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Question 1

Robert has developed an ischemic stroke. However, the most likely cause is embolic stroke. An ischemic stroke occurs when blood circulation to a part of a brain is cut off, leading brain tissue within the area to malfunction. Hui et al. (2021) mention Ischemic stroke is manifested by a lack of proper blood circulation to perfuse cerebral tissues because of restricted or clogged arteries going to or inside a brain. Ischemic strokes are split into two categories: thrombotic as well as embolic strokes. The most common artery implicated with stroke seems to be the middle cerebral artery (MCA). Four segments provide a substantial portion of a lateral area of a brain, along with a part of basal ganglia along with an internal capsule (M1, M2, M3, and M4). The basal ganglion, which is essential for motor control, sensorimotor, executive activities, including emotions, is supplied by the M1 (horizontal) section. The parietal lobe, superior temporal lobe, insula, as well as inferolateral frontal lobe are all supplied by the M2 (sylvian) section (Hui, Tadi, & Patti, 2021). Whenever a clot occurs in a different part of the system, it is referred as embolic episode. If a clot develops inside an atrium during atrial fibrillation as well as dislodges through into arterial vasculature, it can lead to embolic stroke. The most obvious suspect of the clotting seems to be the chambers or valve of the heart. As the clot gets dislodged and placed inside the right MCA that supplies blood to the brain, a lack of blood supply occurs, which can damage the basal ganglia (Hart et al., 2017). As the basal ganglia get damaged it can cause motor dysfunction. Due to this reason Robert is feeling left sided weakness.

Typical clinical manifestation of cerebrovascular accident (CVA) includes one-sided weakness, numbness on one side, facial drop, and dysphagia. However, it is possible to develop some degree of breathing difficulty. Even in some serious situations, it is possible to develop one-sided paralysis. It is important to note that if the right side of the brain gets harmed, it can influence the left side and if the left side of the brain gets harmed it can influence the right side. In this case, Robert's CVA must have occurred on the right side; therefore, his left side was affected as a result (Phipps & Cronin, 2020). Initial management for Robert's CVA includes (Phipps & Cronin, 2020) administration of clot-busting medicine, Tissue plasminogen activator (tPA), to re-establish the blood circulation.

1. Neurological examination

The neurological examination is being used to determine the site of a stroke, determine baseline capability after hospitalisation, rule out the transient ischemic attack (TIA) or even other stroke mimickers. It also helps determine probable comorbidities. It consists of cranial neurological function checking; checking the mobility function using range of motion, muscular strength tests, perceptual integrity, vibratory sensation, cerebellar activity, walking, language, psychological condition, as well as state of awareness tests (Herpich & Rincon, 2020). The National Institutes of Health Stroke Scale (NIHSS) is used to assess baseline functioning, which considers the degree of awareness, visual as well as neuromuscular activity, sensibility and cognition, cerebellar feature, and linguistic ability (Zöllner et al., 2020). 

Question 2 - Nursing Assessment

In Robert's care, performing this test should be a priority because it can help to identify the type of the stroke; if it is a TIA the care plan would be different compared to normal CVA intervention. Also, in this case, the exact onset of the stroke is not noted. Therefore, performing this assessment will help to determine how much neurological damage has occurred in his brain. Also, the findings from this test will help to determine how much Robert’s motor function is affected due to CVA (Arch et al., 2016). The assessment findings will help to identify if Robert needs additional support like ambulatory support or fall prevention management. This assessment needs to be performed initially as it requires less time and help to stabilise the patient initially.

2. Peripheral vasculature examination

The patient's carotid, radial, femoral, as well as posterior tibial pulses are all palpated during a peripheral vascular assessment. A peripheral vascular assessment is a clinical examination which checks for symptoms of abnormality within the arteries as well as veins of a leg along with feet. It is done based on the physical assessment or if a person mention of leg pain that might suggest a cardiovascular issue (Tadi & Lui, 2018).

 In this case, Robert also has weakness in his lower limb; also he has a cardiovascular problem. However, Kolls et al., (2016) mention the main reason for performing this experiment to check if the patient has peripheral artery disease. Kolls et al. (2016) stated ischemic strokes including TIA are common in people having acute peripheral artery disease (PAD). Age, atrial fibrillation, diabetes mellitus, hypertension, and location were all found to be significantly linked to all-cause CVA. In this case, Robert also suffers from hypertension and atrial fibrillation. Also, he is already 78 years old. Therefore, he is already at increased risk of developing stroke.

Nursing intervention for Robert’s airway and ventilation can include:

Positioning the patient in a specific way can help to improve the airway and ventilation. Therefore, in this case, the nurse needs to reposition Robert to improve his airway and ventilation. The nurse can reposition Robert in a semi-Fowler position. This position can help to improve breathing function. Mezidi and Guérin (2019) mention the diaphragm descends downwards inside the semi-Fowler's posture. It can ease the labour of breathing while improving ventilation and lung volume. Also, this position can help to improve lung dilation, improving the gas exchange and thus ultimately leading to higher oxygen saturation levels. To maintain this position, the nurse needs to elevate the angel of Robert's bed from 30-45 digress (Kiyak et al., 2019). Also, the legs should be straight. Higher blood oxygen saturation will help to prevent the episode of seizure.

As Robert is experiencing seizures, it can indicate his brain is receiving a low amount of oxygen. This is due to the low blood oxygen saturation level. Therefore, to improve the blood oxygen saturation level the nurse needs to administer additional oxygen. This should be completed as soon as feasible and as effectively as possible. After the decision is made, the nurse needs to start administering the proper amount of oxygen (Gupta et al., 2020). In this case, a normal Hudson mask can be used instead of the high flow method because the condition because Robert's condition is not serious. This mask provides approximately 35-45% oxygen and also is frequently employed as the first oxygen delivery system during a pulmonary emergency. However, in case of serious oxygen deprivation, this device cannot be used because it has a limited value of 45% (Gupta et al., 2020).

Question 3

The Airway occlusion needs to be provided by the cuff upon an endotracheal and tracheostomy line. In this case, Robert needs the appropriate ventilator settings, including tidal volume (TV) as well as oxygenation, whenever the cuff is properly inflated (Alkhouri et al., 2017). For a nurse, inflating the cuff according to hospital protocol and then checking for correct inflation pressure with the help of the minimal leakage approach as well as minimal occlusive capacity seems to be necessary. The nurse needs to carefully perform these procedures with a trained professional or with the help of a respiratory clinician to avoid tracheal discomfort and injury due to excessive cuff pressure. Moreover, it is important to always use the correct method for Robert while adding air inside a cuff (Alkhouri et al., 2017).

Mode of action

Lorazepam reacts with benzodiazepine channels in a postsynaptic GABA-A ligand-gated chloride circuit neuron at different places throughout a central nervous system (CNS). Lorazepam improves the conductivity of the chloride ions across the cell by improving the inhibitory activity of GABA. This cell plasma membrane is hyperpolarised as well as stabilised as the consequence of the changes inside the chloride ions. Lorazepam helps with anxiety and depression because of its inhibitory effect on the amygdala, and it helps with seizures because of its inhibition effect inside the cerebral cortex (Ghiasi et al., 2021). Hence, to lower the level of anxiety and the occurrence of seizures, Lorazepam was prescribed to Robert.

Indications

This medication is mainly given to Robert to manage his anxiety. Unmanaged anxiety can cause a recurrence of stroke. Moreover, Lorazepam can prevent the chance of seizures that the patient is experiencing (Wu et al., 2016).

Nursing administration

Lorazepam could be taken by mouth. It could be given intravenously (IV) or intramuscularly (IM) injection. If given via IV, it takes 1-3 minutes to take effect; if given IM, it takes 15-30 minutes to take effect. However, the level of dosages needs to be adjusted according to the patient's condition (Ghiasi et al., 2021).

Adverse effects

CNS, as well as respiratory distress, is a common dose-dependent adverse effect of using lorazepam, as they are benzodiazepines. However, large dosages might have more severe side effects. The serious adverse effects that may occur in Robert include sedation, dizziness asthenia, ataxia, reaction at the injection location, depression of the lungs, IV usage causes hypoventilation, hypotension, fatigue, amnesia, and confusion (Ghiasi et al., 2021).

Contraindications

The blood-pressure-lowering effects of furosemide, as well as LORazepam, might be addictive. Head, vertigo, dizziness, collapse, and/or modification of circulation or pulse rate are all possible symptoms. Enalapril, as well as LORazepam, could also work together to reduce blood pressure. Therefore, as Robert is already taking furosemide and enalapril, extra precautions need to be taken (Ghiasi et al., 2021).

The nursing evaluation for lorazepam can include:

1. Lower rate of anxiety

The main purpose of lorazepam is to lower the level of anxiety. Therefore, in this case, the primary evaluation will be a lower level of anxiety. Prolonged anxiety can increase the chance of having a stroke and increase blood pressure. Therefore, to make sure that Robert does not develop any anxiety problems, it is important to evaluate his mental condition. Moreover, a high level of anxiety can increase the chance of depression. Hence, in this case, the nurse needs to engage in therapeutic communication with Robert using a set of questionaries, to assess his mental condition (Ghiasi et al., 2021).

Question 4

2. Decrease in the seize symptoms

Another important use of administering lorazepam is to lower the level of seizing complications. Therefore, it is expected that after administrating this medication, Robert's seize condition will be improved. This can be evaluated with the help of neurological assessment. Previously, Robert had a GCS score of 10, which can indicate a mild to moderate level of brain trauma. Therefore, after the administration of lorazepam, it is expected that Robert will have a GCS score of 15, and he will be fully oriented. This can be checked by assessing his verbal, sensory, optical and motor function 9Zhao et al., 2016).

3. Rule out the chance of epilepticus

Another important evaluation criterion for this drug will be to rule out the chance of epilepticus. Epilepticus can develop due to severe seizure complications. Status epilepticus is generally stated as a seizure lasting over five minutes or having more than one seizure in a 5-minute timeframe without recovering to a regular consciousness among episodes. It can cause significant brain damage. Hence, not having any epilepticus will be an important criterion for this drug (Brigo et al., 2016).

Robert's stroke can have a significant effect on the psychological state Agnes. Therefore, in this case, providing family centred care (FCC) is necessary to manage the situation. In FCC the focus will be incorporating the family member of the patient in the actual care plan as much as possible. According to the concept of FCC; the nurse needs to respect the decision taken by Agnes (Banerjee et al., 2018). Also, the nurse can incorporate her in the decision making for Robert. This step will help to reduce the level of stress and can help to improve patient satisfaction, leading to a positive outcome. The nurse needs to focus on taking an informed concept from Agnes regarding the treatment choices. The provided care needs to be more cooperative and collaborative. The nurse needs to explain the treatment plan to Agnes. Also, add Agnes's suggestions to the treatment plan. The nurse needs to acknowledge all the concerns of Agnes and needs to provide an empathic response (Banerjee et al., 2018). Moreover, providing necessary health education and motivation is necessary to manage stress.

References

Alkhouri, H., Vassiliadis, J., Murray, M., Mackenzie, J., Tzannes, A., McCarthy, S., & Fogg, T. (2017). Emergency airway management in Australian and New Zealand emergency departments: a multicentre descriptive study of 3710 emergency intubations. Emergency Medicine Australasia, 29(5), 499-508. https://doi.org/10.1111/1742-6723.12815

Arch, A. E., Weisman, D. C., Coca, S., Nystrom, K. V., Wira III, C. R., & Schindler, J. L. (2016). Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke, 47(3), 668-673. https://doi.org/10.1161/STROKEAHA.115.010613

Banerjee, J., Aloysius, A., Platonos, K., & Deierl, A. (2018). Family centred care and family delivered care–What are we talking about?. Journal of Neonatal Nursing, 24(1), 8-12. https://doi.org/10.1016/j.jnn.2017.11.004

Brigo, F., Bragazzi, N. L., Bacigaluppi, S., Nardone, R., & Trinka, E. (2016). Is intravenous lorazepam more effective and safe than intravenous diazepam as first-line treatment for convulsive status epilepticus? A systematic review with meta-analysis of randomized controlled trials. Epilepsy & Behavior, 64, 29-36. https://doi.org/10.1016/j.yebeh.2016.09.020

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2021). Lorazepam. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532890/

Gupta, M., Bansal, P., & Sharma, S. (2020). Oxygen therapy. Anaesthesia, Pain & Intensive Care, 24(2), 249-250. https://doi.org/10.35975/apic.v24i2.

Hart, R. G., Catanese, L., Perera, K. S., Ntaios, G., & Connolly, S. J. (2017). Embolic stroke of undetermined source: a systematic review and clinical update. Stroke, 48(4), 867-872. https://doi.org/10.1161/STROKEAHA.116.016414

Herpich, F., & Rincon, F. (2020). Management of Acute Ischemic Stroke. Critical care medicine, 48(11), 1654–1663. https://doi.org/10.1097/CCM.0000000000004597 

Hui, C., Tadi, P., & Patti, L. (2018). Ischemic stroke. https://www.ncbi.nlm.nih.gov/books/NBK499997/?report=classic

Kiyak, H., Yilmaz, G., & Ay, N. (2019). Semi-Fowler positioning in addition to the pulmonary recruitment manoeuvre reduces shoulder pain following gynecologic laparoscopic surgery. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques, 14(4), 567–574. https://doi.org/10.5114/wiitm.2019.84384

Kolls, B. J., Sapp, S., Rockhold, F. W., Jordan, J. D., Dombrowski, K. E., Fowkes, F. G. R., ... & Patel, M. R. (2019). Stroke in patients with peripheral artery disease: insights from the EUCLID study. Stroke, 50(6), 1356-1363. https://doi.org/10.1161/STROKEAHA.118.023534

Mezidi, M., & Guérin, C. (2019). Effect of body position and inclination in a supine and prone position on respiratory mechanics in acute respiratory distress syndrome. Intensive Care Medicine, 45(2), 292-294. https://doi.org/10.1007/s00134-018-5493-1

Tadi, P., & Lui, F. (2018). Acute Stroke. https://europepmc.org/article/NBK/nbk535369

Wu, W., Zhang, L., & Xue, R. (2016). Lorazepam or diazepam for convulsive status epilepticus: A meta-analysis. Journal of Clinical Neuroscience, 29, 133-138. https://doi.org/10.1016/j.jocn.2015.10.038

Zhao, Z. Y., Wang, H. Y., Wen, B., Yang, Z. B., Feng, K., & Fan, J. C. (2016). A comparison of midazolam, lorazepam, and diazepam for the treatment of status epilepticus in children: a network meta-analysis. Journal of child neurology, 31(9), 1093-1107. https://doi.org/10.1177/0883073816638757

Zöllner, J. P., Misselwitz, B., Kaps, M., Stein, M., Konczalla, J., Roth, C., ... & Strzelczyk, A. (2020). National Institutes of Health Stroke Scale (NIHSS) on admission predicts acute symptomatic seizure risk in ischemic stroke: a population-based study involving 135,117 cases. Scientific Reports, 10(1), 1-7. https://doi.org/10.1038/s41598-020-60628-9

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