Kaorou Kashin, a 74-year-old patient, is admitted to the telemetry unit with the diagnosis of acute ischemic stroke. The patient is experiencing paroxysmal atrial fibrillation with a controlled ventricular rate on the monitor. The CT of the head without contrast reveals no evidence of hemorrhage. The transesophageal echocardiogram reveals moderate mitral valve insufficiency and embolism as a primary cause of the stroke. The patient is on a weight-based heparin protocol. The patient received digitalis to keep the ventricular rate of the atrial fibrillation controlled. The patient has right-sided paralysis and global aphasia. The patient has unilateral neglect of her right side and has right field homonymous hemianopsia. There is papilla edema present bilaterally. The patient is drooling from the right side of her mouth and coughs periodically. The patient was found by her daughter after her daughter had gotten out of work and arrived at her mother’s home. The daughter stated her mother was normal before she left for work, and 10 hours later the mother exhibited the symptoms described above. The time of onset for the stroke could not be safely determined so no interventions could be used to treat the stroke.
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What principles of nursing management should the nurse provide the patient during the acute stage of the ischemic stroke based on the assessment findings from the case study? Place the assessment findings that are supported by the nursing principle(s) in parenthesis.
The most important thing to remember when dealing with stroke patients is that we need to do everything we can to help them recover smoothly. As much as possible, we do not want them to have a recurrence of the attack. To do that, we must carefully observe the patient for any event that might prompt medical or surgical management. In patient Kaorou Kashin’s case, it is important that we have diagnosed her stroke as acute ischemic stroke with embolism as the primary cause, because strokes that are hemorrhagic in nature would require other interventions.
Of course, before anything else, continuous monitoring of the patient is required, given the condition. Frequent neurological assessments are a must. Assessment of the body for any impairment of any functional parts should also be kept in mind. These can include assessment of the level of consciousness, orientation to surroundings, response to painful stimuli, and assessment for flaccidity or stiffness in any part as well as knowing the hourly rate of pulse and respiration plus the blood pressure. We can use the Glasgow Coma Scale and even the NIH Stroke Scale (NIHSS).
Depending on the physician’s orders, we can continue in cardiac monitoring for at least 24 hours to see if there will be any critical changes or if there would be arrhythmias. The patient does not need any thrombolytic therapy for now, mainly because there is not enough information about the onset of stroke. The patient should continue her weight-based heparin protocol. To control the ventricular rate, she should also continue her digitalis until stopped by the attending physician.
The patient has right-sided paralysis and global aphasia. The patient has unilateral neglect of her right side and has right field homonymous hemianopsia. It should be remembered that when a stroke occurs, there is weakness on the opposite side of the affected part of the brain. Because of the attack, the patient cannot do the things he would normally do and as nurses, we need to assist and guide him while prioritizing his safety. Aside from that, there is no awareness on one side of the body. The patient will face difficulties with reading, writing, speaking and communicating in general. This is why the proper positioning of the body is important. Aside from the rationale that it gives the patient comfort and helps him with his mobility, proper body positions are needed to be achieved for optimal oxygen saturation. Early mobilization can also help reduce complications. For patient Kaorou, we need to prevent arm adduction and internal rotation. Good body alignment also helps prevent compressive neuropathies, especially the ulnar and peroneal nerves. Since the patient has right-sided paralysis, the most beneficial position for him is to lie down on his left side with his right arm forward. Flat pillows should be placed under the head, right arm and right leg of the patient for support. Make sure that the elbow is positioned higher than the shoulder and the wrist higher than the elbow. This will help prevent the occurrence of joint fibrosis, which will make the patient unable to properly move if the patient regains control of the right arm. The fingers need to be barely flexed. Make sure that the patient’s shoulders are forward and not pulled back. The hips and knees are bent to prevent joint deformities. Do not forget to change the patient’s position every 2 hours. An individual ‘position chart’ can be employed (as seen in some wards of MDH) and posted on the wall to keep both the nurse and caretaker updated. Before moving the patient, place a pillow between his legs without much flexion to keep him comfortable and to promote venous return. If not contraindicated, patient Kaorou can be in a prone position, but only for 20-30 minutes. This position helps in the hyperextension of the hip joints which is needed to have good gait and posture. Prone position also helps drain bronchial secretions and avoids any potential deformities in the shoulders and knees. For the affected extremities, they must be assessed and then exercised passively. Four to five times a day is enough to help the patient regain motor control faster and prevent atrophy in the neuromuscular system, thus enhancing circulation. During the exercise, observe for signs of too much cardiac activity and signs that indicate pulmonary embolus. These include shortness of breath, chest pain, cyanosis and increasing pulse rate. To ensure safety, care plan can involve armrests, wheelchair footplates, padded bars and rails. It is also necessary for a patient with marked visual and perceptual deficits to address them straight-on and within the visual field. In the case of our patient, we should not be talking to him on the left side, or else there will be problems that will probably be encountered. Because the patient has homonymous hemianopsia, it is important for the nurse to constantly remind the patient of the other side of the body, to maintain good alignment of the body and to place his extremities on the side where he can see them. To enhance communication, use gestures or pictures to talk to the patient. For the patient, maybe the use of visual aids and paper and pen will be helpful. We must also be sure to make our voices loud and clear while extraneous noises and sounds are down to a minimum level.
There is papilla edema present bilaterally. A patient with papilledema presents episodic visual loss that can be precipitated by changes in posture and position. Administer eye care and do not let the patient’s eyes dry. Depending on the physician’s orders, glucocorticoids and diuretics may decrease intracranial pressure and CSF production. To aid increase in patient’s vision, increase natural or artificial lighting and provide eyeglasses if possible. Make eye contact and encourage patient to move his head to sound and respond to the nurse.
The patient is drooling from the right side of her mouth and coughs periodically. First, we must evaluate the patient’s swallowing capabilities. Kaorou must be observed for coughing, food dribbling out of or pooling in one side of the mouth, food retained in the mouth for a long period of time, and even nasal regurgitation when swallowing liquids. If the patient is evaluated as incapable of orally feeding himself, then there is a great chance that if left unattended, the patient can develop pneumonia, dehydration, malnutrition. He also has a great risk for aspiration. For now, the initial management we can give the patient is to insert NGT because it is obvious that he cannot feed himself properly anytime soon. We are responsible for elevating the head of the bed to avoid aspiration and making sure that the food is being given slowly. The feeding tube must be aspirated periodically to make sure that the feedings are passing through the gastrointestinal track. After some time has passed, we can check up on the patient and evaluate the patient’s ability to chew and swallow, with the use of the Chin Tuck technique of course.
Other nursing interventions can include helping the patient with self-care. Because of the sensory and muscle impairment, the nurses must encourage personal hygiene activities to be done by the client with some assistance. Encourage independence, because self-care can also double as mobilization. The patient may also have trouble urinating because of inability to perceive urinary urgency due to the bladder becoming atonic. An indwelling catheter is sometimes needed to treat urinary retention and incontinence but it should be kept in mind that there is always the risk for infection. To cope, nurses can offer bedpans and urinals. It would probably be helpful for the patient to wear a diaper also if there is bowel constipation. During this aspect of rehabilitation, patient Kaorou can be taught to void freely without any difficulties by being in an upright posture with assistance until such time that the patient is demonstrating independence. A high fiber diet and adequate oral fluid intake should be provided. Establish a regular time schedule for the patient to follow for defecating. Also, family members need to be aware of the patient’s condition and the ways they can help him. The Kashin family must be supported and informed that the rehabilitation process can be a long time and it’s expected that the patient can never live like he used to anymore.
Case study 2
Luke Skywalker, a 71-year-old male patient, is being discharged from the rehab unit 8 weeks after an ischemic stroke. The patient’s spouse stated that they used to enjoy going to golf outings with their friends, but the patient has not golfed since her husband had the stroke, and she does not want to try to golf once her husband is discharged home because he has to use a walker and can barely ambulate. She also states that her husband still has trouble speaking, and his short-term memory is not very astute so it would be embarrassing to be on a golf outing with him. The patient’s spouse has worn the same outfit to the rehab unit the past 3 days, and the nurse notices the patient’s hair is unkempt and her affect is flat. The rehab nurse has made arrangements with the social worker for a physical therapist, speech therapist, and occupational therapist to provide three sessions of therapy at the patient’s home for the next 4 weeks, and then a reevaluation will follow to determine if the patient will need further therapy. The patient is able to sit independently, stand independently, and use a walker. The patient is able to ambulate 30 feet with the walker, and then he requires a short rest before he is able to ambulate another 30 feet. The patient slurs words occasionally and has hesitant speech. The patient has problems with short-term speech.
What educational topics should the nurse provide the family about home care for the patient after stroke?
The topic I would provide is about independence. The family must help the patient feel self independence and promote self independence. The patient may have difficulty in restoring his daily activities but he must not be fully dependent on the persons he lives with. The family must continue the rehabilitation therapy until the patient can return to his daily living. The family is enlightened of what activities the client is allowed to do. These activities will help the client feel more confident about him self.
Next topic will be the prevention of the reoccurrence of another stroke by avoiding the factors that may exacerbate attacks like smoking, diet, and sedentary lifestyle. The family is given information on how to monitor the signs and symptoms of condition of Mr. Skywalker.
Another topic the nurse should provide is the strengthening of weakened muscles by continuous stimulation, massage and passive ROM so that muscles would not atrophy. The family is instructed on proper techniques to facilitate passive range of motion to help prevent muscle atrophy. Massage techniques could also be beneficial.
Coping mechanisms should not be forgotten in the topics to be discussed to the family, especially Mrs. Skywalker. The family must know and be aware of the proper coping techniques that they can utilize to help them with the situation concerning Mr. Skywalker. These coping techniques will help the family to understand and accept the situation that Mr. Skywalker is undergoing.
Another topic that must not be missed to be discussed is the importance of the family in the recovery process of the patient. The family must show their support for the patient. Mr. Skywalker needs all the support and the attention he can get from his significant others. The role of the family in the providing effective and efficient care must be emphasized to them and the nurse must make sure that the family understood their role completely.
What assessment of the spouse does the nurse need to make, and what should the nurse suggest?
Family members are important in the recovery of the patient. Seeing her husband struggle as he recovers put a great deal of burden and stress to her. The spouse must be assessed of emotional or physical stress in caring for her husband. She must be also assessed if she can handle the stress that is brought upon this incidence. The spouse may have hard time in accepting the condition of the patient. The spouse must be assessed if she can accept the fact of the condition of his husband and if she can provide effective care at home for her husband. She must be assessed if she is coping properly and if she is coping with the situation at all. If her coping mechanism is ineffective, she must be counseled and advised proper coping mechanism suitable for her and the situation. The nurse must suggest to the spouse that firstly the focus of the family must be of the recovery of Mr. Skywalker. The nurse must tell Mrs. Skywalker that her husband needs her to be strong for him. Mrs. Skywalker needs to accept the condition of her husband to effectively provide care for her husband and promote proper wellness. The nurse can also suggest that the family seek counseling to address the families concern and burden about the predicament. The nurse must suggest that it may take time for the recovery but after it the patient may return to his activities. And when recovered the patient and the family must choose what activities to be continued or to be stopped. Activities of daily living are gradually returned to normal if the client is able to.