Delivering of Nursing Care: a Patient who is at the Risk of Developing Transient Ischaemic Stroke - Essay Example

? An Evaluation of the Planning and Delivering of Nursing Care - The Case of a Patient who is at the Risk of Developing Transient Ischaemic Stroke - Student’s Name Student ID Number Course Title & Code Instructor’s Name Date Total Number of Words: 3,000 Introduction Ischaemic stroke, a.k.a. cerebral vascular accident (CVA) is pertaining to “a sudden loss of brain function resulting from a disruption of blood supply to a pert of the brain” (Johnson, 2004, p. 235). Basically, this study will focus in analyzing the case of a 52-year old patients who is at risk of suffering from ischaemic stroke. Considering the case of the patient, this study will discuss the importance of health promotion / health prevention, the acute management of ischemic stroke, and other nursing consideration whilst living with or managing the long-term health condition of the patient. Health Promotion / Health Prevention Aspect Health promotion aims to educate the patients not only on how they can effectively prevent the onset of a disease but also ways on how they can improve their overall well-being (Leddy, 2006, p. 24). Considering the case of the 52-year old patient, this study will focus on discussing the health promotion or health prevention related to ischaemic stroke. Primary Prevention Ischaemic stroke happens in case the brain artery is blocked (Stroke Association, 2012). This causes the blood supply unable to circulate in the brain. According to Wills (2007, p. 16), the three levels of health prevention includes: the primary prevention, secondary prevention, and tertiary prevention. In line with this, primary prevention is all about implementing some strategies that could effectively reduce the risk of a disease. The risk factors of ischaemic stroke can be used to determine what specific health promotion should be advise to the patient. Ischaemic stroke can be triggered by several monogenic disorder (i.e. mutation in Notch 3 gene, etc.) (Hassan and Markus, 2000). Although genetic disorders that can lead to stroke can be hereditary by nature, most of the risk factors of stroke are highly modifiable. Since the modifiable risk factors associated with ischaemic stroke include: smoking, hypertension, diabetes, poor diet, atrial fibrillation, lack of exercise, and obesity among others (Ahmad and Lip, 2012; NHS, 2008; Sudlow, 2008; Goldstein et al., 2006), the nurses can provide a primary prevention by teaching the patient the importance of healthy eating (i.e. eat more fish, fruits and vegetables, leanmeat, whole grain, restriction on fat, sugar, and salt intake), include a 30-minutes of regular exercise each day or at least five (5) times each week, refrain from binge drinking and limit the intake of alcohol, and avoid or stop the use of tobacco (WHO, 2012; NHS, 2008). Through health teachings, the nurses can empower the patient through self-actualisation. After conducting a health teaching, the nurse can refer to patient to stop smoking clinics in case the patient is a smoker. In case the patient is at risk of stroke due to poor eating habits, the nurse can refer the patient to a professional nutritionist. Secondary Prevention The secondary prevention is all about shortening the incidence of stroke through early diagnosis and treatment (Wills, 2007, p. 16). Assuming that the patient has suffered from a mild stroke, the secondary prevention should include encouraging the patient to modify their lifestyle and receive early treatment. If the patient has a history of smoking, the nurse should educate and encourage the patient to stop smoking. Likewise, it is equally important for the nurse to encourage the patient to avoid alcohol consumption, watch his diet, and maintain his accepted body weight through regular exercise (Sudlow, 2008; Goldstein et al., 2006). On top of modifying the patient’s lifestyle, the nurse should encourage the patient to receive annual check-up and treatment for signs of risk factors related to the development of a vascular disease. Hyptertention is one of the common risk factors of ischemic stroke (Ahmad and Lip, 2012; Goldstein et al., 2006). For this reason, nurses should not only explain to the patient why it is necessary to monitor his blood pressure but also teach the patient on how he can effectively control hypertension (i.e. diet modification such as lessening the intake of salty foods and increasing the intake of potassium, avoid alcohol consumption, weight reduction, avoid smoking, stress control / management, etc.) (Gupta and Guptha, 2010). Considered as one of the common symptoms of thromboembolic events and heart failure, atrial fibrillation or dysrhythmia may arise because of a reduced myocardial contractility and/or altered electrical conduction that causes a sudden decrease in cardiac output (Natale and Jalife, 2008, p. 8; Doenges, Moorhouse and Murr, 2006, p. 679). According to Hohnloser et al. (2008), “the morbidity and mortality associated with atrial fibrillation are related to ischaemic stroke”. Therefore, part of the patient management programme should include the “prevention of thrombolism” (Hohnloser et al., 2008). For example, in case the patient is suffering from non-vulvular atrial fibrillation, the nurse should immediately consider the use of thromboprophylaxis such as an adjusted dose of warfarin or a thrombin inhibitor – ximelagatran (as prescribed by the physician) to effectively reduce the patient’s risk of bleeding and effectively prevent thromboembolic events which may occur because of non-vulvular atrial fibrillation (Lip and Edwards, 2006). Even though combining aspirin with warfarin (in any dosage) is better than the use of adjusted-dose warfarin, the study of DiMarco et al. (2005) strongly suggest that combining these two drugs could only increase the patient’s risk of bleeding. Around 50 mg to 100 mg of aspirin can be used to prevent ischaemic stroke (Albers et al., 2008; The Dutch TIA Trial Study Group, 1991). However, nurses should take note that apirin dosage of more than 50 mg to 100 mg per day can increase the patient’s risk of bleeding (The Dutch TIA Trial Study Group, 1991). Therefore, nurses should educate the patient to limit the intake of aspirin to 50 mg to 100 mg per day. With regards to administering antithrombotic treatment, the nurse should keep in mind that oral anticoagulants should only be given to patients with either persistent or paroxysmal atrial fibrillation unless this particular treatment is contra-indicated (Hohnloser et al., 2007; Joint British Society, 2005). Likewise, the use of anticoagulants is also indicated in the treatment of other cardiovascular risk factors such as thromboembolism (Furie et al., 2011). The National Institutes of Health has recently published that the use of clopidogrel – an anti-platelet drug combined with aspirin (as prescribed by the physician) is no longer considered the most effective in treatment for patients with lacunar stroke (Stimson, 2012). Likewise, the combination of aspirin with clopidogrel should never be recommended as a secondary prevention of stroke (Albers et al., 2008). After comparing the clinical effects of using clopidogrel and oral anticoagulants, Hohnloser et al. (2007) found out that the use of aspirin combined with clopidogrel can increase the risks of developing unexplainable bleedings as compared to the use of oral anticoagulants. After testing whether the process of combining aspirin with clopidogrel is more effective in preventing vascular events and risk of higher bleeding as compared to the use of clopidogrel alone, Diener et al. (2004) found out that there is no significant differences in reducing the risks of major vascular events after combining aspirin with clopidogrel and that the process of combining these two drugs can only trigger a life-threatening situation due to major bleeding. Considering the adverse effects of combining aspirin with clopidogrel, nurses should educate the patient to avoid combining the use of these drugs. Tertiary Prevention The third prevention is all about controlling the patient’s disability which may arise out of the complications of the said disease (Wills, 2007, p. 16). For example, stroke patients are at risk of developing complications like cerebral hypoxia (Johnson, 2004, p. 238). If this happen, part of the immediate nursing intervention should include assessing the patient’s vital signs and oxygenation status, administer supplemental oxygen to improve the patient’s respiratory gas exchange (when necessary or in case the patient is experiencing difficulty in breathing), and maintain the patient’s haemoglobin and hematocrit levels (Johnson, 2004, pp. 240 – 241). Basically, maintaining the patient’s cardiac output is possible by fluid administration and medications. Health Teachings to Family Members Nurses should deliver holistic care not only to the patient but also to the patient’s family members. For this reason, depending on the health condition of the patient, the nurse should be able to provide the family members with counseling and extend necessary support to enable them cope with the burden that the family is facing. Aside from informing the family members on what to expect after the patient has gone through a stroke, it could help if the nurse could educate them on stress management techniques (Johnson, 2004, p. 245). It is equally important for nurses to encourage the family members to extend their emotional support and show positive attitude when dealing wiht the patient (Johnson, 2004, p. 245). Using these nursing strategies, the nurse can help the family members cope with the patient’s health condition. The Acute Management According to O’Brien-Pallas and Baumann (2001), acute care management is defined as the “short-term hospital care provided to clients with conditions of short duration requiring stays of, on average, less than 30 days” [cited in Daniels, 2004, p. 407]. In general, the incidence of an acute ischaemic stroke can lead to serious damages to the patient’s CNS and other organs (Coplin, 2012). In the case of a patient who had experience an acute ischaemic stroke was admitted to the hospital, the nurses should immediately stabilize the patient’s vital signs followed by conducting a compete patient assessment and evaluation tests such as imaging and other related laboratory tests preferreably within the first 60 minutes upon the patient’s arrival to the hospital (Adams et al., 2007). Nurses should consider all therapeutic options that needs to be given to the patient. To lessen the risk of neurological injury, the nurse should consider providing both thrombolysis and anti-platelet therapy to the patient (Andrews, 2004). Likewise, it is equally important on the part of the nurses to keep in mind that patient’s assessment should always include checking and monitoring the patient’s airway, breathing, and circulation (ABC) patterns, pulmonary status, blood pressure, cardiac function, blood glucose control, body temperature, and the risk of life-threatening cerebral edema (Ahmad and Lip, 2012; Coplin, 2012; Goldstein et al., 2006; Andrews, 2004). Hyperthermia is a condition wherein the body temperature is higher than the normal range (Doenges, Moorhouse and Murr, 2006, p. 299). According to Jauch and Lutsep (2012), incidence of hyperthermia on stroke patient can increase their risk for morbidity. Therefore, the rationale behind the need to monitor the patient’s body temperature is to reduce the risk of hyperthermia. In case the patient’s body temperature is high, the nurse should immediately provide a tepid-sponge bath or use a cooling blanket and either rectal or oral acetaminophen to the patient (Jauch and Lutsep, 2012). One of the main reason why nurses should closely monitor the patient’s blood glucose is because of the risk that the patient can suffer from either hypoglycemia or hyperglycaemia. According to Bruno et al. (2008), nurses should be able to immediately treat hypo- and hyperglycaemia to avoid the development of symptoms that are similar to that of ischaemic stroke and prevent the risk of aggravating the presence of neuronal ischemia. The normoglycemia is betwene 90 to 140 mg/dL (Jauch and Lutsep, 2012). In general, hypoglycemia is a case wherein the patient’s blood sugar level falls below the normal level of 50 to 60 mg/dL (Johnson, 2004, p. 442). In case the patient is suffering from hypoglycaemia, the nurse should be able to immediately implement the administration of glucose (i.e. 15 g of fast-acting sugar, 4 to 6 ounces of fruit juice or regular soda, 2 to 3 tsp of honey or sugar, etc.) (Johnson, 2004, p. 444). On the other hand, hyperglycaemia is a health condition wherein the blood glucose is above the normal level. In case the patient is suffering from hyperglycaemia (>200 mg/dL), the nurse should inject insulin to the patient (Jauch and Lutsep, 2012). One of the known complications of ischaemic stroke is cerebral hypoxia (Johnson, 2004, p. 238). Among the common factors that can trigger hypoxia on patients with acute ischaemia stroke include: atelectasis, aspiration in the oropharyngeal or stomach, hypoventilation, and partial obstruction in the airways (Milhaud et al., 2004). For this reason, nurses should closely monitor the patient’s monitoring the patient’s airway, breathing, and circulation (ABC) patterns. In case the patient is showing signs of breathing difficulty, the nurses should immediately provide supplemental oxygen (SaO2 < 94%) (Jauch and Lutsep, 2012; Johnson, 2004, pp. 240 – 241). Another common risk factors of ischaemic stroke is hypertension. Therefore, nurses should closely monitor the patient’s blood pressure (Ahmad and Lip, 2012; Coplin, 2012; Goldstein et al., 2006; Andrews, 2004). In case the patient’s blood pressure is high, the nurses should consider initial therapy for hypertension management which includes: dihydropyridine calcium channel blockers (CCB), angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARB) (Gupta and Guptha, 2010). However, in case the patient is hypotensive (low blood pressure); the nurses should consider the use of inotropes (i.e. noradrenaline and dopamine) as part of the patient’s initial treatment (Bakry and Adnan, 2005). Lastly, it is important for nurses to closely monitor the patient’s cardiac function. Through cardiac monitoring, the nurses can immediately detect signs of strial fibrillation or ischaemic changes (Jauch and Lutsep, 2012). If this happens, the nurses can consider administering between 50 mg to 100 mg of aspirin (as prescribed by the physician) to prevent the risk of another ischaemic stroke (Albers et al., 2008; The Dutch TIA Trial Study Group, 1991). Several studies revealed that there are some medications that can result to bleeding (i.e. combining the use of aspirin with warfarin, administering apirin dosage of more than 50 mg to 100 mg per day, etc.) (Albers et al., 2008; Hohnloser et al., 2007; Lip and Edwards, 2006; DiMarco et al., 2005; Diener et al., 2004; The Dutch TIA Trial Study Group, 1991). For this reason, it is the duty of the nurses to observe the patient for signs of bleeding (Coplin, 2012). In case the nurses have seen signs of bleeding, the nurses should immediately report the case directly to the patient’s physician. According to Furie et al. (2011), the inability of the patient to implement a primary and secondary stroke prevention including his or her inability recognize a near-term stroke could increase the patient’s risk for another transient ischaemic attack within the next 48 hours to 30 days. Therefore, before discharging the patient from the hospital, the nurses should be able to deliver effective health teachings that can lessen the patient’s risk of having another stroke (Coplin, 2012). In case the patient’s health condition worses, future treatment should include re-canalising the vessels. By doing so, the health care professionals can effectively prevent the risk of further neurological damage (Andrews, 2004). Whilst Living With and Managing a Long-Term Health Condition According to Andrews (2004), almost 1/3 of the patients who had an acute ischaemic stroke requires assistance with their activities of daily living. In line with this, Johnson (2004, pp. 236 – 237) mentioned that patients who had undergone a transient inschaemic stroke are most likely to encounter problems related to motor loss or inability to move their physical body, communication loss or the inability to express their own thoughts and opinions verbally, perceptual disturbances and sensory loss, impaired cognitive and psychological effects, bladder dysfunction or the inability to control the flow of urine. In case the patient is suffering from motor loss, the proposed nursing intervention should focus on designing a rehabilitation programme that will help the patient improve his mobility. In line with this, the nurses can design a suitable exercise programme that focuses on improving the patient’s range-of-motion. By encouraging the patient to engage himself in a full range-of-motion exercises for at least 4 to 5 times a day, it is possible for the nurses to maintain and increase the patient’s joint mobility and regain his motor control (Johnson, 2004, p. 241). In other words, implementing this particular nursing intervention is effective in terms of preventing the patient from experiencing further deterioration of his neuromuscular system. Joint or muscle contracture is referring to the permanent shortening of the joints and muscles respectively (Clavet et al., 2008). In case the patient with motor loss is resting, the nurses should encourage the patient to change his lying position every after 2 hours and encourage the patient to lie in a prone position for at least 15 to 30 minutes from time to time in order to prevent the risk of muscle contractures (Johnson, 2004, p. 241). Another way to help the patient regain his ability to perform activities of daily living is to encourage the patient to do his own personal care and hygiene (Johnson, 2004, p. 242). To prevent the patient from being discouraged, the nurse should encourage the patient to do his own self-care using his unaffected body parts. Eventually, the nurse should instruct the patient to try to use his affected body parts. By assisting the patient do his own activities of daily living, the patient can slowly regain his motor abilities and self-confidence. In case the patient is experiencing communicatin loss, the nurses should first create an environment that is conducive for verbal communication. Since the patient at this point is having difficulty trying to communicate verbally, the nurse should not only show patience and understanding but also extend moral support to the patient (Johnson, 2004, p. 244). At this point, the nurses should also encourage the family members to provide emotional support to the patient. By teaching the family members about the patient’s health condition, the family members can have better understanding on how they should treat the patient. Conclusion Most of the risk factors of ischaemic stroke is highly modifiable. Therefore, the nurses should provide effective health teachings to empower the patient in terms of preventing the onset of the disease. It is the duty of nurses to provide holistic care to the patient and his/her family members. Therefore, health teachings should not only be given to the patient but also to his family members. References Adams, H., del Zoppo, G., Alberts, M., Bhatt, D., Brass, L., Furlan, A., et al. (2007). 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