Cerebrovascular accident (CVA) or commonly known as “stroke,” is one of the most disabling chronic diseases that affect many individuals and their families. According to Centers for Disease Control and Prevention (2016), stroke is currently the fifth leading cause of death in the United States and is also the major cause of serious disability for adults. As a matter of fact, someone in the U.S. has a stroke every forty seconds (CDC, 2016). What makes this disorder very fatal is because it affects the normal blood supply in the brain (Pellico, 2015). Brain cells become deprived of oxygen, resulting in the loss of memory and motor function of the affected area of the brain. As a result to its severity and persistent incidences across the nation and around the world, caring for people suffering from stroke has become a priority. Health care professionals who work with these patients should be aware of stroke. Nurses should be well prepared to care for this type of patients (Pellico, 2015). The aim of this case study is to explain stroke including it’s etiology, complications, nursing interventions, and complications. Knowing information about stroke will allow nurses to develop a care plan that can help with the recovery process of someone that is affected by stroke.
DISEASE PROCESS
Stroke occurs when blood flow to an area of brain is disrupted. This disorder is characterized by the onset of one or more neurological deficit that results from the reduced cerebral blood flow (Pellico, 2015). According to National Stroke Association (2017), when brain cells die, functions that are controlled by that area of the affected brain such as memory and muscle control are lost . As a result, stroke imposes an enormous burden to the person that is affected, their families, as well as the health care system (Ponomarev, Miller, Govan, Haig, Wu, & Langhorne, 2013).
There are two major types of stroke: ischemic stroke and hemorrhagic stroke. Ischemic stroke or cerebral infarcts (CI) is the result of the development of thrombi and/ or emboli that accounts for blockages and the deficiency of oxygen in vital tissue (Perna & Temple, 2015). In ischemic stroke, the interruption of blood flow trigger a series of circulatory and metabolic events, also known as ischemic cascades (Pellico, 2015). The ischemic cascades begin when cerebral blood flow declines to less than 25 mL of blood per 100 g of brain tissue per minute. This is far less in comparison to the normal cerebral blood flow of 50 mL of blood per 100 g of brain tissue per minute (Pellico 2015). With a decrease of cerebral blood flow, neurons are unable to sustain aerobic respiration (Pellico, 2015). To compensate, neurons must switch to a less efficient anaerobic metabolism, which renders the neuron to produce adequate amount of adenosine phosphate (ATP) that is needed for depolarization (Pellico, 2015). These ATPs are important because without them, cells will cease to function.
Ischemic stroke is further subdivided into five subtypes: large- artery thrombotic strokes, small penetrating artery thrombotic strokes, cardiogenic embolic strokes, and cryptogenic strokes, and other. These subtypes differ from their pathology, but they do have some overlapping clinical manifestations. Large- artery thrombotic strokes accounts for 20% of ischemic strokes and it results from the disruption of cerebral blood flow due to the obstruction of large blood vessels by atherosclerotic plaques (Pellico, 2015). In contrast, small, penetrating artery thrombotic strokes affect one or more vessels, and are usually caused by “longstanding hypertension, hyperlipidemia, and diabetes” (Pellico, 2015). It is also the most common ischemic stroke, accounting for 25% of ischemic stroke incidence (Pellico, 2015). The third subtype is known as cardiogenic embolic stroke it is accompanied by valvular heart diseases and even cardiac arrhythmias such as atrial fibrillation (Pellico, 2015). Cardiogenic embolic stroke represents 20% of ischemic stroke cases, in which the emboli originated from the heart and circulates to the brain (Pellico, 2015). The last two subtypes are known as cryptogenic strokes, which has unknown causes, and strokes from other causes such as illicit drug use, migraine, and coagulopathies (Pellico, 2015). Being able to understand these different subtypes allows an easier determination when choosing certain therapeutic interventions.
The second type of stroke is called hemorrhagic stroke. While ischemic stroke accounts for 85% of stroke cases, hemorrhagic strokes account only for 15% of stroke cases (Pellico, 2015). It is very different from ischemic stroke in which hemorrhagic stroke refers to bleeding in the brain tissue, the ventricles, or subarachnoid space (Pellico, 2015). This type of stroke is the result of arteriolar hypertensive diseases, burst aneurysm, arteriovenous malformation, bleeding disorders, head injury, and blood thinners (Wang, 2013). Due to bleeding, blood outside the vasculature is able to form a mass that can lead to the compression of brain tissue, ischemia and increased intracranial pressure (ICP) occur (Pellico, 2015). Both ischemic and hemorrhagic strokes are dangerous because it can lead to coma or even death (Pellico, 2015).
Stroke is a serious disorder and people must be aware of its risk factors. Risk factors are classified as modifiable and non-modifiable. Non- modifiable risk factors are those that cannot be change. In stroke, non- modifiable risk factors include old age, male gender, ethnicity, family history, and prior history of stroke (Siddeswari, Suryanarayana, Sudarsi, Manohar, Rao, & Abhilash, 2016). Men usually to have higher risk and incident rate for stroke compared to women (Pellico, 2015). Race and ethnicity also has a significant role to stroke because previous studies have proven that Blacks and Hispanics have a higher chance of suffering stroke (Pellico, 2015). As for having a family history of stroke, genetic influence as well as culture and environmental influences has been found to be associated with stroke (Pelicco, 1251). Although these non- modifiable risk factors cannot be changed, it is important that they must be addressed because their associated modifiable risk factors can be treated.
Fortunately, not all stroke’s risk factors are non modifiable. There are also modifiable risk factors, which include cigarette consumption, alcohol consumption, illicit drug use, hypertension, dyslipidemia, diabetes, and atrial fibrillation (Siddeswari et al., 2016). Lifestyle modification such as weight reduction, where a normal BMI of 18-24 should be maintained, can lower the risk of stroke (Siddeswari et al., 2016). A DASH diet plan that is rich in fruits and vegetables must also be initiated. In addition, low- fat dairy products, with a reduced content of saturated and total fat, also help with the inhibition of stroke (Siddeswari et al., 2016). Other lifestyle modification that one can adapt includes dietary sodium restriction, regular aerobic physical activity, and moderation or cessation of alcohol, illicit drug, and cigarrete consumption (Siddeswari et al., 2016).
If these lifestyle modifications were disregarded by someone who is at high risk of stroke, it is likely that stroke will occur to them. They will suffer from neurologic deficits, depending on the location of the lesion, which vessels are obstructed, and the size and area of unperfused brain tissue (Pellico, 2015). The most common symptoms that a stroke-affected- individual will endure includes sudden numbness or weakness of the face, arm, or leg, sudden confusion or change in mental status, sudden trouble speaking or understanding speech, sudden disturbances, difficulty walking, dizziness, or loss of balance, and severe headache (Pellico, 2015). It is significant to be aware of these symptoms to help distinguish stroke from other disorders or diseases.
COMPLICATIONS
There are a variety of potential complications that may develop after a person suffers a stroke. Experiencing these complications is the reason for the increased in mortality and length of hospital stay (Bovim, Askim, Lydersen, Fjærtoft, & Indredavik, 2016). In a research study published by Ponomarev, Miller, Govan, Haig, Wu, & Langhorne (2013), they investigated several complications that were caused by stroke and how these complications had led to re-admissions in hospitals. The study was published in 2016, but data was collected from three consecutive surveys in three different years (Ponomarev et al., 2013). In the study, there were a total of 19,434 individuals who responded to the survey. However, only 168 of them had been hospitalized from stoke (Ponomarev et al., 2013). Furthermore, only 141 people were at high risk for readmission, but only 106 were readmitted (Ponomarev et al., 2013). The most frequent readmission complication was due to a cardiovascular- related event (Ponomarev et al., 2013). This includes conditions such as endocardial structure diseases, hypertensive heart disease, ischemic heart disease, cardiomyopathy, heart failure, and other vascular diseases (Ponomarev et al., 2013). Same study also found out that infection such as pneumonia, intestinal infection, and urinary tract infection has caused re-hospitalization of stroke patients in 29 cases (Ponomarev et al., 2013). Several variables may have contributed to these infections, which include age, gender, social class, smoking, generalized weakness, and diabetes (Ponomarev et al., 2013). Because cardiovascular and infection complications from a stroke are very serious, nurses can teach stroke patient regarding cardiovascular screenings and infection control.
As mentioned previously, patients with stroke also suffer from neurologic deficit complications. These neurological deficits will corresponds with the location in the brain that is affected by the ischemia or hemorrhage. If a stroke occurred in the left hemisphere of the brain, then the right side of the body is affected. As a result, a patient will suffer from right paralysis and right visual deficit, aphasia, altered intellectual ability, and slow behavior (Pellico, 2015). In contrast, if the stroke occurred in the right hemisphere of the brain, then the left side of the body is affected. This type of patients will suffer from left- sided paralysis, left visual field deficit, perceptual deficits, increased distractibility, impulsive behavior, poor judgment, and lack of awareness (Pellico, 2015).
With neurological deficit from stroke, hemiparesis or also known as weakness of one side of the body occurs. Patients will either have difficulty moving one side of the body or they will not be able to move it at all (Pellico, 2015). Paralysis of one side of the body will affect range of motions and a patient’s ability to do activities of daily living such as eating, dressing, bathing, and toileting. This can turn fatal because it increases the patient’s risk of aspiration. Moreover, language and communication will also be affected, as patients will suffer from dysarthria, dysphasia or aphasia, and apraxia. These terms are all associated with speaking, although they have different meanings. Dysarthria is difficulty speaking and it is caused by the paralysis or weakness of the muscles that are mainly responsible for speech (Pellico, 2015). In contrast, dysphasia is partial impairment of language that results from brain injury, while aphasia is the complete impairment of language (Pellico, 2015). The last term is apraxia, which is the failure to perform previously- learned actions such us combining syllables together to produce speech (Pellico, 2015). Having one of these speech dysfunctions is a complication because it can affect a patient’s ability to communicate what they want and to receive and understand the message in return.
Beside from motor and communication loss, patient that suffers a stroke will also have sensory loss. Meaning, it will be harder for them to perceive senses such as touch (Pellico, 2015). Moreover, perceptual disturbances such as visual- perceptual dysfunction will also occur. Patient will have impairment with their eyesight because they might suffer from homonymous hemianopia, which is the loss of half of visual field (Pellico, 2015). This is a complication because it can interfere with daily living. For example, if a patient has hemianopia on his or her right eye, they may not be able to see the foods on the right side of their plate when they are eating. Therefore, assistance must be given to help them. Another complication of stroke is cognitive impairment of the part of the brain that has been affected. A decrease in learning capacity, memory, and intellectual functions can be detected if frontal lobe of the brain is affected (Pellico, 2015). Psychological effects such as depression, lack of cooperation, and hostility are another type of major complications that may require therapeutic management (Pellico, 2015). All of these complications are hard to recover, but there are therapies that could help patient to reduce its severity. It is important for patients and family members to be aware of these complications.
PATIENT EDUCATION
After a stroke, patient and their family members face many changes. Patient education is an important key factor of patient care. Patient and their family must be taught based on their individual’s health literacy. The areas that should be addressed when providing an education for patient with stroke are: disease prevention and disease specific education (Cameron, 2013). For disease prevention, the nurse could inform patient of different risk factors of stroke and help them form a patient- specific goals (Cameron, 2013). Hypertension, cigarette consumption, and alcohol consumption has been previously identified as risk factors. Since stress and atherosclerosis can cause increase in blood pressure, nurses must teach patient different ways to cope with stress and provide a list of healthy diet to prevent atherosclerosis. A list of foods consisting of low cholesterol, low sodium, high potassium, high calcium, and high fiber must be taught and provided to help can help prevent the recurrence of stroke (Wang, Chen, Liao, & Hsiao, 2013).
Aside from teaching them about risk factors, another way to prevent stroke is through medication adherence and early recognition of warning signs (Cameron, 2013). Patients need to understand that treatments with intravenous recombinant tissue plasminogen activator within three hour of onset of acute ischemic stroke can make a difference because it help improve neurological outcome (Wang et al., 2012). Fewer compilations can occur if patients adhere to medication administration. In addition, complications can also be lessened if patients were to be educated about early warning signs of stroke. Nurses can teach the F.A.S.T acronym that is used as a mnemonic to detect stroke. It stands for facial drooping, arm weakness, speech difficulty and time to call for help. Nurses can help decrease stroke occurrence by providing community teaching as well as providing patient education to patients and their family at the beginning of admission.
After disease prevention, disease- specific education should be addressed next. This is the part of patient education where the nurse must include the disease’s pathophysiology and a detailed treatment of treatment and rehabilitation plan (Cameron, 2013). Information in regard to the area of the brain affected and a thorough explanation of the lasting effects a patient might experience should be discussed (Cameron, 2013). For example, life threatening side effects such as dysphagia should be discussed due to the fact that it causes aspiration. Because of this, nurse should teach the patient and their family member about proper positioning and the consistency of solid and liquid food the patient could consume. After talking about stroke and its side effects, nurses should introduce detailed information regarding treatment options such as medications and rehabilitation programs (Cameron, 2013). They need to know that rehabilitation can aid in the physiological and psychological conditions of patients with stroke (Wang et al., 2012). Rehabilitation program may be necessary in order for the patient to re-learn basic skills that are needed in daily life such as bathing, eating, walking, and more. Through rehabilitation, patient will learn to dress their affected area first and to look at their affected side regularly. Knowing treatment options and what they can do allow patient and their family to have a sense of control when it comes to deciding the appropriate treatment plan for them.
When stroke occur, family members are also affected. Their roles within their family are modified (Cameron, 2013). Some member will have to be responsible for new tasks such as cleaning, paying the bills, and looking after the patient with stroke (Cameron, 2013). Most often, this results to role conflict and distorted relationships, which can lead to stress (Cameron, 2013). As an advocate, nurse must provide emotional support to family members to provide various methods on how to deal with stress. For example, a nurse can teach family members coping skills such as recognizing their feelings, acknowledge their feelings, and talking to someone to ease out their problem. By teaching family members these strategies, family members will benefit because this can prevent them from acquiring stress-induced illness.
NURSING INTERVENTIONS
Nursing care has an important role toward a patient’s recovery. Stroke survivors often have impairments. These deficits can lead to life-threatening complications, but these can be prevented, treated, and managed through nursing interventions (Catangui & Slark, 2012). These nursing interventions can be initiated through nurse- led ward rounds. With ward rounds, a nurse will be able to examine a stroke patient and establish a plan of care for the particular patient (Catangui & Slark, 2012). In a research study done by Catangui and Slark, they were able to examine how nurse- led ward rounds contribute to stroke care. They developed a proforma or criteria to guide nurses in their physical assessment. The performa contains categories of nursing interventions for a stroke patient such as assessing skin integrity, continence, oral care, and medications. Within each category, further questions were addressed. For example, within the ‘skin integrity’ category, questions such as type of wound, location, and current treatment were asked. As for the ‘continence’ category, questions such as the use of urinary catheter, bowel movements, and the use of laxatives were asked. For ‘oral care’ category, signs of candidiasis and the condition of oral mucosa were questioned. These types of questions from the performa/ criteria will be answered if a nurse were able to perform ward rounding. Being able to assess each category will allow the nurse better understand the client’s condition and to prioritize what nursing intervention is the most important.
According to the same research study, a nurse must do these following roles during ward rounding: evaluate changes in patient’s physiological parameters such as vital signs, they must assess foe early signs of decubitus ulcer, check and evaluate patient’s mouth status, check and assess any bowel movement, assess the need for bladder training if incontinent but not on catheter, evaluate any changes of patient’s body weight, body mass index, fluid and nutritional intake, nurses must assess patient’s mood using appropriate depression scale such as the SODS scale, they should assess and evaluate patient’s functional outcome using stroke tools such as the Barthel Index, and they must ensure that nursing documentation is thorough and updated (Catangui & Slark, 2012). The findings from these assessments during ward rounding will help the nurse develop a plan of care that is specific for a particular patient.
After doing assessments and developing goals for a plan of care, nurses must initiate actions to reach those goals. First, stroke patient is at risk for skin breakdown due to lack of sensation, incontinence, and impaired circulation (Catangui & Slark, 2012). As a result, it is likely that the nurse will initiate a plan in which he or she would assess signs of pressure ulcer every two hours, turn the patient every two hours, and request for pressure relieving bed mattress (Catangui & Slark, 2012). This intervention deceases complications such as impairing skin integrity.
Second, stroke patients are also at risk for incontinence. Although indwelling catheter is necessary, it increases the risk of UTI (Catangui & Slark, 2012). There are other nursing interventions nurses can offer other than using an indwelling catheter. These interventions include offering the patient a “bedpan commode or urinal every two hours during walking rounds and every 4 hours at night” (Catangui & Slark, 2012). Nurses can also teach and encourage patient to have high fluid intake during the day and to decrease their intake at nighttime (Catangui & Slark, 2012). This will help the patient to have a restful sleep at night because they will not be awakened by the urge to urinate.
Third, due to their paralysis, stroke patients are at risk for constipation. If the nurse determines that a patient is at risk for constipation, the nurse must encourage having the patient ambulate, eat a high fiber diet, and to increase their fluid intake unless contraindicated (Catangui & Slark, 2012). If a patient were able to do these interventions or actions, it is less likely that they will need to take medications such as laxatives or stool softener.
Fourth, if the nurse assessed that the patient is at risk for dry mouth and oral ulcers due to medications, the nurses can help the patient by making sure that the patient receive oral care (Catangui & Slark, 2012). Nurses must also review the patient’s medications and must have another individual check their patient’s drug charts to decrease fatal medication errors (Catangui & Slark, 2012).
Lastly, the nurse should evaluate the patient’s functional ability. They can use the Barthel’s index to evaluate patient’s outcome. The Barthel’s score consists of a 10 items that measure the patient’s daily functioning. These includes: feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing, and incontinence of bowels and bladder (Catangui & Slark, 2012). The scores range from “0, representing a totally dependent bedridden state, to a maximum score of 20 that indicate that the patient is fully independent” (Catangui & Slark, 2012). Nurses can help patients to assist with those daily livings, depending on the score of the patient. They can also help them to try to recover and increase independency by consulting an occupational therapist as well as teaching the patient and family about rehabilitation programs. All of these interventions will help the patient decrease the burden of stroke. Ward rounding is an important nursing intervention in which nurses can assess their patient and develop a plan of care based on those assessments.
Conclusion
Overall, stroke has been a major issue in the US and worldwide, causing increase cases in mortality and morbidity. This aim of this paper is to discuss and evaluate the physiology of stroke and its complications, as well as to provide patient education and various nursing interventions to help the patients and their family members gain knowledge about this condition. Stroke happen when the blood supply in the brain is interrupted, either due to a clot or hemorrhage. As a result, cells become oxygen deprived and die. Because of this, the function of different areas of the brain will be affected and will not work normally. This can leads to neurological deficits, resulting in motor loss, communication loss, perceptual disturbances, sensory loss, cognitive impairment and physiological effect. As a result to those impairments, stroke patient become at risk to further complications such as infections and cardiovascular diseases. Nurses must educate patient and family about risk factors, the disease process, various forms of treatments, and different coping skills to help prevent the occurrence of stroke and relieve the burden of this condition to those that are affected. Nurses can also initiate nursing interventions such as doing assessments during ward rounding. Doing so will allow the nurse to gain knowledge about the severity of the patient’s condition and will also help them in determining complications that the patient may be at high risk. Knowing details about the patient condition will allow the nurse to initiate a care of plan to help with the recovery of the patients. Stroke is a very serious condition and education must be provided within the community or at the beginning of admission so that occurrence and re-admission will be prevented.
References:
Cameron, V. (2013). Best Practices for Stroke Patient and Family Education in the Acute Care Setting: A Literature Review. MEDSURG Nursing, 22(1), 51-55.
Catangui, E. J., & Slark, J. (2012). Nurse-led ward rounds: a valuable contribution to acute stroke care. British Journal Of Nursing, 21(13), 801-805.
Centers for Disease Control and Prevention. (2016). Stroke Facts. Retrieved from https://www.cdc.gov/stroke/facts.htm
Chen, C., Liao, W., & Hsiao, C. (2013). Evaluating a community-based stroke nursing education and rehabilitation programme for patients with mild stroke. International Journal Of Nursing Practice, 19(3), 249-256. doi:10.1111/ijn.12064
National Stroke Association. (2017). What is Stroke?. Retrieved from http://www.stroke.org/understand-stroke/what-stroke
Pellico, L. H. (2015). Focus on Adult Health Medical- Surgical Nursing. Lippincott Williams & Wilkins.
Perna, R., & Temple, J. (2015). Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes. Behavioural Neurology, 20151-6. doi:10.1155/2015/891651
Ponomarev, D., Miller, C., Govan, L., Haig, C., Wu, O., & Langhorne, P. (2013). Complications following incident stroke resulting in readmissions: an analysis of data from three Scottish health surveys. International Journal Of Stroke, 10(6), 911-917. doi:10.1111/ijs.12191
Reiten Bovim, M., Askim, T., Lydersen, S., Fjærtoft, H., Indredavik, B., & Bovim, M. R. (2016). Complications in the first week after stroke: a 10-year comparison. BMC Neurology, 161-9. doi:10.1186/s12883-016-0654-8
Siddeswari, R., Suryanarayana, B., Sudarsi, B., Manohar, S., Rao, N. S., & Abhilash, T. (2016). Comparative study of risk factors and lipid profile pattern in ischemic and haemorrhagic stroke. Journal Of Medical & Allied Sciences, 6(1), 8-13. doi:10.5455/jmas.210760, L.,