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For this assessment you can choose which case study you would like to focus your assessment. Case Study 1 Mr Sam Kwon  OR Case Study 2 Mr Patrick Drew.

Types of Cerebrovascular Accident

Cerebrovascular accident (CVA), commonly referred to as stroke occurs when the blood flow to specific parts of the brain are stopped due to presence of some blockage or rupture of the major blood vessels. Some of the most common types of CVA include haemorrhagic stroke and ischemic stroke. Commonly manifested symptoms of stroke comprise of dizziness, loss in balance and coordination, speaking difficulty, paralysis and numbness, and blurred vision. Haemorrhagic stroke occurs when there is a rupture of the vessels (Kim, Baumgartner & Clements, 2013). Conversely, blockage leads to ischemia. Both the types of CVA deprive the brain of their essential blood and oxygen, thereby leading to death of the cells (Marieb & Hoehn, 2007). The case study focuses on Mr. Sam Kwon, aged 74 years, who has been admitted on account of aphasia, hemiparalysis on the right side and facial drooping. The essay will elaborate on the prevalence and incidence of the physiological abnormality in Australia and will further illustrate on the different steps of disease assessment and implications to nursing.

Stroke can be defined as the onset of sudden neurological deficit due to vascular abnormalities. This deficit usually lasts for more than 24 hours. This condition is largely avoidable due to the range of risk factors that can be modified or avoided by people at an increased risk of suffering from the condition. Approximately 377,000 individuals (171,000 females and 206,000 males) that form 2% of the entire Australia population were hospitalised for stroke rehabilitation in 2013-14. Most of the patients were aged more than 65 years (71%) (Aihw.gov.au, 2018). The average hospitalization length for acute care due to stroke was 8 days, and that for rehabilitation was 14 days. Stroke is recognised as the third leading reason for death in Australia (Abs.gov.au, 2018). There were an estimated 10,869 stroke related fatalities in 2015, which accounted for 6.8% of the total deaths (159,052).  Males aged under 85 years of age, show higher mortality rates due to stroke, when compared tofemales. On the other hand, high death rates were observed among females,aged 85 and more(Strokefoundation.org.au, 2018).The median age for death due to stroke in Australia is 86.6 years. While this data elaborates on the fact that most stroke related death incidents occur among older adults, it also feature as the top leading reasons of death among persons aged more than 45 years. Similar findings are also presented by epidemiological studies that have confirmed CVA as the third leading contributor to death in the US. An estimated 140,000 individuals die due to CVA in the United States every year. Furthermore, approximately 795,000 people suffer from stroke in the country of which 185,000 are recurrent attacks (Stroke Center, 2018).

Prevalence and Incidence of Stroke in Australia

Clinical assessments are a way of diagnosing and preparing a treatment plan for a patient to gather relevant information regarding the current health status. Stroke scales are considered as standardized assessment tools that help in identifying the underlying factors and health abnormalities present in the patient. Sudden deterioration of brain function is one of the primary features of an ischemic stroke (Marieb & Hoehn, 2007). An assessment of the patient Mr. Kwon will be conducted with the use of different assessment scales that will measure his level of consciousness, stroke related deficits, disability, mental status, motor function and balance. Information pertaining to his medical history will also be gathered with the aim of understanding about the potential risk factors and formulating a care plan (Harrison, McArthur & Quinn, 2013). Physical assessment is most imperative in this case as it will help in recording the vital signs of the patient. The physical examination will encompass all organ systems, such as, the airways, breathing, circulation (ABC) and the vital signs. This can be attributed to the fact that patients with reduced levels of consciousness are at a risk of damage to the airways. Furthermore, assessing the vital signs can help in the identification of approaching clinical deterioration and will also facilitate narrowing down the process of differential diagnosis.

Most stroke patients have been found hypertensive in baseline measures and the blood pressure shows an elevation following a CVA. Temperature changes might act as indicators of brain dysfunction and intracranial pressure (Bullock & Hales, 2012). A comprehensive neurological assessment will involve determining the gross and fine motor skills, the sensory function and the level of consciousness.  The level of consciousness will be assessed wi8th the use of a Glasgow Coma scale that has been established as a practical method that helps to determine consciousness in response to external stimuli. This will involve assessing the patient against the scale criteria, followed by giving the patient certain scores between 3 and 15 (Teasdale et al., 2014). Fine and gross motor skills will be evaluated with the Motor Assessment Scale designed for stroke patients. Its utility is related to the valuation of functional task performance, in place of isolated movement patterns. Mr. Kwon will be tested for his tone, posture, symmetry, coordination, and gait. His sensory function evaluation will comprise of assessing the hearing ability, taste, response to touch, smell and vision (Duffy et al., 2013). The Fugl-Meyer is another alternative that can be used in this scenario. This scale is widely used to measure presence and severity of motor impairment following a stroke incident (See et al., 2013).

Assessment of CVA Patient

It will help in determining presence of symptoms that are related to lower and upper extremity sensory and motor impairment. Furthermore, owing to the fact that the patient has hemiplegia, the NIH Stroke Scale can also be used, with the aim of quantifying the severity of his CVA (Saposnik et al., 2013). The patient will also be evaluated for determining the adequacy of his cardiac output and the assessment will comprises of several techniques of inspection/observation, palpation, and auscultation. Additionally, MRI has increasingly gained importance in the diagnosis of acute ischemic stroke and will produce a clear image of the brain structures that might have been affected due to deprived blood supply and oxygen.

Stroke management and care plan formulation is imperative to optimal health outcomes of the patient. Stroke patients who require admission must be immediately admitted to the stroke units that are staffed by a coordinated interdisciplinary team that is essential for patient care. Early assessment of the patient will reduce the chance of mortality. Emergency treatment for the patient will involve detection of the type of stroke that he has suffered from. Following admission of the patient, clot-busting drugs must be administered with 4.5 hours to improve his chances of survival. This will be facilitated by the administration of tissue plasminogen activator (tPA) or alteplase, the gold standard for ischemic CVA (Bullock & Manias, 2013). The care plan will include injecting tPA through the vein into the arm that will restore the blood flow in the patient by dissolving all blood clots or blockages that had resulted in the stroke (Powers et al., 2015). The use of tPA must be followed by regular monitoring of the patient for bleeding. Management of intracranial pressure also forms an essential aspect of stroke care plan. This will generally be conducted by the administration of osmotic diuretics that will prevent reabsorption of sodium and water by increasing blood osmolality (Jovanovic et al., 2014).


Furthermore, efforts will be taken to maintain the PaCO2 near 30-35 mm Hg. One essential component of the care plan will be associated with appropriate therapeutic positioning of the patient to promote his optimal recovery (Steiner et al., 2013). Five positions in which the patient will be kept are lying on the affected or unaffected sides, supine, and sitting up on chairs or the bed. The care plan will also comprise of maintaining a flow sheet to assess the essential measures of the clinical status of Mr. Kwon such as, changes in his levels of consciousness, presence of involuntary movement extremities, neck flaccidity, eye opening and pupil size, blood pressure, speech ability and bleeding (Lang et al., 2013). Appropriate positioning will help in preventing contractures, reduce pressure and eliminate chances of neuropathies.

Management and Care Plan of CVA Patient

Adduction of affected arm will also be prevented. Elevating the head of bed by 15-30 degrees, at low fowler’s position will increase the venous return (Kubota et al., 2015). Furthermore, a trained clinician will also assist the patient with his activities of daily living to maximise the outcomes and enhance the perceptual, sensorimotor and cognitive faculties (Lee, 2013). A speech pathologist will be crucial in managing all forms of swallowing deficits (if any), while the patient is kept on a monitored diet and fluid intake. Additionally, efforts will also be taken to prevent breakdown of the skin that can occur due to inability of the affected person to move extremities, or incontinence (Brown et al., 2015). Facilitating communication with the patient and his family members is another essential approach that will help in coping with the condition. A speech pathologist will help in including an aphasia friendly environment in the setting (Flynn et al., 2013). The care plan will also include regular administration of medications for T2D and a constant monitoring on the nutrition and hydration status.

Conclusion

To conclude, nursing professional are vital to the interdisciplinary team for stroke care that will assess the admitted patient in the emergency setting. There need to be a rapid assessment of the patient to facilitate easy diagnosis and nursing interventions. Proper monitoring and reporting in relation to the essential aspects of stroke assessment such as, vital signs, motor control, sensory perception and neurological status are imperative for the prevention and elimination of CVA associated complications. Thus it can be concluded that working in collaboration with the other members of the interdisciplinary team will help in maximising the amount of nursing interventions.

References

Abs.gov.au. (2018). 3303.0 - Causes of Death, Australia, 2015. Retrieved from https://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/3303.0~2015~Main%20Features~Stroke~10003

Aihw.gov.au. (2018). Retrieved from https://www.aihw.gov.au/getmedia/c420f6f1-0464-4f43-b55a-62f995a0f8f3/ah16-3-6-stroke.pdf.aspx

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2015). Lewis's Medical-surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Bullock, S., & Hales, M. (2012). Principles of Pathophysiology. Pearson Higher Education AU.

Bullock, S., & Manias, E. (2013). Fundamentals of pharmacology. Pearson Higher Education AU.

Duffy, L., Gajree, S., Langhorne, P., Stott, D. J., & Quinn, T. J. (2013). Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: systematic review and meta-analysis. Stroke, 44(2), 462-468.

Flynn, D., Ford, G. A., Stobbart, L., Rodgers, H., Murtagh, M. J., & Thomson, R. G. (2013). A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tool developers. BMC health services research, 13(1), 225.

Harrison, J. K., McArthur, K. S., & Quinn, T. J. (2013). Assessment scales in stroke: clinimetric and clinical considerations. Clinical interventions in aging, 8, 201.

Jovanovic, A., Stolic, R. V., Rasic, D. V., Markovic-Jovanovic, S. R., & Peric, V. M. (2014). Stroke and diabetic ketoacidosis–some diagnostic and therapeutic considerations. Vascular health and risk management, 10, 201.

Kim, R., Baumgartner, N., & Clements, J. (2013). Routine left atrial appendage ligation during cardiac surgery may prevent postoperative atrial fibrillation–related cerebrovascular accident. The Journal of thoracic and cardiovascular surgery, 145(2), 582-589.

Kubota, S., Endo, Y., Kubota, M., Ishizuka, Y., & Furudate, T. (2015). Effects of trunk posture in Fowler's position on hemodynamics. Autonomic Neuroscience, 189, 56-59.

Lang, C. E., Bland, M. D., Bailey, R. R., Schaefer, S. Y., & Birkenmeier, R. L. (2013). Assessment of upper extremity impairment, function, and activity after stroke: foundations for clinical decision making. Journal of Hand Therapy, 26(2), 104-115.

Lee, G. (2013). Effects of training using video games on the muscle strength, muscle tone, and activities of daily living of chronic stroke patients. Journal of physical therapy science, 25(5), 595-597.

Marieb, E. N., & Hoehn, K. (2007). Human anatomy & physiology. Pearson Education.

Powers, W. J., Derdeyn, C. P., Biller, J., Coffey, C. S., Hoh, B. L., Jauch, E. C., ...& Meschia, J. F. (2015). 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46(10), 3020-3035.

Saposnik, G., Guzik, A. K., Reeves, M., Ovbiagele, B., & Johnston, S. C. (2013). Stroke prognostication using age and NIH Stroke Scale: SPAN-100. Neurology, 80(1), 21-28.

See, J., Dodakian, L., Chou, C., Chan, V., McKenzie, A., Reinkensmeyer, D. J., & Cramer, S. C. (2013). A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials. Neurorehabilitation and neural repair, 27(8), 732-741.

Steiner, T., Juvela, S., Unterberg, A., Jung, C., Forsting, M., & Rinkel, G. (2013). European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovascular diseases, 35(2), 93-112.

Stroke Center. (2018). Stroke Statistics. Retrieved from https://www.strokecenter.org/patients/about-stroke/stroke-statistics/

Strokefoundation.org.au. (2018). Facts and figures about stroke — Stroke Foundation - Australia. [online] Available at: https://strokefoundation.org.au/About-Stroke/Facts-and-figures-about-stroke [Accessed 9 Aug. 2018].

Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2014). The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology, 13(8), 844-854.

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