Understanding Ischemic Stroke And Effective Nursing Interventions - Case Study

Causes and Symptoms of Ischemic Stroke

A stroke or cerebrovascular accident (CVA) occurs when a patient’s brain does not receive proper blood supply. Thus, the brain cells start dying due to a lack of oxygen and nutrients. It is often sudden and can cause long-lasting damage to the brain, disability, or even death. Stroke is primarily of two types: ischemic stroke and hemorrhagic stroke. Robert had presented with moderate weakness in the lower and upper limbs, facial drooping on the left side of the face, and aphasia. His medical history also identifies STEMI, hypertension, and hypercholesterolemia which are potential risk factors for ischemic stroke. Hence, the type of stroke Robert suffered from is most probably an ischemic stroke. 

An ischemic stroke can be defined as the type of stroke that results because of insufficient blood flow to the brain. This blockage is usually due to the build-up of fats and cholesterol on the arterial walls. This thereby causes insufficient oxygen and nutrient levels in the brain causing brain damage. This is the most common type of stroke comprising about 87% of all stroke cases (Karthik et al., 2020). 

The main cause of ischemic stroke is the narrowing of arteries due to the deposition of fats and cholesterol which reduces blood flow to the heart (atherosclerosis). Robert has a history of hypercholesterolemia and hypertension. Hypercholesterolemia is the presence of high cholesterol in the blood. This high level of cholesterol over time accumulated in the blood vessels which reduced the blood flow through Robert’s blood vessels thereby causing a stroke. In addition, hypertension could have caused excess pressure during blood flow through arteries causing tearing of the vessels. The body heals these tears with scar tissues that might get trapped and form a plague. Apart from that, Hypertension is the most prevalent risk factor for stroke with 64% of stroke patients suffering from it (Wajngarten & Silva, 2019). 

Clinical manifestation of ischemic stroke involves numbness of limbs, particularly on one side of the body, lack of balance or coordination, sudden trouble in speaking and understanding, sudden loss of sight in one or both eyes, sudden confusion, dizziness, fatigue, and reduced sensation of touch. Robert had weakness in his left-sided limbs, aphasia, and facial droop all of which are indicative of an ischemic stroke. 

The administration of an intervenous injection of recombinant tissue plasminogen activator (TPA) within the first 3-4.5 hours of ischemic stroke is considered the gold standard for the treatment of stroke (Shabanizadeh et al., 2021). TPA helps restore the blood flow to the affected regions of the brain and hence focuses on limiting and reducing the risk of functional impairment and damage.   

The most important assessment will be assessing the responsiveness of the patient. This can be performed by using the Glasgow Coma Scale. This assessment of Robert will help the nursing professionals to assess the level of depth and duration of his impaired consciousness. Using this tool all the three main areas of Robert’s behavior (motor response, verbal response, and eye-opening) can be assessed independently. As Robert was unable to communicate (aphasic), this assessment can provide information about the extent of the damage.  

Treatment of Ischemic Stroke

This assessment is a priority because it can help healthcare professionals to carry out necessary interventions and treatment approaches by assessing the severity of brain damage. It will, therefore, help in improving his condition and prevent further brain damage. Apart from that, this assessment should be a priority because it will help the nursing professionals timely and effectively manage Robert’s condition. Also, appropriate intervention is necessary because long-term unconsciousness can lead to insufficient oxygen delivery to the brain. 

Another important assessment can be assessing the level of pain that Robert might be experiencing. Severe pain is experienced in patients after an episode of stroke as it causes brain tissue damage. Robert might feel the pain as a throbbing, burning, or cold sensation. A pain scale assessment is therefore important for Robert. The numerical rating pain scale is considered the gold standard for evaluating pain but because Robert is presented with aphasia, he will not be able to rate his pain. Thus, the Abbey pain scale can be used for Robert because it is effective and reliable in the assessment of pain in those who are not able to communicate.

This assessment is a priority because it will enable the healthcare professionals to take necessary actions after diagnosis of the pain Robert must be experiencing. Regular assessment of Robert’s pain will help decide whether there is any further deterioration in Robert’s condition thereby guiding healthcare professionals to take necessary actions to improve his overall health condition. It also ensures that the pain treatment provided is effectively working or not (Lewis et al., 2016).

It is important for a nurse to provide patient-centered care for every patient (NMBA, 2022). A high-priority nursing intervention will be repositioning Robert to a sitting position (semi-fowler position). To achieve the semi-fowler position the head of the patient is raised to an angle of 30 to 45 degrees while keeping his legs straight. This increases the lung capacity by 10-15% along with enhancing diaphragm muscle motion (Zhu et al., 2020). Lung’s expansion and gas exchange capacity are also significantly increased at this position.  The maximum expansion will also ensure that his oxygen saturation levels increase by increasing the patency of his airways (Abd El-Moaty et al., 2017).

Another important intervention can be teaching Robert breathing exercises like diaphragmatic breathing and pursed-lip breathing. Deep breathing will ensure that Robert uses 100% of his lung capacity which helps in enhancing his lungs' efficiency. Using the diaphragm effectively will make his breathing easier. This intervention will also help relax Robert’s muscles and increase oxygen levels by improving ventilation. He should be explained that he needs to take in breathe with his nose by placing one hand on his chest and the other on his belly till he can no longer take any more air without straining in a supine position (Hamasaki, 2020). Then he should slowly exhale for the next four seconds. This whole process needs to be repeated several times. It will help him relax and thereby increase the clearance of his airways by improving his ventilation. For pursed-lip breathing, Robert needs to be taught to pucker his lips and exhale which will increase his lung capacity and ventilation (Nguyen & Duong, 2021). This technique will help to keep his airways for a long time and relieve dyspnea. 

Nursing Interventions for Ischemic Stroke Patients

The last intervention should be teaching Robert proper ways of coughing. It can be taught by explaining to hold a long breath for two seconds and then coughing two to three times consecutively. The most appropriate technique for removing almost all secretions is coughing. Hence, it is important to help the patient learn and perform this activity. This when followed by deep breathing help increase oxygenation. The reduction in functional residual capacity (FRC) of the lungs may cause diminished cough flow volume which is characteristic of a deflating lung and that can cause pressure on the expiratory muscles (Ward et al., 2017). Thus, teaching Robert to cough effectively after fixed time periods will help Robert to get rid of unwanted materials in his airways. 

Robert’s condition started deteriorating and he started having seizures. Thus, lorazepam was administered to him. Lorazepam is a benzodiazepine drug that produces a calming effect on the central nervous system. Benzodiazepine drugs are the preferred medication in seizure episodes because they require prompt action to improve the patient's condition (Kobata et al., 2020). It works by improving the inhibitory impacts of GABA which in return increases the conductance of chloride ions into the cell. This chloride-ion shift stabilizes the cellular plasma membrane (Ghiasi et al., 2021). This inhibitory activity in the cerebral cortex helps in dealing with seizure disorders. It is provided to a patient having anxiety or seizures. Hence, lorazepam is administered to help stabilize his condition. It can also be administered to create amnesia before providing anesthesia. Lorazepam may be administered orally, or by intravenous or intramuscular injections. As Robert is having a Cerebrovascular accident he is prescribed a lorazepam dosage of 8mg that has to be administered intravenously. The rate of administration should be maintained at a maximum of 2 mg/min. This can be repeated every 5-10 minutes. The usual dose is 0.1 mg/kg and the maximum can be 4 mg. The dose must be diluted with saline in a 1:1 ratio.  Its action starts within 1-3 minutes when administered intravenously (Ghiasi et al., 2021). 

Normal adverse effects of lorazepam include dizziness, dry mouth, nausea, diarrhea, tiredness, and weakness among others. Serious adverse effects can occur if the dose of administration is high. Severe adverse effects may include CNS and respiratory depression, tachycardia, respiratory failure, cognitive deficits, blood dyscrasias, insufficient blood flow to the brain, and withdrawal symptoms if discontinued suddenly after long-term use. It should not be administered to patients having suicidal thoughts, lower levels of albumin in the blood, asthma, severe liver or kidney diseases, COPD, or patients who are pregnant.

The three most important evaluations after the administration of Lorazepam to Robert may include: evaluating his white blood cells, checking his oxygen saturation levels in order to assess respiratory depression, and performing liver function tests. 

His white blood cell count must be evaluated after Lorazepam administration because it has a tendency of lowering the white blood cells in an individual. A lower white blood cell (WBC) count increases the susceptibility of an individual to infections. A severe decrease in WBC (leucopenia) can cause life-threatening conditions like sepsis. Hence, evaluating his WBC count is of utmost importance as it will help identify Robert’s risks of acquiring infections which in turn will ensure that prompt actions are taken to prevent any further complications (McCuistion et al., 2021).  

The other important evaluation is the evaluation of oxygen saturation level of Robert. It is necessary because the most important risk factor of lorazepam administration is respiratory depression (Kutt & Resor, 2020). Thus, its administration may cause difficulty in breathing which in turn can decrease the patency of his airway and reduce oxygen levels in Robert’s body. Hence, respiration must be closely monitored along with SpO₂ levels in the patient to help the nursing professional to take immediate and adequate interventions if and when there is a shortage of oxygen (Bourenne et al., 2017).

The last evaluation should be performing a liver function test to evaluate Robert’s liver condition. This needs to be performed because lorazepam may cause symptomatic liver disease due to its extended half-life. Thus, performing liver function tests will ensure that the functioning of his liver is routinely assessed thereby evaluating any liver damage as soon as possible if it arises. If any change in the liver function is observed that may be detrimental to Robert, the dosage of lorazepam may be adjusted accordingly to prevent any further damage (Arai et al., 2018).  

Family-centered care can be defined as the planning, delivery, and assessment of health care that focuses on mutual benefits for the healthcare workers, the patient, and their families. One major goal of this is to promote and maintain the well-being of the patient as well as their family. As a cerebrovascular accident happens suddenly, it provides little time for families to prepare for emotional, psychological, and physical caregiving. Thus, family-centered care can reduce the stress that caregiving for a critical patient may create (Kokorelias et al., 2019). Guidelines of clinical practice advocate the inclusion of families of stroke patients throughout the care planning by recommending shared decision-making for planning the treatment. Not involving the family members may create negative impacts on their mental health because of not being able to provide the required care to the patient. Agnes should be explained Robert’s treatment plan properly as that will enable her to better handle Robert once he is discharged. Care provided during rehabilitation is greatly dependent on support from family support. Agnes should also be recommended support groups for families of stroke patients where she can discuss and learn about caring for stroke patients. This will help relieve her stress and improve both their health conditions. 

References

Abd El-Moaty, A. M., EL-Mokadem, N. M., & Abd-Elhy, A. H. (2017). Effect of Semi Fowler’s Positions on Oxygenation and Hemodynamic Status among Critically Ill Patients with Traumatic Brain Injury.‏.‎ 

https://www.noveltyjournals.com/upload/paper/Effect%20of%20Semi%20Fowler%E2%80%99s%20Positions-1130.pdf

Arai, T., Kogi, K., Honda, Y., Suzuki, T., Kawai, K., Okamoto, M., ... & Murata, N. (2018). Lorazepam as a Cause of Drug-Induced Liver Injury. Case Reports in Gastroenterology, 12(2), 546-550.  https://www.karger.com/Article/Abstract/492209 

Bourenne, J., Hraiech, S., Roch, A., Gainnier, M., Papazian, L., & Forel, J. M. (2017). Sedation and neuromuscular blocking agents in acute respiratory distress syndrome. Annals of Translational Medicine, 5(14).  https://dx.doi.org/10.21037%2Fatm.2017.07.19 

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2021). Lorazepam. In StatPearls [Internet]. StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK532890/

Hamasaki, H. (2020). Effects of diaphragmatic breathing on health: A narrative review. Medicines, 7(10), 65.

https://doi.org/10.3390/medicines7100065

Karthik, R., Menaka, R., Johnson, A., & Anand, S. (2020). Neuroimaging and deep learning for brain stroke detection-A review of recent advancements and future prospects. Computer Methods and Programs in Biomedicine, 197, 105728.

https://doi.org/10.1016/j.cmpb.2020.105728

Kobata, H., Hifumi, T., Hoshiyama, E., Yamakawa, K., Nakamura, K., Soh, M., ... & Japan Resuscitation Council (JRC) Neuroresuscitation Task Force and the Guidelines Editorial Committee. (2020). Comparison of diazepam and lorazepam for the emergency treatment of adult status epilepticus: a systemic review and meta?analysis. Acute Medicine & Surgery, 7(1), e582

.https://doi.org/10.1002/ams2.582

Kokorelias, K. M., Gignac, M. A., Naglie, G., & Cameron, J. I. (2019). Towards a universal model of family centered care: a scoping review. BMC health services research, 19(1), 1-11.doi.org/10.1186/s12913-019-4394-5

Kutt, H., & Resor, S. R. (2020). Lorazepam. In The Medical Treatment of Epilepsy (pp. 353-356). CRC Press.https://www.taylorfrancis.com/chapters/edit/10.1201/9781003066736-43/lorazepam-henn-kutt-stanley-resor

McCuistion, L. E., Yeager, J. J., Winton, M. B., & DiMaggio, K. (2021). Pharmacology E-Book: A Patient-Centered Nursing Process Approach. Elsevier Health Sciences. https://books.google.co.in/books?hl=en&lr=&id=9HVWEAAAQBAJ&oi=fnd&pg=PP1&dq=lorazepam+nursing+consideration&ots=My-UhLP-4L&sig=LNJafv4zgC84IxgnRh6TBMz0q5k&redir_esc=y#v=onepage&q=lorazepam%20nursing%20consideration&f=false 

Nguyen, J. D., & Duong, H. (2021). Pursed-lip Breathing. In StatPearls [Internet]. StatPearls Publishing.

 https://www.ncbi.nlm.nih.gov/books/NBK545289/ 

NMBA. (2022). Nursing and Midwifery Board of Australia - Registered nurse standards for practice. Nursingmidwiferyboard.gov.au. Retrieved 29 April 2022, from

https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx.

Shabanizadeh, A., Rahmani, M. R., Yousefi-Ahmadipour, A., Asadi, F., & Arababadi, M. K. (2021). Mesenchymal Stem Cells: The Potential Therapeutic Cell Therapy to Reduce Brain Stroke Side Effects. Journal of Stroke and Cerebrovascular Diseases, 30(5), 105668.https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105668

Tadi, P., Lui, F., & Budd, L. A. (2021). Acute Stroke (Nursing).

https://www.ncbi.nlm.nih.gov/books/NBK568693/

 Wajngarten, M., & Silva, G. S. (2019). Hypertension and stroke: update on treatment. European Cardiology Review, 14(2), 111.10.15420/ecr.2019.11.1

Ward, K., Rao, P., Reilly, C. C., Rafferty, G. F., Polkey, M. I., Kalra, L., & Moxham, J. (2017). Poor cough flow in acute stroke patients is associated with reduced functional residual capacity and low cough inspired volume. BMJ open respiratory research, 4(1), e000230.

https://doi.org/10.1136/bmjresp-2017-000230

Zhu, Q., Huang, Z., Ma, Q., Wu, Z., Kang, Y., Zhang, M., ... & Huang, F. (2020). Supine versus semi-Fowler’s positions for tracheal extubation in abdominal surgery-a randomized clinical trial. BMC anesthesiology, 20(1), 1-9.  

https://doi.org/10.1186/s12871-020-01108-5