Ischemic Stroke - Case Study Example

Cardiovascular Disease case study Introduction This case study conducted in order to further the understanding of the clear, distinctive characteristics of Ischemic Stroke, along with its associated signs and symptoms. The focus of this case study is on a certain elderly patient with Ischemic Stroke. Ischemic Stroke is one of the cardiovascular diseases that occur following the blockage of the artery to the brain (Bamford, 2001). As often is the case, blood transports nutrients and oxygen to the brain and carries away the cellular wastes and carbon dioxide. In cases where an artery becomes blocked, the neurons (brain cells) become unable to make enough energy causing it to stop working (Bartolucci & Howard, 2006). The blockage of the remaining artery for a period exceeding few minutes causes the brain cells to die. There are various kinds of diseases that can cause Ischemic stroke. The main cause is the narrowing of arteries in the head or neck (Bartolucci & Howard, 2006). This is often due to either gradual cholesterol deposition or atherosclerosis. With arteries becoming exceedingly narrow, blood cells collect and form blood cells. Following this, blood clots might end up blocking the arteries where they are formed, or otherwise become dislodged and be trapped within the arteries that are closer to the brain. Blood clot in the heart occurring because of the irregular heartbeat and heart attack, as well cause stroke (Bartolucci & Howard, 2006). Patient Profile and Social History Patient P is an active health appearing woman, 60 years of age, married with two children: the married son and a married daughter. Patient P has no history of smoking and professionally, she is a teacher. While attending on her daily chores, she became unconscious and collapsed at home. Her 27-year old married daughter, while paying her a visit at the time, failed to witness her collapse, but found her on the floor, confused, awake, and short of breath. Having been informed that the transportation and triage of a person with suspected stroke was similar to the person that has a serious trauma, and thus treatment was recommended within a period of three hours after the start of the stroke, the daughter did an estimation and called EMS within a period of five minutes after her collapse, which responded within the ten minutes. The EMS did an evaluation of the Patient P, drew blood for the glucose level, and concluded that the patient might have had a stroke. Because of limited time that was available for the diagnosis and assessment, prior to the optimal treatment, EMS dispatcher had to notify the EMS personnel on the sport in order to coordinate the transportation of a patient to an emergency facility (stroke care facility). This was done in coordination with her daughter who discovered the closest designated comprehensive stroke center that she would arrive with the patient within twenty minutes. Patient Medical History After arriving in the emergency department, the Patient P is triaged immediately. Given the state of confusion of Patient P, the daughter was asked to give reliable information she knew of the history of the patient given that she was close to her mother, and she was in the right position to explain the patient’s medical history. The daughter reported that her mother had several episodes of sudden-onset numbness alongside tingling in her right limb, with slurred speech and slight confusion, in the previous 3 days. According to her, these episodes had lasted only five minutes, and Patient P did not call her primary care physician. Additionally, the information provided by the patient’s daughter showed that Patient P had been treated for hypertension for a period of fifteen years, and she was also quick to note that that Patient P was not prone to complaining with antihypertensive medicine, a diuretic she had been using. According to her, Patient P had never smoked, though occasionally drinks and is of normal weight. On physical examination, the blood pressure of patient P was found to be 150/95mmHg. She was characterized by pains in her left arm alongside a slight headache. Additionally, she had slight carotid bruits on her right. When she was accessed using the NIHSS, result showed that she had left spartial or visual neglect and the left hemiparesis. The laboratory test results, with the inclusion of a complete blood count, serum electrolyte levels and prothrombin time, renal function studies and the cardiac biomarkers, were all within the normal limits. The brain CT indicated that a thrombus in the branch of right internal carotid artery, having approximately fifty per cent occlusion because of atherosclerosis. She had an area of the infarction in a right anterior hemisphere with lacking evidence for the subarachnoid hemorrhage. Treatment and progress Basing on the fact that Patient P had two prominent, significant risk factors for stroke. The first being long history of hypertension. Research indicates that about two-thirds of persons who are older than 65 years are hypertensive (Iso, Jacobs, Wentworth, Neaton &Cohen, 2000). It was, therefore, prudent for patient P who is also affected by hypertension to be taken through the process of regular blood pressure screening, in making sure she maintains a blood pressure values that are less than 140/90 mm Hg during her stay in the hospital. For years, Antihypertension therapy has been applied in reducing incidences of stroke, and it has been said to reduce stoke by about 35% to 44% (Dormandy, Charbonnel & Eckland, 2005). This, thus, implies that the failure of Patient P to comply with antihypertension medicine she had been given likely includes her among those 65% of the known hypertensive persons in whom blood pressure fails to be controlled. Her characteristic previous episodes of confusion, slurred speech, and numbness seem to be evidence for A TLA, which is another known risk factor for stroke. As research would have it, approximately five percent of patients become affected with ischemic stroke in a period of seven days after a TIA. Moreover, for patients with TIAs, who fail to seek treatment within seven days, the risk of stroke has been known to double (Hebert, Gaziano JM & Hennekens, 1995). Likewise, as is the case for persons who have TIA, patient P, failed to seek medical attention given that her clinical symptoms appeared to resolve fast. This is contrary to what was expected of her since research show that urgent treatment need be provided for TIAs, now that early treatment for TIA alongside minor stroke has been found to reduce on risks of early recurrent stroke by 75% (Hebert, Gaziano, & Hennekens, 1995). Patient P was, therefore, eligible for the thrombolytic therapy with the rt-PA as administered. This was quite in line with the evidence based guidelines that were developed by AHA or ASA. It is worth noting that Patient P’s blood pressure was below 185/110 mm Hg, the beginning of symptoms was less than three hours before the onset of treatment, with the laboratory values being within the normal limits. Considering that it is recommended for patients that have TIA or stroke that results from the intracranial atherosclerosis with 60 % to 99% to be treated with the antiplatelet therapy of aspirin 50 mg to about 325 mg daily (Med Mathers, & Boerma, 2009), this treatment was done accordingly. Research indicates that athiplatelet therapy is not appropriate as an adjunctive therapy in a period of 24 hours of the thrombolytic therapy (Guercini, Acciarresi, Agnelli,& Paciaroni, 2008). After the condition of Patient P stabilized, the primary care physician assigned to her, as well as her neurologist had to provide her with a referral for the rehabilitation of the stroke. The multidisciplinary rehabilitation team was also formed with a purpose of assessing her rehabilitative requirements, come up with a treatment strategy geared towards her daily specific requirements including the daily antiplatelet therapy, and, as well as be recommending her proper rehabilitation setting. Patient P was also assessed with NIHSS which indicated that her score was improving towards 12. With the use of FIM for evaluation, it was clear that her communication, as well as her cognitive skills, were intact, except the previously spatial or left visual neglect. During evaluation of the patient P, evaluation for the risks for the complications was done. She was screened with Berg Balance and instructed to stop walking in the course of taking the test. This was done following her spatial neglect. The Berg Balance score was 44, though the patient did not stop walking in order to take part in the conversation. The psychosocial assessment she was taken through included screening using the Center for the Epidemiologic Studies Depression scale, alongside reviewing her medical history, as well as reviewing her conversation with her children and there were no depression signs present. It was found that her 12 score on the NIHSS fell within the range between 6 to 15 indicating that she could benefit from the rehabilitation process. Carrying out an evaluation of the survivor’s risk of the stroke of complications is an essential component of the entire assessment and is noted as one of the most common complications including the pressure ulcers, bladder and bowel dysfunction, deep vein thrombosis, swallowing dysfunction, and the depressive symptoms (Fairhead, Mehta, & Rothwell, 2005). This, thus imply that in order to assess the risk of complications, using the Berg Balance Scale seems to be the most suitable screen for the patients prone to falling. A scoreless than 45 is the most associated score for increased likelihood of falling (Fairhead, Mehta, & Rothwell, 2005). Whenever the patient stops walking to talk, as was the case of patient P during when she was undergoing the Stops Talking When Walking test, her risk of fall, also increases. Generally, the treatment process for patient P entailed the use of antithrombolytic therapy, mechanical thrombolysis, oral antiplatelet therapy, intra-arterial thrombolysis, management and prevention of the stroke medical complications, monitoring complications such as angioedema, intracranial hemorrhage and bleeding, fluid management, management of hypertension including enalapril, labetelol, hydralazine, nicardipine and hydralazine. The general management care geared towards treatment of patient P case, included bladder and bowel care, skin care, monitoring urinary tract and pneumonia infection, as well as recognition of the involuntary depression and emotional expressional disorders. Patient P was admitted at the emergency department in the evening of 5th May 2010 at 7.00 PM and triaged immediately. Physical examination was done with the blood pressure noted to be 150/95mmHg. On arrival, patient P was complaining of pains in her left arm and a slight headache, as well as a slight carotid bruits on her right. Using the NIHSS, Patient P was found to have experienced visual neglect. When the laboratory tests were conducted results for the complete blood count, serum electrolyte levels and prothrombin time, renal function studies and the cardiac biomarkers, were all within the normal limits. The brain CT showed a thrombus in the branch of right internal carotid artery, having approximately fifty per cent occlusion as a result of atherosclerosis. It was also found that she had an area of the infarction in a right anterior hemisphere with lacking evidence for the subarachnoid hemorrhage. Basing on this and other symptoms, patient P was diagnosed with Ischemic Stroke and taken through the treatment process as described below and she was later discharged on 5th Sep 2012. While, in hospital, patient P’s diet consisted of food items with less fat and cholesterol. The diet was composed of the trans-fats and the saturated fats that served the purpose of reducing the plaque in the arteries of the patient. Moreover, diet rich in vegetables and fruits was adopted with an intention of managing the levels of stroke. In respect to this, Patient P maintained a diet containing six daily servings of vegetables and fruit while at the hospital. With the obstructive sleep apnea detected after doing the overnight assessment on patient P, the doctor, recommended that the patient be given oxygen every night, which was maintained until the patient’s condition improved. The diet provided was controlled such that the patient’s healthy weight was maintained. The patient was taken through an exercise practice as a dietary medication for purposes of controlling weight. Noting that compromising nutrition interferes with the recovery of the patient from Ischemic stroke, the assessment of the nutrition status of the patient was conducted following the admission of patient P to the hospital. Initially, the doctor had suspected patient P had swallowing problems. This, thus, probed him to perform a structured bedside swallowing assessment level 2. Nutrition was then initiated after 60 hours after this swallowing assessment. Following the condition of Patient P, the enteral nutrition was pursued. This was done considering that enteral nutrition has many advantages (Sims &Muyderman, 2009). This includes lowering risks of infection, low cost, utilizing the normal physiological digestion and absorption functions, simpler application, as well as maintenance of intestinal mucosa. The intestinal functional functions, as well as motility, were assessed and monitored on a regular basis surported by the metoclopramide as a stimulant. With dysphagia expected to continue for seven weeks after her admission, the postyploric feeding through the percutaneous endoscopic gastrostomy was considered. Intervention measured vital for a patient entailed screening for depression signs since depression signs have been known to affect about 25 % of the stroke survivors (Bartolucci & Howard, 2006). More often than not, signs for depression remain subtle and might be vague. There are many tools to be used for screening although there is lacking the universally agreed upon tool to be used in cases of post-stroke setting. For the case of Mrs. P, the CES-D was used given that it was found to be easy to administer, and it is reported as the most effective tool for screening in stroke population, it is commonly used for older persons, with the exception of persons with aphasia. Diagnosis of depression among the survivors of stroke need be based upon sources other than to the formal screening tool, like the self-report of the patient, observing the behavior of the patient, medical evaluation, staff reports concerning changes in the patient behavior and the patient history (Bartolucci & Howard, 2006). The rehabilitation team had to discuss the assessment results with the son and daughter of Patient P, both of whom reside about 50 minutes far from the patient. The family and team members explored all the possible options in order to find the best approach for rehabilitation. A decision was made concerning patient P to be discharged into an inpatient stroke unit, alongside establishing a rehabilitation program. One of the nurses belonging to the team discussed the program with patient P along with her children explaining the expectations and the course of the rehabilitation. In respect to this issue, the rehabilitation process focused on the exercise program that consisted of balance and coordination activities, stretching, strength training and the aerobic exercise. The early initiations of the rehabilitation were the predictors of the improved outcome. This is because rehabilitation for the case of stroke unit has been widely cited to be closely associated with better quality of life, functional status at 6 years relative to any general healthcare facilities Hankey, Sudlow, & Dunbabin, 2000). So far there are no studies that have shown the superiority of a rehabilitation setting, and choosing the impatient setting was primarily for ensuring that there is consistency of the care, despite the distance children of patient p lived, and the limited support she had for the healthcare requirements. The decision concerning the program and the setting for the rehabilitation need be shared with other family members. The caregivers need to be given the education resources on the process of rehabilitation. The exercise programs that were developed specifically for Patient P were meant to assist her to regain the ability to carry out the normal living activities independently and safely in order to regain the functional levels of ambulation. Benefits of the exercise program cut across increasing strength, flexibility, fitness, strength, improving function, reducing risks of stroke recurrence, as well as preventing injuries and falls. Patient P eventually regained her ability to operate independently, and after a period of more than three weeks while, in the stroke rehabilitation unit, title NIHSS score had improved to about five. Before being discharged back home, she was provided with exercise instructions by the rehabilitation team in order to help her continue while at home recommending moderate physical activities as secondary prevention measures. The team, as well was dedicated at educating patient P concerning how crucial it was for her to maintain normal blood pressure by using the antihypertension medication along with the lifestyle modifications. When the primary care physicians followed up patient P, at three months, he found out that her blood pressure was 135/80mm Hg. The patient reported that she had become compliant with the antiplatelet and antihypertension medicine she had been given. Summary and conclusion There is the need to educate persons within the community concerning clinical signs of brain attack and other related diseases. They should also be notified of contacting the Emergency Medical System or any other applicable telephone numbers. Two out of the possible applicable five components of the measures of education performance certification of stroke-centre, which involve recognizing the common signs of stroke and alerting EMS personnel, need be educated in order to rapidly recognize signs of stroke. This is essential for determination of the onset of the signs. In order to overcome ischemic stroke the diet for the patient should be composed of the trans fats and the saturated fats that can help in reducing the plaque in the arteries and a diet rich in vegetables and fruits should be impressed to help manage the levels of stroke (Hankey, Sudlow, & Dunbabin, 2000). After discharge, Patient P has to make sure a diet a diet containing six to eight daily servings of vegetables and fruit is maintained. Moreover, the diet provided need to be controlled such that the patient’s healthy weight is maintained. The patient should be taken through an exercise practice as a dietary medication for purposes of controlling weight (Hankey, Sudlow & Dunbabin, 2000). These exercise programs should be developed specifically to assist her to regain the ability to carry out the normal living activities independently and safely in order to regain the functional levels of ambulation. This is because benefits of the exercise program can help a great deal in boosting the strength, flexibility, fitness, strength improving function, reducing risks of stroke recurrence, as well as preventing injuries and falls. References Bamford et al. (2001). Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337 (8756): 1521–6. Bartolucci A, & Howard G. (2006). Meta-analysis of data from the six primary prevention trials of cardiovascular events using aspirin. Am. J. Cardiol. 98 (6): 746–50. Dormandy JA, Charbonnel B, & Eckland et al. (2005). Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet 366 (9493): 1279–89. Guercini F, Acciarresi M, Agnelli G,& Paciaroni, M. (2008). Cryptogenic stroke: time to determine aetiology. Journal of Thrombosis and Haemostasis 6 (4): 549–54. Hebert PR, Gaziano JM, & Hennekens, C. (1995). An overview of trials of cholesterol lowering and risk of stroke. Arch. Intern. Med. 155 (1): 50–5. Hankey GJ, Sudlow CL, & Dunbabin, DW. (2000). Hankey, Graeme. ed. Thienopyridine derivatives (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other serious vascular events in high vascular risk patients. Cochrane Database Syst Rev (2): CD001246. Fairhead JF, Mehta Z, & Rothwell PM. (2005). Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology 65 (3): 371–5. Med Mathers, C, & Boerma, T. (2009). Global and regional causes of death. British medical bulletin 92: 7–32.. 320 (14): 904–10. Iso, H, Jacobs D, Wentworth K, Neaton, J, &Cohen JD. (2000). Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the multiple risk factor intervention trial. N. Engl. J. Sims NR, & Muyderman H. (2009). Mitochondria, oxidative metabolism and cell death in stroke. Biochimica et Biophysica Acta 1802 (1): 80–91. Read More