Clinical Assessment, Care Planning, And Intervention For Stroke Patient

Causes and Clinical Problems of Stroke Patient

According to the case scenario, it has been reported that Mr Jay Seah had been admitted to the medical unit after encountering a stroke. From this information, it can be interpreted that he must have undergone atherosclerosis which might have prevented optimum blood flow in the arteries and thereby have caused ischemia or restricted blood flow to the tissues. According to evidences, it has been indicated that atherosclerosis is one of the most prevalent risk factors underlying causation of ischemic stroke and thus leads to shortage of oxygen throughout the body. In such situation, it is highly important to conduct clinical assessments such A to E assessment (Airway, Breathing, Circulation, Disability, Exposure) so that a comprehensive data regarding the overall status of the patient can be obtained in such acute condition and on the potential clinical issues based on which necessary care plan can be implemented.

From the above interpretation, the clinical problems which can be identified in Mr Jay Seah’s case study, include Tachypnoea and diminished oxygen saturation level. Tachypnoea is the condition manifested by rapid breathing and it is generally triggered by a mismatch between oxygen and carbon- di- oxide levels in the blood. In stroke patients, due to inadequate blood supply to the brain tissues it is often observed that respiratory rate is affected due to any of the following causes. Disturbance in generation of central rhythm might occur during this clinical condition or descending respiratory pathways might be interrupted due to insufficient oxygen supply through blood and thus might result into reduced respiratory drive, bulbar weakness which is responsible for causing aspiration. Similarly, due to interrupted blood supply in the brain during a stroke the overall physiological system experiences low oxygen saturation in the blood causing decreased SpO2 level.

Establishment of nursing goals is considered one of the most vital stages of the clinic reasoning cycle invented by Levett- Jones since from this stage care planning is commenced and thus recovery of the patient can also be prompted. Considering the abovementioned potential problems in the patient (i.e., decreased blood oxygen saturation and Tachypnoea), it can be emphasized that prevention of aspiration must be achieved along with attaining stability in physiological homeostasis of the patient. Stability of physiological homeostasis can be reflected through measurement of vital signs within normal ranges.

The first action that should be emphasized in the care planning of Mr Jay Seah would include conducting a swallow screening within first 24 hours of his admission. In support with this action, it can be said that dysphagia is a common symptom in acute stroke patients. Malnutrition, aspiration, and mortality are all linked to this condition. It is therefore critical to identify the risk factors associated with dysphagia at an early stage through a proper swallowing examination (Henke, Foerch & Lapa, 2017). According to the study by Johnson et al. (2018) it has been recommended that for individuals who have encountered a stroke, or the medical patients who are admitted in acute care setting, nurses may successfully conduct dysphagia screens utilising valid and accurate dysphagia screening instruments. Considering the set goals for the patient, it is highly significant for a nursing professional to implement actions which might be beneficial in terms of preventing the aspiration. Dysphagia or swallowing difficulty is one of the major causes underlying aspiration among the stroke patient and as a part of the nursing intervention ensuring effective swallowing screening within first 24 hours is important in such cases (Gunes et al., 2020).

Establishment of Nursing Goals for Stroke Patient

Secondly, it is highly essential for the healthcare professionals to monitor the consciousness as well as clearance of the airways in the patient. It has been extensively observed among the stroke patients that due to inadequate oxygen supply to the brain display acute confusion and loss of consciousness which are often difficult to manage. Early consciousness disorder (ECD) is a clinical condition that affects many people who have had an acute ischemic stroke in the early stages. Stroke, along with trauma and hypoglycaemia, is one of the three most common causes of conscious disruption in emergency departments. Hence, the nursing practitioners must monitor all the vital signs and the signs of consciousness very carefully so that homeostasis of the physiological systems can be ensured. According to several stroke registries, 4–38 percent of stroke patients have a reduced state of awareness or coma, while 13–48 percent have disorientation or delirium (Johansson et al., 2021). In individuals who have had an acute ischemic stroke, nothing is known regarding the incidence or risk factors for ECD. In this regard, Glasgow coma scale (GCS) score might be measured since it has been evidenced as one of the most effective tools to measure level of consciousness and also the risk level among the stroke patients (Purbianto, 2018).

Decreased level of oxygen saturation is one of the main indications of disturbed homeostasis in the human body. This is often defined as hypoxaemia and might be responsible for impaired physiological functions in the body. Oxygen saturation level above 95% is considered as normal and thus restoration of homeostasis of the physiological systems can also be anticipated. Hence achievement of SpO2 level to at least 95% will be emphasized in this case. Normal oxygen physiology is a carefully controlled system, from the oxygen saturation of haemoglobin in the pulmonary capillaries through its dissociation and distribution in the tissues. Mild hypoxia, or a lower than usual quantity of oxygen in the blood, is prevalent in stroke patients and can cause substantial injury to a brain which is already deficient in oxygen because blood flow to parts of the brain is decreased after and during stroke. According to the research conducted by Ferdinand & Roffe (2016) it has been evidenced that restoration of normal oxygen saturation level might be beneficial for the stroke patients in terms of recovery. Adequate distribution of oxygen throughout the body might promote restoration of the physiological functioning of the organ systems and thus might also ensure maintenance of homeostasis. Persistent hypoxic condition in the body may be fatal for stroke patient since this is associated with poor clinical outcomes such as aspiration, loss of consciousness and even brain death. In order to eliminate the risk of such complications, it is highly essential to achieve the blood oxygen saturation level to at least 95%.

Since a very long time, the treatment of acute ischemic stroke includes administration of recombinant tissue plasminogen activator (rtPA) and this is considered as a gold standard intervention as well (Polk et al., 2018). This intervention is typically implemented in order to dissolve the blood clots which are mainly responsible for restricted blood flow in the brain. However, this has been simultaneously evidenced that use of r-tPA and the mechanism of thrombolysis might result into clinical complications which include major systemic haemorrhage or symptomatic intracranial haemorrhage (Thomalla et al., 2020). It has also been evidenced through clinical studies that 5% of the stroke patients receiving treatment with r-tPA experience angioedema (Cheong et al. 2018). In order to evaluate the risk of such complication it is important for the nursing professionals to monitor the vital signs of the patient especially the blood pressure, heart rate and oxygen saturation level of the patient which might be affected by blood loss. It is usually suggested by the experts that caregivers of the patient must continue to monitor the blood pressure of the patient in every 15 minutes during administration of intravenous r-tPA and post completion of tPA infusion it should be checked in every for 2 hours, then after 2 hours, it should be recorded at an interval of every 30 minutes for a duration of 6 hours (Chugh, 2019). Secondly physical assessment such as capillary refill time measurement, observation of the extremities (signs of oedema) might help.

Care Planning for Stroke Patient

This case study and the actions taken for the patient have helped me to learn about the usefulness of swallow screening assessment for the stroke patient. Previously, I had very limited knowledge about this particular assessment tool, however while planning evidence- based nursing actions for the stroke patient, I have found that dysphagia is the most prevalent complications that the stroke patients experience within first hours of their illness. I have also learnt that the Gugging Swallowing Screen (GUSS) is effective in terms of assessing the risk of aspiration among the stroke patients (Park, Kim & Lee, 2020). Thus, swallowing screening might be performed in order to reduce the risk of dysphagia as well as aspiration pneumonia in these patients. I have also come to know about the consensus-based swallow screening approach while researching on swallowing assessment. A three-step test makes up the screening tool. The first stage is to determine if the patient qualifies for the water swallow test by evaluating consciousness, trunk and head muscle control, and the patient's capacity to protect the airways. The water swallow test, which can be conducted with or without a fluid thickening, is the next step if this evaluation is good.  (Sivertsen, Graverholt & Espehaug, 2017). After completion of the second phase, if the result is satisfactory, then the patient is sent for the third and final step which include swallowing 50 ml of water and in this way final swallowing ability is assessed.

References

Cheong, E., Dodd, L., Smith, W., & Kleinig, T. (2018). Icatibant as a potential treatment of life-threatening alteplase-induced angioedema. Journal of Stroke and Cerebrovascular Diseases, 27(2), e36-e37. doi: 10.1016/j.jstrokecerebrovasdis.2017.09.039

Chugh, C. (2019). Acute ischemic stroke: management approach. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(Suppl 2), S140. doi: 10.5005/jp-journals-10071-23192

Ferdinand, P., & Roffe, C. (2016). Hypoxia after stroke: a review of experimental and clinical evidence. Experimental & translational stroke medicine, 8(1), 1-8. doi: 10.1186/s13231-016-0023-0

Gunes, T., Liman, E., Bas, I. P., Soylemez, C., Erdal, Y., Emre, U., & Akdeniz, E. (2020). The simple and fast swallowing function assessment in acute stroke patients. Northern Clinics of ?stanbul, 7(4), 391. doi: 10.14744/nci.2019.00821

Henke, C., Foerch, C., & Lapa, S. (2017). Early screening parameters for dysphagia in acute ischemic stroke. Cerebrovascular Diseases, 44(5-6), 285-290. doi: 10.1159/000480123

Johansson, Y. A., Tsevis, T., Nasic, S., Gillsjö, C., Johansson, L., Bogdanovic, N., & Kenne Sarenmalm, E. (2021). Diagnostic accuracy and clinical applicability of the Swedish version of the 4AT assessment test for delirium detection, in a mixed patient population and setting. BMC geriatrics, 21(1), 1-16. doi. 10.1186/s12877-021-02493-3

Johnson, K. L., Speirs, L., Mitchell, A., Przybyl, H., Anderson, D., Manos, B., ... & Winchester, K. (2018). Validation of a postextubation dysphagia screening tool for patients after prolonged endotracheal intubation. American Journal of Critical Care, 27(2), 89-96. doi: 10.4037/ajcc2018483

Park, K. D., Kim, T. H., & Lee, S. H. (2020). The Gugging Swallowing Screen in dysphagia screening for patients with stroke: A systematic review. International journal of nursing studies, 107, 103588. doi: 10.1016/j.ijnurstu.2020.103588

Polk, S. R., Stafford, C., Adkins, A., Efird, J., Colello, M., & Nathaniel, T. I. (2018). Contraindications with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke population. Neurology, psychiatry and brain research, 27, 6-11. doi: 10.1016/j.npbr.2017.11.002

Purbianto, D. A. (2018). Effect of Sensory and Tactile Stimulation to Increase Glasgow Coma Scale (GCS) Score on Stroke Clients Who Have Consciousness Disorders at Abdul Moeloek Hospital, Lampung. EXECUTIVE EDITOR, 9(12), 12560.

Sivertsen, J., Graverholt, B., & Espehaug, B. (2017). Dysphagia screening after acute stroke: a quality improvement project using criteria-based clinical audit. BMC nursing, 16(1), 1-8. doi: 10.1186/s12912-017-0222-6

Thomalla, G., Boutitie, F., Ma, H., Koga, M., Ringleb, P., Schwamm, L. H., ... & Geran, R. (2020). Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. The Lancet. doi: 10.1016/S0140-6736(20)32163-2.