s history includes depression and lower gastro-intestinal bleeding associated with haemorrhoids. She has no known allergies. A critical literature review in the context of this case scenario is worthwhile to analyse the pathophysiology attributed to the conditions of hemorrhagic and ischemic CVA and their underlying precipitating factors. A research in this direction can significantly improve the clinical practice in terms of diagnostics, nursing and medication management on case to case basis. PATHOPHYSIOLOGY Hemorrhagic CVA The pathophysiology associated with hemorrhagic stroke includes bleeding in the brain, which is attributed with the damages to the brain and the nearby tissues. This type of stroke is characterized by bursting of blood vessels inside the brain. According to Bendok & Naidech (2011), because of its hypersensitivity to bleeding, the brain can be easily damaged rapidly presence of blood or an accumulation of fluids around it that increase pressure on the brain and injure it by pushing it against the skull. Presence of blood in the brain irritates the brain tissue and causes swelling. Bendok & Naidech (2011) argue that the surrounding tissues of the brain try to contain the extent of the bleeding, which is contained by formation of mass. Apparently the formation of hematoma and the swelling increase the pressure thus compressing and replacing the normal brain tissue. The onset of hemorrhagic stroke can be rapid and can deteriorate fast. Ischemic CVA Acute ischemic stroke has been widely attributed to vascular occlusion primarily following a case of thromboembolic disease. The stroke is associated with cell hypoxia and the depletion of cellular energy (adenosine tiphosphate-ATP) (Hamalainen 2008). The depletion of cellular ATP deprives the brain tissues of the ability to maintain normal balance of ionic elements across the cell membrane and the cell depolarization. According to Hamalainen (2008), the resulting influx of sodium and calcium ions and the slow penetration of water into the cell lead to a cystoxic edema, which serves an early sign of cerebral ischemia. The ischemia causes a dysfunction in the cerebral vasculature, which results in the destruction of the blood-brain barrier usually within 4-6 hours secondary to an infarction (Haddad & Yu 2009). The clinical physiological effect of the barrier breakdown is a vasogenic edema, which results from proteins and water flooding the extracellular space. The infarction witnessed in the case of ischemic stroke precipitate the necrosis of astrocytes and the supporting oligodendroglial and microglial cells (Haddad & Yu 2009). NURSING MANAGEMENT: MR. MIDDLETON A successful management of a stroke patient is underpinned by efficient diagnosis that details the cause and enables adequate nursing care planning. The initial examination on Mrs. Middleton reported paralysis of the right arm and face, and loss of sensation to touch on the right side of her face and right arm, which are canonical symptoms of ischemic stroke. Additionally, she had developed speech challenges and had a history of depression and lower grastro-intesinal bleeding. A nursing management remedy must target mitigation of these symptoms. From a nursing perspective, I would be concerned in stabilizing Mrs. Middleton through frequent assessments for vital signs and the management of the blood pressure with a purpose of preventing escalation of complications such as aspiration. In particular, the early blood pressure management would be very essential for checking the deterioration of her condition. THROMBOLYSIS Thrombolysis was not indicated for Mrs. Middleton. Middleton’s ischemic stroke could be managed using thrombolysis, which essentially involves an injection with alteplase; a medicine that busts blood clots. However, researchers have generated adequate evidence that alteplase is only effective if administered within the first four and half hours after the stroke attack (Eissa, Krass & Bajorek 2012). Middleton received a CT scan test after six hours of arriving at the hospital, which was way too far from the recommended efficacy window for thrombolysis. This justifies the exclusion of her indication for the alteplase treatment approach. Eissa, Krass & Bajorek (2012) emphasize that even within the narrow time frame for thrombolysis treatment, the faster alteplase is administered the more the potential of quick recovery from stroke. The bedrock for use of thrombolytic agents is their approval for immediate treatment of stroke. The rationale for use of the drugs is to dissolve blood clots, which are the main causes of ischemic stroke. The commonly used thrombolytic agent is the tissue plaminogen activator (tPA) (Bergman 2011). Quick administration of thrombolytic agents within the four–hour window can instrumentally mitigate stroke damage and disability. The point to note is that Mrs. Middleton was not indicated for thrombolysis because the treatment has not been shown to have substantial benefits after sometime of the onset of the stroke. MEDICATION MANAGEMENT A regular dose of aspirin as prescribed for Mrs. Middleton is recommendable for a recovering ischemic stroke patient. Aspirin is an anti-platelet medication that helps in making platelets less sticky, which minimizes the potential of a continued blood clotting (Greer 2008). Aspirin is a recommendable choice and the doctor acted accordingly to ensure administration of the right coagulant in consistency with treating Mrs. Middleton’s condition. However, there is a significant risk of prescribing aspirin to patients that show adverse allergic reactions. Other than managing the blood clotting in ischemic stroke conditions, it is recommendable that medication for managing blood pressure be prescribed. Mrs. Middleton’s blood pressure (BP) was very high, which warranted the doctor’s choice of medication to lower it. The carvedilol drug is an effective nonselective medication in the class of beta blockers (Ruth 2013), which has been demonstrated to effectively reduce high blood pressure. It is important that the doctor prescribed the medication to Mrs. Middleton to help reduce her high blood pressure as a way of stabilizing her during the ischemic stroke treatment. High blood pressure is often associated with increased level of cholesterol in the blood. The high cholesterol concentration is treated using a class of medicines called statins (Ruth 2013). Statins work by reducing the efficacy of liver enzymes that produce cholesterol. The prescription of Atorvastatin, which is one of the best statins was a right action for managing Mrs. Middleton’s condition. ATRIAL FIBRILLATION Despite the contemporary improvements in diagnosis and treatment of cerebrovascular disease, stroke remains an important cause of mortality and disability. Epidemiologic studies have shown that patients with vascular risk factors are faced with higher risks of stroke attacks. Among the high profile risk factors for ischemic stroke is the systolic blood pressure, cardiovascular disease, and atrial fibrillation (AF). The AF is generally described as an irregular heartbeat that predisposes an individual to higher risk of stroke attack. According to Natale & Jalife (2008), AF develops from an irregular and inefficient contraction of the atria of the heart. The physiological consequence of the irregular heart function is the stagnation of blood within the heart’s left atriums, which can then clot and embolize to the cerebral vasculature (Harvad Men’s Health Watch 2011). Atrial fibrillation is therefore an important risk factor for ischemic stroke. Atrial fibrillation is a significant risk worth attending to for ischemic Mrs. Middleton. The sustainable intervention of fibrillation in this context is a tired approach that addresses the three primary objectives: prevention of thromboembolic complications, managing ventricular rate, and importantly the restoration of the sinus rhythm. There is an inexcusable need to start and sustain a prophylaxis of thromboembolic complications, which increase as the duration of unattended fibrillation exceeds two days (Harvad Men’s Health Watch 2011). The best pharmacological intervention in this context includes a case by case administration of anticoagulants that help reduce blood clotting and maintain required fluidity. Because Mrs. Middleton does not have a permanent prevalence of fibrillation, the use of aspirin or other anticoangulants should be continued under closer assessment to stop when her condition normalizes. The control of ventricular response is one of the primary pharmacological strategies of managing atrial fibrillation (Mainardi, Cerrutti & Sornmo 2008). In this context Mrs. Middleton should be kept under drugs that act on atrioventricular (AV) node. This implies that the prescription of carvedilol, which is classified under beta-blockers, is adequate and can be sustained for management of AF but with continual monitoring of the victim’s condition. POST ISCHEMIC STROKE MANAGEMENT Several problems can develop in people that have had stroke. The complications are important to reckon with because many of the deaths after stroke are associated with medication (Patel & White 2011). In the first few days or weeks after the patient has been managed at hospital for stroke, family and clinicians need to work closely to reduce some of the risks. Some of the risks include blood clots that result from the inability to move and may complicate the recovery process. It is imperative that in addition to the pharmacological interventions meant to manage Mrs. Middleton’s stroke before further deterioration there needs to be a post-stroke plan to alleviate the paralysis of the right hand side of her body and the speech challenges. Harvad Men’s Health Watch (2011) observes that some of the complications after the stroke attack that can face Mrs. Middleton include difficulties of eating and drinking, bleeding of the digestive system as she has a long history of having such a problem, heart attack and bed sores because of lengthy time in the bed. These are among others factors that should be incorporated in a post-stroke patient management plan. The clinicians and other healthcare personnel taking care of Middleton should gradually provide guidance to Paul and his siblings regarding the risks of their mother’s long-term disability on the paralyzed side of her body and the coping mechanisms. Although ischemic stroke can be burdening in terms of disability and even death, there is a possibility that Mrs. Middleton can recover substantially considering her age and the early arrival to hospital for treatment. CONCLUSION This analysis revolved around the ischemic stroke, the most prevalent type globally. Mrs. Middleton developed the symptomatic signs and was rushed for emergency care at the hospital in good time that her case was managed appropriately. Ischemic stroke is characterized by blood clotting in the brain, and specialized pharmacological interventions that stem bursting of the lumps and increase blood fluidity are recommended. The management of high blood pressure and fibrillation is equally critical in treating Mrs. Middlteon’s stroke. Post-stroke patient management plan is important in order to prevent recurrence of predisposing risks. REFERENCES Bendok, B & Naidech, A 2011, Hemorrhagic and ischemic stroke: medical, imaging, surgical and interventional approaches, Stuttgart, Germany, Thieme Medical Publishers. Bergman, D 2011, ‘Preventing recurrent cerebrovascular events in patients with stroke or transient ischemic attack: the current data,’ Journal of the American Academy of Nurse Practitioners, vol. 23, no. 12, pp. 659-666. Eissa, A, Krass, I & Bajorek, BV 2012, ‘Barriers to the utilization of thrombolysis for acute ischemic stroke’, Journal of Clinical Pharmacy & Therapeutics, vol. 37, no. 4, pp. 399-409. Greer, DM 2008, Acute ischemic stroke: an evidence-based approach, Hoboken, NJ, John Wiley & Sons. Haddad, GG & Yu, SP 2009, Brain hypoxia and ischemia: with special emphasis on development, New York, Springer. Hamalainen, E 2008, New trends in brain hypoxia ischemia research, Hauppauge, NY, Nova Publishers. Harvad Men’s Health Watch 2011, ‘Atrial fibrillation: common, serious,treatable,’ Harvard Men’s Health Watch, vol. 16, no. 4, pp. 4-8. Mainardi, L, Cerruti, S, & Sornmo, L 2008, Understanding atrial fibrillation: the signal processing contribution, New York, Morgan & Claypool Publishers. Natale, A & Jalife, J 2008, Atrial fibrillation: from bench to bedside, New York, Springer. Patel, RAG & White, CJ 2011, ‘Acute ischemic stroke treatment: state of the art,’ Vascular Medicine, vol. 16, no. 1, pp. 19-28. Ruth, S 2013, ‘Prevention and treatment of acute ischemic stroke,’ Nursing Order People, vol. 25, no. 8, pp. 34-39. Read More