Scenario of a Patient with Left Vascular Accident - Case Study Example

?Case Scenario of a Patient with Left Vascular Accident (CVA /Stroke) I. Formative Assessment Opportunity for Learning This paper is about the case scenario of a patient with Left Vascular Accident (CVA/Stroke). I have particularly chosen to write this case because cerebrovascular accident or stroke is one of the most common causes of emergency hospitalisation and unexpected death now a days. The holistic point of view of nursing care among patients with cerebrovascular accident can be applied in this case for this will open the door for us to grow more personally and professionally as a whole. Moreover, it had also given us insights on how to deal with our clients in a holistic manner as well as an overview on certain issues at work that must be tacked on. Inter and intradisciplinary communication which may strengthen the teamwork among the healthcare team managing the patient must also be discussed in the paper. The theoretical perspectives of communication will be explained wonderfully and proper communication skills that include the explanation on engagement, skills in listening, empathy, and warmth will be expounded as well. The most import part of this paper is practicing value formation through holistic nursing care of the patient with cerebrovascular accident. This includes the application of management about caring, dignity, and respect in care among the patients. The aforementioned values are always taken for granted in the nursing practice, especially with the current trend and advances of technology and nursing shortages, the holistic approach to the emotional needs of the patients that preserves their dignity is already forgotten. Caring the patient with utmost dignity and respect has to be incorporated in the nursing care planning of patient with CVA. The nursing process will be applied in this case as well. I have learned that taking care of the patient does not end up in the provision of treatment, but also, extends even up to collecting feedbacks from the treatment rendered and what a nurse have learned while practicing clinically. Learning opportunity assessment provides the nurses and midwives guidance in the professional conduct and support “on matters relating to the creation and maintenance of a quality clinical learning environment and the assessment of nursing/midwifery students in clinical practice” (An Bord Altanais, 2003). This enables the nursing and midwifery students become competent and practice evidence-based nursing/midwifery care enabling the nurse to be safe, caring, competent in making decisions, and most importantly, accept accountability in once self and in their profession (An Bord Altanais, 2003). Additionally, it is important to know that it is the duty of registered nurses/midwives to provide clinical support to help the nursing students question, analyse, reflect on their practice that would help them become safe, caring, and competent nurse/midwives as they master the autonomy in decision – making. I have learned that it is necessary for nursing students and nurses to adapt to the environment in the clinic and learn to have inkling in the clinical practice (Arkell, 2007). I have also learned that the greatest priority of the nurse is to deliver patient care even during busy times (Arkell, 2007). The Association of State and Territorial Directors of Nursing (undated) noted that it is imperative for the nurses to continuously move forward and develop evidence – based strategies and approaches that are successful in the practice of settings despite of enormous daily challenges that faces the public health nurses. This is done to achieve the populations’ optimal health and well – being. References: 1. American Association of Colleges of Nursing, 2007. White Paper on the Role of the Clinical Nurse Leader. [Online] Available at: < http://www.aacn.nche.edu/publications/white-papers/cnl> [Accessed 20 February 2021] 2. An Bord Altranais , 2003. Guidelines on the Key Points that may be Considered when Developing a Quality Clinical Learning Environment. [Online] Available at: [Accessed 20 February 2012]. 3. Arkell, S., 2007. How Nursing Students Can Make the Most of Placements. Nursing Practice Clinical Research, 103(20): 26. 4. Association of State and Territorial Directors of Nursing, undated. The Public Health Nurse’s Role in Achieving Health Equity: Eliminating Inequities in Health. [Online] Available at: < http://www.astdn.org/downloadablefiles/ASTDN-health-equity-11-08.pdf> [Accessed 20 February 2012]. 5. Sheffield Hallam University, 2008. Student Learning Outcome for Practice Placement. [Online] Available at: < http://www3.shu.ac.uk/hwb/placements/nursing/studentlearningoutcomesforpracticeplacement.html> [Accessed 20 February 2012] II. Reflective Essay After attending the seminar, I was able to go deeper on the importance of the nursing practice, the nursing care plan, and the whole coursework that has to be applied in the hospital and community setting. Nursing practice is a continuous process of learning, and the inputs learned during series of seminars doesn’t have to stop inside the four corners of the room but must be given importance by all the nurses who are practicing their profession. It is important that the lessons learned in the modules are reviewed at home and be instilled not only in mind but most importantly, at heart. Nursing care is a holistic approach and nursing care planning entails not only provision of treatment, but also, dealing with the emotional and spiritual aspect that must be incorporated in the care planning. Patients are individuals with spirit and emotions. When they get sick, they are not only sick physically, but their spirit and emotions need also healing. Hence, what has been presented in the coursework that makes nursing practice holistic in approach must be thoroughly applied in the hospital and community settings. The principle of caring the patient with utmost respect and dignity must not be taken for granted in the day to day nursing practice even with advancement of medical technologies, or even with nursing shortages. I have learned that nursing care planning does not only end up in providing treatment physically, emotionally, and spiritually; it is also important to note feedback of the treatments rendered. Things that needs to be improved after learning the necessary feedbacks from the patient’s care does not stop in the paper, but necessary changes has to be done to improve the nursing practice. III. Summative Module Assessment Case Presentation: Mr. William Fountain is a retired teacher aged 70 years and lives with his wife, Deborah in London. They have been married for forty years and enjoy holidays abroad and bowling as members of a local club. Their son, an accountant is married with three teenagers under sixteen. The children spend most school holidays with their grandparents and it is always pleasurable time for all. Five years ago, Mr. Fountain was diagnosed with hypertension and obesity with a BMI of 27. He recently had a consult with the GP with complaints of tiredness, headaches, and dizziness. The GP is concerned that his blood pressure is high despite changes in his medications and advised him to continue his treatment and rest. One morning a month ago, William felt weak and found it hard to get out of bed. Deborah noticed that patient had a right-sided facial paralysis since he could not raise his right arm and leg. His speech was slow, slurred and difficult to understand. He was admitted to the local hospital and diagnosed with Left Cerebral Vascular accident (CVA/Stroke). William is three weeks in the ward and has made some progress with inter-professional (doctors, nurses, physiotherapies, etc.) team work and collaboration for his care. You are on placement in the ward and you are allocated to care William and three other patients. Paralysis on the side of his body affects his balance and coordination resulting in mobility problems and dependent on daily activities of living (ALs). He has bowel and urinary incontinence. He also has difficulty in mastication and dysphagia affecting his fluid and food intake. William is sometimes confused with memory loss and seems to forget or ignore his disability as at times he tries to stand with no assistance. He has labile emotions with outburst of anger, depression, crying spells, and laughter. He seems frustrated with the dysphasia and not being understood. Deborah and the family are very supportive to William. A. Introduction Cerebrovascular accident, otherwise known as stroke, is a condition that resulted from the disruption and impaired blood supply to the brain resulting to death of brain cells and compromised blood flow by means of several mechanisms (Wedro, 2012). Wedro (2012) noted that the most common cause of stroke is blockage of an artery in the brain by a blood clot that results to deprivation of some parts of the brain with blood and oxygen. As a consequence, the cells in the affected parts of the brain die and affect the part of the body it enervates. Wedro explained that within the brain, a cholesterol plaque that has caused gradual narrowing of the blood vessel, ruptures and starts the process of forming small blood clotting. The following are considered as risk factors of cerebrovascular accident: hypertension, high cholesterol level, diabetes, and smoking. Wedro (2012) noted the five major signs of sudden onset of stroke according to the U.S. National Institute of Neurological Disorders and Stroke. These are: 1. Bilateral or one - sided numbness or weakness in the facial and extremities associated with complete or partial loss of voluntary movement or sensation and tingling sensation in the affected area. 2. Drooling, as a result of facial muscular weakness. Patients also exhibit confusion, trouble speaking or understanding. 3. Difficulty in vision 4. Dizziness, loss of balance and trouble walking 5. Severe headache with unknown cause Mr. William Fountain was diagnosed to have Left Cerebo - vascular accident and as evidenced by the hypertension and obesity as stressors. This is supported by the patient’s complaints of tiredness, headaches, and dizziness as well as continuous increase of blood pressure despite of taking his medications, right – sided facial paralysis, slow and slurred speech. B. Main Body Important Points to Address in this Scenario: The patient is admitted at the ward for three weeks and has a good interpersonal relationship with his doctors, nurses, physiotherapies and other medical healthcare professionals. However, during the stay of the patient in the ward, he is experiencing memory loss and he seems to be in denial with his current condition. The patient was noted to have labile emotions with outburst of anger, depression, crying spells, and laughter. It is also noted that the patient seems to be frustrated with his physical condition; however, his wife and his family are very supportive on his physical ordeal. Aim of this Study: The aim of this study is to show the student’s personal understanding on Cerebrovascular Accident (CVA) and apply its own understanding of nursing care plan in the clinical setting. Nursing Care Plan 1. Nursing Assessment: 1.1 Subjective Cue: Mr. William Fountain states, “I felt weak and found it hard to get out of bed.” 1.2 Objective Cues: Increased heart rate (90/min) Increased blood pressure (160/110 mmHg) Increased Respiratory Rate (25 bpm) Inability to raise right arm and leg Speech was slow, slurred, and difficult to understand Bowel and urinary incontinence Confusion and Memory Loss Outburst of anger, depression, crying spells, laughter, frustration, dysphasia 2. Nursing Diagnosis: Weakness and inability to get out of bed secondary to decreased cerebrovascular blood flow as evidenced by unstable vital signs. Poor bowel and bladder control as evidenced by inability control defecation and urination Unstable emotions and inability of the patient to control his emotions as evidenced by anger outburst, depression, crying spells, and laughter 3. Nursing Care Plan: Short term goal: Within 8 hours of nursing intervention, the patient’s heart rate, blood pressure, and respiratory rate will go back to its normal range, as evidenced by stable vital signs. Nursing Intervention: Obtain vital signs during resting state Monitor vital signs every 2 hours during episodes of high blood pressure Rationale: Current health status of the patient is determined by obtaining the baseline data of the patient and the efficacy of the nursing intervention rendered can be evaluated if the medical health provider knows the baseline data of the patient. Evaluation/Outcome: After 8 hours of nursing intervention, patients’ heart rate, blood pressure, and respiratory rate will be in the normal range. a. Long – term Goal: After 5-7 days of nursing intervention, the patient will be able to regain his strength and slowly raises his right arm and leg. He will slowly regain his speech and be able to understand his spoken language. Nursing Intervention: Develop an exercise program for the patient to follow and refer the patient to an occupational therapy specialist and follow the progress of the patient Refer the patient to speech therapist and follow the progress of the patient Rationale: Exercise improves blood flow of the patient and prevents further deterioration of muscles. It is important to follow up the progress of the patient even though they are referred to other services so that any possible treatment to improve the condition of the patient can be planned. Evaluation: The patient will be able to slowly move his muscles and regains back his speech b. Long term goal for bowel and bladder training: Bowel and bladder training will be performed in the morning shift so that the patient will slowly regain bowel and bladder discipline as evidenced by being able to defecate and urinate in the comfort room regularly. Nursing Intervention for Bowel Training: Establish a regular bowel history and take into consideration the medical condition of the patient that may interfere during the training. Establish a normal and convenient time of training program and must make sure that this is done in a regular basis A stimulus that may help rectal emptying may be needed Teach the patient how to do Kegel Exercises Rationale: Improve stool consistency The patient will be able to establish a regular time of defecation (Plummer, 2009) Stimulate emptying on a regular basis; however, prior to training the patient, it is important to rule out faecal impaction that could interfere with the intervention that may eventually frustrate the patient. (Plummer, 2009) Peristalsis or wave-like movement can be created with stimulus (Plummer, 2009) Kegel exercises stimulate rectal muscle tone that oftentimes results to pelvic and rectal muscle tone strengthening (Mannheim, 2012). Evaluation: After 5-7 days of nursing intervention, the patient will slowly regain the urge to defecate and after weeks of nursing intervention, the patient will be able to have a good bowel control Nursing Intervention for Bladder Training: Teach the patient how to perform the proper Keggel Manuever Teach the patient to practice timed-voiding Teach the patient how to do double voiding and delayed voiding Rationale: Exercising the pelvic muscles provides benefits in an overactive bladder by tightening its muscles to be able to hold back its urine and conversely, allow the urine to pass by relaxing it (Orenstein, 2012). Timed voiding is another technique of bladder control training. It is a technique of going to the bathroom in a schedule basis rather than going to the bathroom when there is urgency (Orenstein, 2012). Double voiding and delayed voiding is done to outsmart bladders that are over reactive (Orenstein, 2012). Evaluation: After weeks of nursing intervention, the patient is capable to hold or relax his pelvic floor and control his urine output. c. After 15 days of nursing intervention, the patient will be able to control his emotions as evidenced by slow to anger, happy outlook, no more crying spells, laughter, and emotional stability. The patient’s emotional problem is already identified by the nurse in charge. At this time, nursing diagnoses were already made. Hence, it is important to begin nursing care planning for the patient with emotional instability. It is also important to involve the family of the patient as well as the members of health care team during the treatment, which include, being able to determine the priorities, set goals of treatment, select appropriate nursing action, and develop in writing proper nursing care plan. Nursing Intervention: During routine patient care, it is important that a nurse must closely observe the behaviour of the patient that may lead to self harm (Beck, 2011). Rationale: Closely observing the behaviour of the patient protects him from self harm Evaluation: The patient remains unharmed and safe C. Concept of Dignity in Relation to the Problem Identified Dignity as Defined Gallagher (2008) stated that being of value or worth is the concept of dignity that seems to be generally accepted. It is during the Aristotles’s Eudemian Ethics that the earliest references to dignity appeared as one of fourteen virtues or character that lies between being in excess or deficient of being an unaccommodating or servility. Hence, based from Aristotle’s concept, dignity is considered as a concept or being in the state of excellence. Gallagher (2008) added that human flourishing or happiness has been contributed by this quality called dignity. Dignity and Nursing Care It is the duty of the nurses to ensure that during the treatment, clients are treated with honour and respect or dignity (Kozier, et al., 2004). To understand better the relationship between dignity and nursing care, Kozier, et al. (2004) defined human dignity as “respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues.” It is understandable that dignity and respect of human beings are valued and advocated in the nursing practice (Kozier, et al., 2004). Lothian (2001) noted that a quality delivery of health care includes health promotion, prevention of diseases, and provision of the primary health care, general hospital care, care of specialist such as geriatric, psychogeriatric, and services in the palliative care. Moreover, intermediate and long term provision of community care as well as in the residential and nursing homes can be also provided to the patient (Lothian, 2001). On the other hand, in older people who are suffering from stroke, falls, and its consequence such as depression and demention, a detailed attention can be provided to its care (Lothian, 2001). An advise that is based on the value of fair access of care, an approach that is person cantered, and working whole system and not merely in accordance to evidence based practice can also be provided to the patient (Lothian, 2001). Gallagher (2008) noted that in relation to provision of care to older and vulnerable people, dignity has become the central concern in the UK policy. Health and social care services has become indignified and care deficit. This concern has caught the attention of the media and the government, and its response of this issue is that, NHS Hospital should have “dignity nurses” (Gallagher, 2008) Application of Concept of Dignity to the case of Mr William Fountain In the case of, Mr. William Fountain, the condition of the patient needs to be treated and handled by his attending nurse with utmost care and dignity. Based from the history, the patient has been suffering from the negative physical and psychosocial consequences of cerebrovascular accident. Hence, nursing care plan that caters the needs of the patient must not only be directed to the physical aspect but most importantly, to the emotional and social aspect of the patient and his family. As a nurse, it is expected that the patient must be treated with dignity and honour as a human beings with feelings and emotions and not merely as an object to consider. This treatment should not only stop in the ward, but must be inculcated that to care for the patient has to be considered as a complex culture of care as part of the nursing care planning (Gallagher, 2008). In the ward, it is expected that nursing staff are capable of providing highly dependent Mr. Fountain, a dignified care even during bathing, toileting, feeding, and etc. Carrying out respect of dignity towards the patient in the nursing practice is identified to be complex but achievable (Gallagher, 2008). Hence, behaviours that may diminish or promote dignity must be addressed speedily and such undignified practices must be addressed readily (Gallagher, 2008). D. Preservation of Dignity of the Patient The dignity of the patient, Mr. Fountain, must be preserve by the nurse while he is being treated in the ward. This act must not only stop in the ward, but also, even after the patient is discharged from care. The family of the patient and circle of societal influence must also respect and treat Mr. Fountain with dignity. Although it is a fact that patients like Mr Fountain is a burden to the family, the fact remains that he has the right to live and treated in a dignified manner. While the patient is still confined in the ward, it is the duty of the nurse to take care not only the physical needs of the patient, but also with the spiritual and emotional needs. It is important that during the rehabilitation phase, a nurse must carry out orders for patient’s rehabilitation plan, and encourage mobilization and ambulation (California Pacific Medical Center, 2007). A nurse is also responsible in assessing and supporting the nutritional as well as provision of Mr. Fountain and his family spiritual and emotional support. In this case, it is important that the patient’s symptoms of depression and other psychological sequelae that resulted from his current medical condition must be addressed as soon as possible (California Pacific Medical Center, 2007). Lastly, as a nurse, it is also expected that the discharge needs of Mr Fountain is catered. Hence, prior to Mr. Fountains’ discharge, it is expected from his nurse to facilitate acute rehabilitation care from acute care transition as well as referral to skilled nursing facility, or assistance of case manager or social workers at home (California Pacific Medical Center, 2007). E. Supporting Literatures A review of literature of Duncan, et al. (2005) states that In the United States, stroke remains to be the primary cause of disability leaving forty percent of patients in moderate impairments in their function and severe disability in about 15-30 percent. Recovery process and functional disability are minimised after initiating early effective rehabilitation intervention. As a result, patients’ satisfaction and potential costly long term expenses are diminished, which eventually improves the function outcome of the patient. In managing stroke, Duncan, et al. stressed some important points to remember in managing patients with cerebrovascular accidents or stroke. During the rehabilitation state, it is the primary goal of the clinical provider to prevent further complications, minimise further impairment of the patient and maximize function to its optimum level. Additionally, prevention of the recurring episodes of stroke is the fundamental approach in secondary prevention. These include prevention of further coronary vascular events, and coronary heart disease that may eventually mediate further to death. Duncan et al (2005) stressed that it early assessment and intervention of the patient is critical in optimizing the rehabilitation period of the patient. In developing a comprehensive plan of treatment, it is essential to have standardized evaluation and assessment tools that are valid. To achieve this, evidence – based interventions based on the functional goal of the patient must be formulated. Duncan et al (2005) noted that to ensure an optimal outcome of patient’s rehabilitation, the patient must be provided an access to a multidisciplinary rehabilitation team who are experienced enough to handle the case of the patient and utilizes the resources present in the community for community reintegration. . The patient, together with his family and caregiver must be informed of their role being essential members of patients’ rehabilitation team. By educating them, informed decision making, social adjustment, and rehabilitation gain maintenance is improved. Lastly, to ensure the survival of the patient, medical management of risk factors and its comorbidities must be ensured. F. Conclusion Nursing care is a holistic approach to the patients needs. It doesn’t stop on giving the medications and treatment to the patient, but to the extent of taking care on the emotional, spiritual, family needs, and most of all, taking care of the patient even after they are discharged from the hospital. It is an inkling of the clinical practices of the nurses to deliver changes in the management of the patient, his family, and community circle and even during their busiest time, it remains the nurses’ utmost priority to deliver a holistic nursing care planning and treatment to the patient to achieve optimal health and well – being of Mr. Fountain. References: 1. Association of State and Territorial Directors of Nursing, undated. The Public Health Nurse’s Role in Achieving Health Equity: Eliminating Inequities in Health. [Online] Available at: < http://www.astdn.org/downloadablefiles/ASTDN-health-equity-11-08.pdf> [Accessed 20 February 2012]. 2. Beck, J., 2011. Nursing Process in Psychiatric Nursing. [Online] Available at: [Accessed 19 February 2012]. 3. California Pacific Medical Center, 2007. Management of CVA Patients. [Online] Available at: [Accessed 20 February 2012]. 4. Duncan, P., Zorowitz, R., and Bates, B., 2005. “Management of Adult Stroke Rehabilitation Care.” Stroke, 36(2005), pages e100 – e143. 5. Gallagher, K., 2008. “Dignity in the Care of Older People – A Review of the Theoretical and Imperical Literature.” BioMed Central Nursing, 7(11). 6. Grinspun, D., 2005. Stroke Assessment in the Continuum Care. [Online] Available at: [Accessed 20 February 2012]. 7. Kozier, B., Erb, G., Berman, A., and Snyder, S., 2004. Fundamentals of Nursing. 7th ed. New Jersey: Pearson Education Inc. 8. Lothian, K., 2001. “Care of Older People: Maintaining the dignity and autonomy of older people in the health care setting.” British Medical Journal, 322:668. 9. Lindsay, M., Kelloway, L., and McConnell, H., 2005. “Research to practice: nursing stroke assessment guidelines link to clinical performance indicators.” Axone, 26(4): 22-7. 10. Mannheim, J., 2012. Bowel Retraining. [Online] Available at: [Accessed 18 February 2012] 11. Montana State Stroke Initiative – Nursing Workgroup, Undate. Nursing Care of the Acute Stroke Patient. [Online] Available at: [Accessed 21 February 2012] 12. NICE, 2008. Stroke. [Online] Available at: [Accessed 20 February 2012]. 13. Plummer, M., 2009. Bowel Retraining: Strategies for Establishing Bowel Control. [Online] Available at: [Accessed 17 February 2012]. 14. Schonbeck, J., 2002. Cerebrovascular Accident. [Online] Available at: < http://www.enotes.com/cerebrovascular-accident-reference/cerebrovascular-accident> [Accessed 19 February 2012] 15. Scottish Intercollegiate Guidelines Network, undated. Stroke Assessment Booklet for Patient. [Online] Available at: < http://www.sign.ac.uk/pdf/pat108.pdf> [Accessed 20 February 2012]. 16. Stokowski, L., 2007. Stroke and Stroke Nursing: Safeguarding the Brain: Emergency Management of Stroke. [Online] Available at: < http://www.medscape.com/viewarticle/558615_6> [Accessed 20 February 2012] 17. Summers, D., 2011. “Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient.” Stroke, 40(2009): 2911-2944. 18. Ward, N., undated. Assessment and Diagnosis in Stroke. [Online] Available at: < http://www.fil.ion.ucl.ac.uk/~nward/assessment%20and%20diagnosis%20of%20stroke.pdf> [Accessed 20 February 2012]. 19. Wedro, B., 2012. Stroke. [Online] Available at: < http://www.medicinenet.com/stroke/article.htm> [Accessed 17 February 2012]. 20. Wild Iris Medical Education, 2012. Stroke: ICU Care and Potential Complications. [Online] Available at: < http://www.nursingceu.com/courses/328/index_nceu.html> [Accessed 20 February 2012]. Read More