Various Issues Concerning Ischemic Stroke with Respect to Joseph - Case Study Example

Ischemic Stroke Introduction During the occurrence of ischemic stroke, there is an interruption of supply of blood to an individual’s brain, and cells of the brain are dispossessed of oxygen and glucose which they require to function. It is stated that acute ischemic stroke (AIS) is a compound body with various etiologies as well as erratic clinical manifestations. Nearly 45 percent of AIS are due to large or small artery thrombus, twenty percent are of embolic origin, and the rest have causes that are unknown. The assessment of patients who have AIS should be done immediately. The patient’s medical history, general and neurological evaluations create the foundation of emergent assessment of clients with alleged ischemic stroke. According to Lees, et al (2006) the clinical assessment provides clues regarding the neurological symptoms’ cause as well as screening for potential treatment contraindication with agents that are thrombolytic. This paper discusses various issues concerning ischemic stroke with respect to Joseph. Triage category for Joseph based on his initial presentation The term triage is used in clinical setting to mean a classification of sick or injured people with regards to medical attention need in an emergency situation (Bergman, et al, 2012). Triage system is highly used in emergency departments all over the globe so as to deal with overcrowding. One of the major rationales for triage system in the clinical setting is to enhance emergency care as well as to prioritize situations according to clinical urgency. Generally, emergency management is among the most vulnerable areas of medical care. This vulnerability is frequently grounded on a mixture of factors like crowding and urgency. Necessity of care generates from a mixture of psychological and physical distress, which arises in every emergency case where a sudden, unanticipated, distressing and occasionally life threatening situation results in a patient being at the department of emergency (ED). Triage classification is based on the level of patient’s severity in terms of illness or injury. The first category entails ailments such as unconsciousness, acute chest pains, profuse bleeding, and other conditions that are severe. Distinctive level I clients may present with severe dehydration, major burns, anaphylaxis, septic shock, and serious respiratory distress. Patients who are brought to the ED with such medical conditions are categorized in Level 1 priority and require prompt attention. The second level of priority include cases such as abscesses, severe headache accompanied with blood pressure that is high, puncture wound, frame burns, vaginal bleeding, traumatic amputation, and attempted suicide (Bergman, et al, 2012). The 3rd level of triage category entails medical situations that are less serious such as pain suggesting treatment need although does not show a condition that is life threatening, and unexplained cough. The last triage category is level IV which encompasses minor ailments like small bruises and cuts, conditions that are not life threatening. The first level of triage category is considered resuscitation level and requires immediate medical care. The second level is emergent and needs medical care within the first 15 minutes. Level III is regarded as urgent and medical care should be provided in less than thirty minutes. The fourth level is less urgent and medical care is provided in less than 60 minutes. With respect to this classification, Joseph should be categorized in level II of triage category. This is because he has a four-day history of headache and a sudden onset, an hour ago, with a high blood pressure of 175/104mmHg (Bergman, et al, 2012). Factors in Joseph’s history and presentation which might explain his stroke The factors depicted in Joseph’s case which might explain his stroke include history of headache, slurred speech and right sided weakness. Other factors include alertness, being oriented and obeying commands, except on his right side where there is weakness. He has a delayed capillary refill of 2 seconds because the normal capillary flow within his age should be less than 2 seconds. Presentation of high blood pressure is also an indication of stroke. Smoking is considered a risk factor for stroke (Rice, 2006), and this is evident in Joseph’s case who is a heavy smoker. The pathophysiological events leading to stroke Stroke, also known as apoplexy manifests with the abrupt onset of numbness, weakness, slurred speech, paralysis, aphasia, vision problems and other presentations of an abrupt blood flow interruption to a given region of an individual’s brain (Sacco, et al, 2006). The two principal mechanisms that cause damage of brain in stroke entail hemorrhage and ischemia. Ischemic stroke represents almost 80 percent of the entire stroke, and there is absent or decreased circulating blood which takes away neurons of essential substrates. Ischemia effects are reasonably rapid since the brain is not able to store glucose, major substrate of energy and is unable to perform anaerobic metabolism (Ferro, 2009). Of the entire strokes, intracerebral hemorrhage that is non-traumatic represents around 10 to 15 percent. Intracerebral hemorrhage stems from vessels that are deep penetrating and brings about brain tissue injury by interrupting linking pathways and generating localized pressure damage (Adams, et al, 2005). In whichever case, biochemical substances that are destructive discharged from various sources have a significant role in destruction of the tissue. The three major mechanisms that cause ischemic strokes include global ischemia, embolism, and thrombosis (Sacco, et al, 2006). Atherosclerosis is considered the most general pathological characteristic of vascular impediment leading to thrombotic stroke. Endothelium disruption that can happen in the setting of whichever pathological changes instigates a complex process that triggers a lot of vasoactive enzymes that are destructive. Adherence as well as aggregation of platelet to the wall of the vessels follows, shaping tiny nidi of fibrin and platelets. Additional to atherosclerosis, further pathological situations that bring about thrombotic vessel occlusion include formation of clot as a result of hypercoagulable state, arteritis, dysplasia, and vascular wall dissection. Embolic stroke may generate from an artery embolization within the vital circulation from various sources (Lees, et al, 2006). In addition to fibrin, clot, and atheromatous plaque pieces, substances acknowledged to embolize in the vital circulation entail air, fat, metastasis or tumor, foreign bodies, and bacterial clumps. Superficial divisions of cerebellar and cerebral arteries are considered the most common emboli targets. With respect to global or hypotensive stroke, profound decrease in pressure of systemic blood due to whichever reason is accountable for global stroke. A number of neurons are more prone to ischemia compared with others. High blood pressure is considered normal in stroke (Adams, et al, 2005). In summary, when the supply of blood to the brain is disrupted, the vessel that is occluded leads to edema and ischemia within the adjacent tissue. This might bring about symptoms worsening. In the course of a stroke, the tissues and brain cells within the region of the infarction instantly die. The cells revive in case there is a timely perfusion to the affected region. On the contrary, due to the death of the tissue and brain cells, the ischemic occurrence leads to more edema and damage. This progresses except when blood flow is restored. Research indicates that stroke is more frequent in males. The major pathophysiology in stroke is the underlying blood vessel or heart ailments (Ferro, 2009). The secondary presentations within the brain are due to risk factors or the underlying illnesses. The basic pathologies involve atherosclerosis, dyslipidemia, hyperlipidemia, hypertension, and heart disease. Risk factors that can be reduced include decreasing blood pressure that is elevated, and heart disease management (Sacco, et al, 2006). Key assessment findings that support the diagnosis of a stroke Assessment of patients with stroke starts with detection of the stroke incident during the prehospital stage of management and progresses throughout management. Within the ED, when stroke is suspected, a patient is managed as an event that is acute until evidence of diagnosis suggests otherwise. Assessment of neurology is grounded on both objective and subjective data, in addition to a careful health history which is vital for establishment of the exact onset moment of symptoms and signs of stroke (Adams, et al, 2005). Necessary information to include entails a rapid event timing history, relevant previous history of health, as well as risk factors. The primary goal of early diagnostic evaluation ought to ascertain that the impairments of the patient are as a result of ischemic stroke, not because of another neurological or systemic illness, particularly intracranial hemorrhage. Differentiation of hemorrhagic or ischemic stroke is especially significant, due to the discrete distinction in the care of these situations (Sacco, et al, 2006). However, proper history taking in addition to physical examination facilitates distinguish ischemic from hemorrhagic strokes. On the contrary some studies indicate that diagnostic mistakes exclusively on clinical manifestations still happen and the degree of accuracy is not sufficient to lead management decisions. Anatomic localization grounded on clinical characteristics can assist establish the vascular circulation of the lesion of ischemia (Ferro, 2009). A stroke within the circulation of the central cerebral artery may arise from cardioembolism, arterial dissection, thrombosis of local artery, or carotid occlusion. With thrombolytic therapy availability for AIS in chosen patients, the health provider ought to carry out a succinct, but correct, neurologic assessment on clients with alleged stroke syndromes (Adams, et al, 2005). Significant elements of the neurologic assessment entail evaluations of: motor function, cranial nerves, cerebellar function, sensory function, gait, mental status, deep reflexes of the tendon, and consciousness level. The spine and skull of the patient also need to be examined, in addition to seeking for meningismus signs. Laboratory tests carried out in ischemic stroke assessment and diagnosis include: the count of entire blood cell also known as (CBC) which acts as a basic study and might reveal stroke such as (thrombocytosis, leukemia, polycythemia, and thrombocytopenia) or provide indication of coexisting ailment (Adams, et al, 2005). Fundamental chemistry panel acts as a basic study and might show a mimic of stroke (like hyponatremia and hypoglycemia) or offer proof of concurrent ailment like renal insufficiency or diabetes (Adams, et al, 2005). Coagulation examinations may show a coagulopathy which is helpful when anticoagulants or thrombolytics are planned for management. Cardiac biomarkers can be very significant due to the relationship between coronary artery illness and cerebral vascular illness. Toxicology screening might help in identification of intoxicated patients who have behavior/symptoms that mimic stroke syndromes (Sacco, et al, 2006). Even though uncommon in patients with alleged hypoxemia, blood gas in the artery establishes hypoxemia’s severity and might be applied to identify acid-base interruptions. Most of the diagnostic analyses are available within nearly all EDs twenty four hours in a day. In the ambulance, blood glucose is able to be checked and is useful in disqualifying hypoglycemia being a source for the occurrence or hyperglycemia being the compounding factor. According to Stroke management (2011) a major diagnostic test is the computed tomography (CT) scan with no contrast is proposed in ruling out hemorrhagic stroke presence that would prevent the application of thrombolysis. Additional studies might comprise cerebral angiography, CT angiogram, and magnetic resonance imaging (MRI). CT angiogram is able to be applied to discover occlusion or stenoses of large vessels. MRI permits for enhanced visualization of potential infracted regions, while angiography is applied when thrombolysis of intraarterial (IA) is designated or when interventions of surgery are being reflected on (Muir, et al, 2006). An emergency nursing management plan for Joseph including relevant ED pathways and pharmacological management in ED Time is considered as the most essential factor in the optimal management if an individual who has manifestation of clinical presentations of an attack to the brain (Adams, et al, 2005). The initial intervention done for Joseph is airway monitoring therefore it is important that airway equipment be available. A lot of patients who have ischemic stroke may not need intubation; on the other hand, the potential for respiratory distress is raised with huge infarctions (Ferro, 2009). It is vital to observe for respiratory compromise signs and expect that the respiratory needs of the patient might need intubation. Intubation done on emergency might be required before the outcome of stroke is established. It is important to advice the patient’s family and assist them decide about intubation period once the result is evident. Titration of oxygen is important in order to uphold saturation of oxygen above 92 percent by the use of pulse oximetry (Adams, et al, 2005). Respiratory distress can take place once the brainstem is involved or when an increase in intracranial pressure (ICP) occurs. Assessment of respiratory status of the patient entails monitoring lung auscultation, respiratory rate, and constant saturation of oxygen (O2). Use of supplemental oxygen within 4-6L can be considered once the patient is not able to maintain saturation of oxygen above 92 percent (Sacco, et al, 2006). ABGs are considered once the client is not able to sustain saturation of O2 at 92%. An IV access should be established. A whole blood count as well as platelet count, levels of blood glucose and serum chemistries ought to be carried out. Monitoring the vital signs, oxygen saturation, neurological deficits, and cardiac rhythm should be done frequently (Rice, 2006). The cardiac rhythm of the patient needs to be assessed and managed once abnormalities are established. This is because cardiac arrhythmias may result in reduced cardiac output as well as reduced cerebral perfusion pressure (CPP). An ECG needs to be carried out within the ED in order to disqualify myocardial ischemia (MI). MI is among the leading causes of death in patients who have acute stroke (Townend, et al, 2005). The patient should be positioned with a midline position of the head. When the head is kept flat, cerebral perfusion may be improved whereas HOB elevation can reduce intracranial pressure. The patient’s BP should be closely monitored. BP elevation is common in acute stroke; however, prompt management is required when the BP is more than 220/110. Elevated temperatures should be managed since increased temperature deteriorates outcomes (Ferro, 2009). Collaborative management include radiographic evaluation whereby CT scan is done (Muir, et al, 2006), laboratory evaluation is done with regards to and not limited to electrolytes, blood glucose, a count of whole blood cell. AIS pharmacological management is important. This involves antithrombolytic therapy. Thrombolytic remedy for an embolus or thrombus with rt-PA tries to re-establish the flow of blood by breaking up the clot (Fontanella, 2009). After administration of rt-PA, the patient requires admission to an ICU for twenty four hours where he can be observed appropriately. In case antocoagulants or alteplase are not used, aspirin which is an antiplatelet can be used in the first 48hrs of symptoms of stroke (Ferro, 2009). Administration of analgesics is very important so as to relieve the severe pain, as illustrated in the case study. Conclusion The paper has presented a discussion with regards to ischemic stroke. It is important to note the basic differentiation of ischemic and hemorrhagic stroke. In ischemic stroke, there is a blockage of blood vessel within the brain whereas hemorrhagic stroke occurs due to a ruptured vessel of blood within the brain. This differentiation aids in effective care. The patient’s risk factors of stroke ought to be examined, and the family and patient learning needs ought also to be addressed. For instance, with respect to Joseph’s case hypertension must be handled with the intention of ultimately achieving the systolic blood pressure not exceeding 120mmHg and not more than 80mmHg diastolic blood pressure. Addressing issues such as smoking and heavy consumption of alcohol is also a key factor for secondary prevention. Reference Fontanella, A. (2009). 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Sinapse, Vol. 9, Issue 2, pp 5-6. Bergman, K., Kindler, D., & Pfau, L. (2012). Assessment of stroke: a review for ED nurses. Journal of Emergency Nursing: Jen : Official Publication of the Emergency Department Nurses Association, Vol. 38, Issue 1, pp 36-42. Read More