Complications And Interventions For A Patient With Ischemic Stroke

This assessment requires you to explore the evidence base for nursing care of the patient who has had a stroke. You will need to analyse the current best practice nursing literature on nursing care of post stroke complications.

Only research articles are to be used for your identification of best practice. That is, unit protocols or guidelines, textbooks and other secondary sources do NOT qualify as suitable reference material for uncovering the evidence base for best practice. PubMed, The Cumulative Index of Nursing and Allied Health literature (CINAHL) and Medline are useful sources to locate the research evidence for this essay.Mr Steven Chan, a 68 year old male, awoke in the middle of the night and fell when he tried to get up to go to the bathroom. He fell because he was not able to control his left leg. His wife took him to the hospital, where he was diagnosed with an acute ischemic stroke. The stroke protocol was followed and Mr Chan has now been admitted to the acute stroke unit.

Upon arrival he is feeling depressed and fearful about having another stroke. His left leg and arm remain weak and numb. Left sided arm weakness 3/5 and leg weakness 4/5. He has decreased sensation on the left side, particularly in his hand. He currently has dysphagia and left homonymous hemianopsia.
Based on the case study provided identify three (3) complications (consequences) of acute stroke.
In your answer you will need to discuss;
The significance of these complication to the patient
What nursing intervention would be appropriate for these complications
Provide an evidence based rationale for your interventions

Complications of Ischemic Stroke

Stroke is an acute disorder that takes place when the blood vessels present in the brain ruptures and bleeds. It might also take place where there is a blockage in the supply of the blood to the brain (Crotty et al., 2018). This rupture as well as the blockage prevents oxygen and blood from reaching the tissues of the brain. The stroke occurring due to blocked artery is the ischemic stroke whereas the other is called the hemorrhagic stroke (DiBrandia & Wunderink, 2015). This assignment would be based on a case study of a patient who has suffered from ischemic stroke. Different complication that he might face is discussed and accordingly interventions would be provided.

One of the most important complications that remains closely associated with the occurrence of acute stroke is aspiration pneumonia. Dysphagia is a clinical condition when the patients lose the ability to swallow of faces difficulty in swallowing. The patients would feel difficult in starting the swallow and would feel a sensation of food being stuck in the neck or the chest. The patient named Steven may not become aware of food or liquid entering the airway that is thereby termed as silent aspiration. In such situations, thin liquids are seen to become often hard for swallowing safely after the stroke as the food components move quickly through the mouth as well as throat (Smith, 2015). Adequate time is important for the larynx in making adjustment for protecting the airway. When such things do not happen properly as those in cases of patients suffering from dysphagia secondary to stroke, such situations of aspiration may result. In the normal patients, aspiration mainly leads to violent forms of coughing. However, in cases of patients who are suffering from complications of stroke, this might not occur as they have reduced sensation. When prevention of the aspiration cannot take place successfully, minute particles from the mouth het inhaled or might also flow in drops into the airways. During the times of this situation, normal defense mechanisms of coughing mainly helps enhancing clearance before the particles reaches the lungs in normal cases where they can cause infection or might also induce inflammation. In case of the stroke patients like Steven, particles are not cleared appropriately like in situations due to faulty mechanisms or too large volumes of particles, aspiration pneumonia is seen to occur in the patients (Gao & Sabel, 2017).

Aspiration Pneumonia

Therefore, one of the most important interventions that the nursing professionals need to take is the prevention for the occurrence of aspiration pneumonia. Therefore, they should try their best to prevent aspiration and should conduct proper evaluation of the swallowing. Therefore following the stroke, a speech language pathologist should be summoned and along with the help of the expert, the swallowing ability of the patient should be checked. Researchers are of the opinion that such assessment should mainly include evaluation of how well the muscles in the mouth of the patient can be moved by him (Perry et al., 2018). The second step would be that the nursing professionals should be asking questions for determining whether the patient is able to remember the techniques that they need to learn for easy swallowing and to prevent aspiration. The nursing professional should be also listening to the voice of the patient in order to evaluate the functioning of the voice box. It is very important to know that adequate nutrition often becomes a concern for the patients who suffer from acute stroke who had faced dysphagia. Therefore, it is not safe for the individuals to swallow medications, food, beverages and others by mouth and therefore the patient might require tube feeding (Ebihara et al., 2016).

After gaining proper information about the swallowing capability, the healthcare professionals should use this information of Steven for assisting in developing an individualized plan to help the patient to regain his swallowing skills. The professionals should incorporate exercise regimes for improvement of the coordination of the muscle movements in the mouth and the throat. Also techniques should be incorporated for helping Steven for compensating for the lost function. Thickened foods should be given to the patient so that the movement of the food is slower (Takizawa et al., 2016). The nursing professionals should maintain continual reassessment, which is necessary for evaluating the survivor’s progress in an ongoing fashion, and thereby understand when it is safe for eating foods that are more conventional.

The patient named Steven would also be having issues with mobility. He has decreased sensation in his left leg and arm that had become excessively weak. Left sided arm weakness is also quite high and leg weakness is also higher. He has decreased sensation in the left side mainly in the hand. Therefore, there is high chance of bedsores as the patient would not be able to move or change his position on the bed. Bedsores can be described as the pressure ulcers that result from the decreased ability of moving as well as the occurrence of excess pressures on the different areas of the body because of immobility (Lechner et al., 2017). Researchers are of the opinion that bedsores mainly occur in the areas like that over the hip regions, spine, lower back, tailbone, elbows, heels as well as shoulder blades. This pressure is mainly seen to temporarily cut off the supply of the blood flow to the skin resulting in injury to the cells of the skin. Unless the healthcare professionals take the initiative for the pressure to be relieved and blood is mainly seen to  flow in the skin again, the skin soon begins to show signs of the injury.

Prevention of Aspiration Pneumonia

It is very important for the nursing professionals to undertake proper evaluation of the risky areas of the patients that is more prone to development of pressure sores. Depending upon the areas where weakness is higher in the patient named Steven in his left leg and left arm, the healthcare professional should incorporate the following interventions. The first intervention would be to relieve the pressures on the vulnerable areas. The position of the person should be changed frequently, when possible in every two hours when he is in bed (Groah et al., 2015) The nursing professional may use a water mattress, a sheepskin mattress as well as an egg-crate mattress. Randomized controlled trials have shown the efficiency of air-fluidized beds and low-air-loss beds in comparison to traditional beds for the reduction of the likelihood of the occurrence of pressure ulcer. The second intervention would be reducing the shear and friction where the professionals should avoid dragging of the patient across the bed sheets (Pellegrini et al., 2017). The bed should be kept free from any particles that can cause sheer and friction and can thereby use sheepskin boots and elbow pads for reduction of the friction of elbows and heels. The third intervention is inspection of the skin of the personal least once each day. This is mainly because early detection can lead to prevention of stage 1 redness from becoming worse. The nurse should follow the fourth prevention where she should minimize the irritation cause from chemicals and therefore should avoid antiseptics, povidone iodine solution, hydrogen peroxide or other harsh chemicals for disinfecting the skin of the patient. Steven should be also encouraged to eat well as and the patients should be given nutritional supplement if he cannot eat as this helps in preventing or healing of pressure ulcers. The sixth intervention would be encouraging the patient for daily exercises. Researchers are of the opinion that exercises increase the flow of blood and helps in speeding up the healing procedures (Chou et al., 2015). He would be helped to do stretches and simple exercises in bed as much as he can be capable of. The skin of the person should be kept dry as well as clean.

Homonymous hemianopia or the HH is a frequent visual consequence in the patients who had suffered stroke as a result of the post-chaismal damages. Evidences are of the opinion that 8 to 10% of the stroke patients have permanent HH and within them about 52 to 70% of hemianopis are caused by stroke (Tanaka et al., 2018). The ore posterior the lesion takes place, the more congruous the lesion will be. Studies have suggested that patients with HH have been seen to impairments in the mobility as well as the navigational impairment (Bosanquet et al., 2016). They are frequently seen to complain about the bumping of into obstacles on the side of the affected visual field. As the patient was seen to be suffering from left homonymous hemianopsia, he would face the same issues as mentioned above. Researches also suggest that patients with this disorder cannot spontaneously scan into the blind area. Therefore, reading ability of the patients gets impaired and Steven might suffer from this complication. Right side HH and left side HH has different issues. In left HH, patients find it difficult for returning to the start of the next line and therefore, Steven would be also suffering from this problem.

Pressure Ulcers

One of the technique that the healthcare professionals can help the patients to uptake is the visual scanning technique. This mainly encouraged the patient to look on the left as well as the right side in the systematic ways. The professional will help Steven to be more aware of his visual field loss and reminds him to look into his blind side. The professionals might also give the patients different other options like utilization of the line guides during reading, giving good lighting, and thereby using edge markers on the books as well as the newspapers (Goto et al., 2016). Another intervention is the widening of the field of the view of the patient with optical aids. This mainly involves the use of the plastic prism on the glasses, helps in creating an image of the part of the side of the visual field loss, and helps in reflecting it over to the good side. This is very helpful as it acts by looking towards the blind side or may help in noticing things on that side. Vision restorative treatment is also helpful but not enough evidences are present to suggest it to the patient (LeBlanc et al., 2016).

From the above discussion, it is seen that after analyzing the symptoms of the patients, three important complications were noted. These are the occurrence of aspiration pneumonia due to his difficulty in swallowing; he may develop pressure ulcers due to weakness on his left side and loss of mobility. The third complication is left homonymous hemianopsia that resulted in partial visual loss. Therefore, the nursing professionals should be taking up necessary interventions and they should be working in association with the members of the multidisciplinary teams like ophthalmologists, speech therapists and others so that effective care is given. This would help the patient to come back to normal life where he can live with better quality.

References:

Bosanquet, D. C., Wright, A. M., White, R. D., & Williams, I. M. (2016). A review of the surgical management of heel pressure ulcers in the 21st century. International wound journal, 13(1), 9-16. https://doi.org/10.1111/iwj.12416

Chou, C. L., Lee, W. R., Yeh, C. C., Shih, C. C., Chen, T. L., & Liao, C. C. (2015). Adverse outcomes after major surgery in patients with pressure ulcer: a nationwide population-based retrospective cohort study. PLoS One, 10(5), e0127731. https://doi.org/10.1371/journal.pone.0127731

Crotty, M., van den Berg, M., Hayes, A., Chen, C., Lange, K., & George, S. (2018). Hemianopia after stroke: A randomised controlled trial of the effectivenessof a standardised versus an individualised rehabilitation program, on scanning ability whilst walking. NeuroRehabilitation, (Preprint), 1-9. DOI: 10.3233/NRE-172377

DiBardino, D. M., & Wunderink, R. G. (2015). Aspiration pneumonia: a review of modern trends. Journal of critical care, 30(1), 40-48. https://doi.org/10.1016/j.jcrc.2014.07.011

Ebihara, S., Sekiya, H., Miyagi, M., Ebihara, T., & Okazaki, T. (2016). Dysphagia, dystussia, and aspiration pneumonia in elderly people. Journal of thoracic disease, 8(3), 632. doi:  10.21037/jtd.2016.02.60

Gao, Y., & Sabel, B. A. (2017). Microsaccade dysfunction and adaptation in hemianopia after stroke. Restorative neurology and neuroscience, 35(4), 365-376. DOI: 10.3233/RNN-170749

Goto, K., Miki, A., Yamashita, T., Araki, S., Takizawa, G., Nakagawa, M., ... & Kiryu, J. (2016). Sectoral analysis of the retinal nerve fiber layer thinning and its association with visual field loss in homonymous hemianopia caused by post-geniculate lesions using spectral-domain optical coherence tomography. Graefe's Archive for Clinical and Experimental Ophthalmology, 254(4), 745-756. https://doi.org/10.1007/s00417-015-3181-1

Groah, S. L., Schladen, M., Pineda, C. G., & Hsieh, C. H. J. (2015). Prevention of pressure ulcers among people with spinal cord injury: a systematic review. PM&R, 7(6), 613-636. https://doi.org/10.1016/j.pmrj.2014.11.014

LeBlanc, K., Alam, T., Langemo, D., Baranoski, S., Campbell, K., & Woo, K. (2016). Clinical challenges of differentiating skin tears from pressure ulcers. EWMA J, 16(1), 17-23. https://www.researchgate.net/profile/Kimberly_Leblanc/publication/303783562_LeBlanc_K_Alam_T_Langemo_D_Baranoski_S_Campbell_K_Woo_K_2016_Clinical_Challenges_of_Differentiating_Skin_Tears_from_Pressure_Ulcers_EWMA_Journal_161_17-23/links/579a16fa08ae024e100e3a56.pdf

Lechner, A., Lahmann, N., Neumann, K., Blume-Peytavi, U., & Kottner, J. (2017). Dry skin and pressure ulcer risk: A multi-center cross-sectional prevalence study in German hospitals and nursing homes. International journal of nursing studies, 73, 63-69. https://doi.org/10.1016/j.ijnurstu.2017.05.011

Pellegrini, F., Lee, A. G., & Zucchetta, P. (2017). Homonymous hemianopsia due to posterior cortical atrophy. Neuro-Ophthalmology, 41(3), 154-158. https://doi.org/10.1080/01658107.2016.1278556

Perry, S. E., Miles, A., Fink, J. N., & Huckabee, M. L. (2018). The Dysphagia in Stroke Protocol Reduces Aspiration Pneumonia in Patients with Dysphagia Following Acute Stroke: a Clinical Audit. Translational stroke research, 1-8. https://doi.org/10.1007/s12975-018-0625-z

Smith, A. L. (2015). Aspiration Pneumonia After Screening and Diagnostic Procedures for Dysphagia Following Acute Stroke. GUNDERSEN, 8. Retrieved from: https://www.gundersenhealth.org/app/files/public/1232/Research-Medical-Journal-Volume-9-Issue-1.pdf#page=11

Takizawa, C., Gemmell, E., Kenworthy, J., & Speyer, R. (2016). A systematic review of the prevalence of oropharyngeal dysphagia in stroke, Parkinson’s disease, Alzheimer’s disease, head injury, and pneumonia. Dysphagia, 31(3), 434-441. doi: 10.1007/s00455-016-9695-9

Tanaka, K., Hashimoto, S., Harada, Y., Kageyama, T., & Suenaga, T. (2018). A case of painful seizure accompanying ictal paresis and homonymous hemianopia due to post-stroke epilepsy. Rinsho shinkeigaku= Clinical neurology. doi: 10.5692/clinicalneurol.cn-001167