NURSING MANAGEMENT OF A
STROKE PATIENT

INTRODUCTION
Stroke is the only largest cause of adult disability which leaves a devastating and lasting effect on people and their families (DoH, 2007a). The government of the United Kingdom had recognized stroke as a health care priority. Several government agencies developed clinical guidelines which are being implemented today in local health care settings (Williams et al, 2010a). This essay will focus on stroke as the cause of impaired mobility and will tackle on the patient-centered rehabilitation care plan along with its evidence-based rationales. Health and social care policies and its effect on the patient’s chosen journey will also be discussed.

PATIENT PROFILE
This is a case of a 68 year-old, married female who lives in the south of England. Mrs. G was admitted on 12 October 2010 with a presenting complaint of left-sided weakness. Prior to admission, she experienced persistent pain on the back of the head for 2 days, which was unrelieved by Paracetamol intake. On the morning of admission, she collapsed in the bathroom and was found by the husband after 3 hours. She was brought to the hospital via ambulance and upon initial assessment, no shortness of breath, slurred speech, dizziness, palpitation and chest pain were noted. Her vital signs were as follows: blood pressure of 169/59 mmHg, pulse rate of 80 bpm, respiratory rate of 18 breaths per minute, body temperature of 37.5 degrees Celsius, Glasgow Coma Scale of 15, blood sugar level of 5.2 mmol/L, oxygen saturation of 100% on room air. Neurologic assessment revealed neglect on left lateral vision and mild mouth droop. Her laboratory test showed a 0.55 ug/L Troponin I level, an indication of an acute infarct. A small left ventricle cavity size with impaired systolic function was also noted on her echocardiogram. Her past medical history includes hypertension and bladder problems, with non-compliance to Atenolol, Simvastatin and Aspirin. Mrs. G lived with her husband and was independent with activities of living prior to stroke.
In the course of her treatment, Mrs. G underwent series of sessions with the multi-disciplinary team. Her medication management involved daily intake of Aspirin, Atenolol and Simvastatin (RCP, 2000a)). It was found out that people presenting with acute stroke should be given Aspirin and stroke patients who are already receiving Statins should continue their Statin treatment (NICE, 2008).

PATHOPHYSIOLOGY
Mrs. G’s physical disability was due to her left-sided weakness brought about by an ischaemic stroke attack. A stroke is a prolonged interruption in the blood flow through one of the arteries supplying the brain. Hemiplegia or paralysis of one side of the body is a common neurologic product of cerebrovascular accident or stroke.
The motor area on Mrs. G’s right side of the brain incurred an infarct resulting to left-sided hemiplegia as manifested by flaccidity of left arm and left leg. An ischaemic stroke occurs when a thrombus or embolus blocks an artery carrying blood to the brain. Cerebral ischaemia happens when glucose and oxygen to the brain are reduced. The glucose reduction quickly depletes the supply of adenosine triphosphate resulting to anaerobic cellular metabolism and accumulation of toxic by-products such as lactic acid. Oxygen depletion on the other hand, triggers the release of neurotransmitter glutamate which activates N-methyl-D-aspartate neuronal transmitters. These transmitters make it possible for calcium and glutamate to enter the cells in large amounts, causing chaos and the release of free radicals which destroy the brain cells. This assault extends to the zone of cerebral infarction (Timby and Smith, 2003).
Hypertension and a high cholesterol level are risk factors of stroke which were evident in Mrs. G’s medical history. These were managed according to clinical guidelines which include lifestyle change and drug therapy (DoH, 2007b).

ASSESSMENT
The framework used for assessment was the Roper-Logan-Tierney model of nursing which is based on activities of living. This framework promotes independence through complete assessment leading to interventions that sustain patient’s functionality (Roper et al, 2000). Mrs. G’s ability to function was compromised due to her left-side paralysis, which was the reason this framework for assessment has been utilized for this care plan.

Assessment through activities of living:
Maintaining a safe environment
One pre-requisite of rehabilitation is to provide a safe environment for the patient (Healthtree, 2010). As assessed, Mrs. G was conscious, coherent and fully orientated to time, place and person. Her Glasgow Coma Scale was 15/15, blood pressure at 128/79 mmHg and pulse rate of 68 bpm. Although she had normal visual acuity and pupillary size, there was mild neglect on her left lateral vision and weakness on her left side of the body, which made her susceptible to injury and falls.
Communicating
For some stroke patients, their ability to communicate improved quickly during recovery, but there were also some who were left with communication difficulties which required professional help (Healthtalkonline, 2010). Luckily, this patient had no slurred speech or aphasia, nor problems with comprehension. She used the call bell to get help from staff on bay and also socialized with other patients in the ward.
Breathing
Some patients may experience breathing difficulties after stroke (Stroke foundation, 2010). But for Mrs. G, she was not in respiratory distress and was saturating at 100% on room air. There was equal, bilateral chest movement and showed nasal breathing upon inspection. Respiratory rate was at 18 breaths per minute.
Eating and Drinking
Dysphagia is common after stroke, or sometimes patients do not feel the food or water in the mouth (Rhodes, 2009). Although Mrs. G had left side paralysis, her mastication and swallowing ability were not affected. She had a good appetite and was able to eat using her good hand. She was on a low salt, low fat diet.
Eliminating
Bowel problems post stroke may be expected because part of the brain that controls waste removal may have been damaged (NSA, 2009). In Mrs. G’s case, she was continent of both urine and stool and mobilized with the aid of a quad stick to the toilet, with assistance of one person.
Personal Cleansing and Dressing
Hygiene and grooming are part of self-respect (Alexander et al, 2000). Mrs. G was assisted in washing and dressing by providing her a commode chair where she sat while she was supported in cleansing and reminded to care for the weak side of the body.
Controlling Body Temperature
Body temperature control is often disrupted once brain stem stroke occurs (SRA, 2009). As Mrs. G did not suffer from this type of stroke, she remained apyrexic at 36.6 degrees Celsius throughout the periods of assessment. In the mornings, she had physiotherapy exercises and kept herself hydrated by frequent oral fluid intake. At night, she was kept warm by wearing pajamas and three blankets over the cover sheet.
Mobilising
Early mobilization may contribute to improved outcome after stroke (Bernhardt, J. et al, 2008). Mrs. G was able to mobilize early on. However, the major issue was her impaired mobility because it affected her activities of living. While standing, Mrs. G was wobbly even with the use of a quad stick. She was also scared to walk because she was afraid to fall. Due to this unsteadiness, she required a one-person assist in mobilising and transfers.
Working and Playing
For some stroke survivors, getting back to work might be a different experience (NHS-GGC, 2010). But for Mrs. G, it has never been a problem since she has been a devoted housewife to her retired teacher-husband. She was however, an active participant in church activities before her stroke.
Expressing sexuality
The stress that comes with stroke can cause depression and may affect the patient’s sexuality (Vega, 2008). During assessment, Mrs. G manifested her own sense of sexuality by daily grooming which included choosing her clothes for the day, brushing her hair and applying lipstick. She has been married for 48 years, had menopause at the age of 50 and had been sexually inactive since then.
Sleeping
Sleep contributes to the stroke patient’s recovery by strengthening the brain (Cheow, 2010). This was apparent with Mrs. G who always slept 8 to 9 hours per day. She slept with one pillow under the head and another one for the weak arm. Part of her bedtime routine was having tea before dozing off.
Dying
Fear of death associated with stroke is common not only to patients, but to all people in general (SRO, 2010). For Mrs. G, She had accepted it to be a part of everyone’s journey and yet, there was an inner fear of leaving her family behind. She had no living will.

IDENTIFICATION OF PATIENT’S PROBLEM
Among all the problems Mrs. G had during assessment, mobility problem was the most important because it affected her activities of living. Therefore, the focal point of the care plan was on impaired mobility with enhancement on rehabilitation. After all, mobility rehabilitation plays a vital part in the overall treatment of stroke and one in which a nurse has a central role (Williams et al, 2010b).

CARE PLAN Identified Problem Interventions Rationales References

Impaired
Mobility

1.Assessed for functional ability

2.Accomplished Inpatient Faller Identification Tool

3.Assisted and reminded of proper walking techniques using a quad stick

4.Assisted in washing and dressing; encouraged to partake in activity

5.Encouraged to stand and undertake periods of weight bearing

6.Educated patient and relative regarding the importance of quad stick, night light and supervision when mobilising

7.Provided information to patient and relative about risk factors, changes within the home and modifying medication To build aspects of care

A falls prevention intervention can then be offered

To re-educate patient in walking

9

To help patients adapt to their impairment

Prevents imposed dependence

To modulate tonal change and promote use of extensor muscle

These are proven falls prevention strategies

Knowing the risk factors may reduce the likelihood of fall

(Williams et al, 2010c)

(Williams et al, 2010d)

(SIGN, 2002)

(Willacey, 2008))

(Williams et al, 2010e)

(Williams et al, 2010f)

(Kerse et al, 2010)

(Esquenazi, 2008)

10
Health and Social Care Policies Influencing Patient’s Care
Mrs. G was brought to the hospital via ambulance when she suffered stroke because according to the National Stroke Strategy of the Department of Health (2007c), all patients with suspected acute stroke be immediately transported by ambulance to a hospital providing hyper-acute stroke services. She was likewise given prompt diagnosis and treatment as is mandated in the National Service Framework for Long-term Conditions (DoH, 2005). In addition, assessment of her level of consciousness, swallow test, risk for pressure sores, nutritional status, cognitive impairment, needs regarding moving and handling and referral to specialist rehabilitation team were undertaken and documented as stated in the National Clinical Guidelines for Stroke (RCP, 2000b).

Another key component from the National Stroke Strategy of the Department of Health (2007d) is the provision of a specialist coordinated rehabilitation team in the stroke unit. This team, which consists of physiotherapists and occupational therapists facilitated the enhancement in mobility, movement and activities of living of Mrs. G. A concise discharge care plan was made as well on the day of admission. It involved Mrs. G and her family in her overall care plan, including those occurring after hospitalization. Notification was also given to her general practitioner-doctor, primary healthcare teams and community social service and arrangements for all necessary equipment and support services post hospitalization were also carried out as per National Clinical Guidelines for Stroke (RCP, 2000c). A third key component from the National Stroke Strategy of the Department of Health (2007e) is health teaching on risk factors and lifestyle management issues. Mrs. G’s hypertension and high cholesterol level were managed according to clinical guidelines. She was also given a comprehensive advice on behavior and appropriate treatment to reduce risks for coronary heart disease as stated in the National Service Framework for Coronary Heart Disease of the Department of Health (2004).
As per hospital protocol, these tools were used in the medical management of this patient to assess and monitor for physiologic changes. Modified Early Warning Score (MEWS) system is a tool for bedside evaluation which focuses on five parameters: systolic blood pressure, pulse rate, respiratory rate, temperature and AVPU score. It is used to assess and identify medical patients at risk (Subbe et al, 2001). Since Mrs. G was a known hypertensive, MEWS was used to monitor her blood pressure. With the help of medication and lifestyle change, her blood pressure was maintained within normal range. The Waterlow Pressure Ulcer Risk Assessment identifies patients at risk for developing pressure ulcers and recognizes risk factors (RCN, 2001). Due to her hemiparesis, Mrs. G was regularly evaluated for the development of pressure sites on the weak side. This tool which incorporates the Malnutrition Universal Screening Tool (MUST) was used to monitor for changes in her skin integrity. In Mrs. G’s case, her Waterlow-MUST score was low risk since she was mobile, continent and had an average body mass index.

Another tool used was the Inpatient Faller Identification Tool which assesses and classifies patients as being high or low risk for falling (Sherrington et al, 2010). Mrs. G was admitted with a fall and was unsteady on her feet during assessment, hence a high risk score for this tool.

CRITIQUE AND EVALUATION
The Roper-Logan-Tierney model of nursing, which is based on activities of living (ALs) assesses an individual’s relative independence and potential for independence in ALs. As mentioned in the assessment, some of Mrs. G’s activities of living were hampered by her disability from stroke, hence the appropriateness of this model for assessment. This nursing model provided a solid foundation for the care plan of this patient by concentrating on areas that were relevant to her state of condition. The proper use of this type of assessment gave a clear picture of Mrs. G’s well being as well as her needs at that time. This helped the nursing team give a priority-driven care involving skills from the multi-disciplinary team. For example, the problem brought about by impaired mobility had engaged the services of doctors, nurses, physiotherapists, occupational therapists and psychologist, all of whom contributed in rebuilding the confidence and independence of the patient. Coordination with social care services, GP and relatives was also done to ensure continuity of care, as well as to provide physical, emotional and financial support for the patient.
The Roper-Logan-Tierney model of nursing has been suitable in the recognition of the patient’s problem because the patient was appraised through each activity of living. After thorough assessment, it has been identified that priority care should be given on mobility issue as this is associated with patient safety. For instance, the simple routine of toileting needs mobilization. In this case, Mrs. G’s capability to mobilize alone or with assistance; with or without the use of walking aids were evaluated and given appropriate interventions. Assessment also showed that she needed assistance in cleaning and dressing. The extent of this liability was likewise evaluated and given emphasis, so as to avoid occurrence of injuries or falls during bath. This type of assessment was also valuable, in the sense that staff allocation was thought off ahead of time depending on the need of the patient that was being prioritized at that time.
The nursing care plan addressed the need for patient safety to prevent patient falls. It dealt on patient empowerment and health education, as well as safety measures in mobilising. Strength training, for example has been given emphasis to speed up recovery, rehabilitation, and thus prevent future falls. One significant thing about this care plan was that it involved not only the patient, but the relative as well, in reducing identified risks for falls. Majority of the patient’s time are spent with relatives or carers / staff, so it is but wise to include them in the care plan as they are part of the care management team. The goals set in the care plan were to promote independence and to prevent in-hospital falls, as well as future falls. After implementation of said interventions and hard work from all the members of the multi-disciplinary team, Mrs. G was able to remain fall-free and independent on some of her activities of living.

CONCLUSION
Nursing rehabilitation is a crucial aspect of a stroke patient’s care and has to begin immediately after the stroke occurs to maximize benefit. By now, it is apparent that care for stroke patients should be individualized, meaning a person-centered rehabilitation program would ascertain that stroke patient’s needs are met in a way they find most beneficial for them. This type of program requires skilled multi-disciplinary team with strong links to social care, flexibility of care plan and most importantly, periods of intense rehabilitation.
Stroke in itself is a very sensitive issue for most survivors, regardless of gender or nationality. For many of these patients, life after stroke is just the beginning of the long journey of adjustment to and coping with its lingering effects. Recovery from stroke involves treatment, in which rehabilitation plays a big part. Majority of these stroke survivors perceive recovery as going back to pre-stroke activities, which is not always the case. As a result, this creates tension and havoc among patients, relatives and the multi-disciplinary team. One way to mend differences among all the people involved in the treatment is to incorporate communication, compassion and patience. These tools are vital in accomplishing the goals set by each person. On top of that, it is important that both the patient and relatives adapt to and accept the illness and its consequence, so as to become active members in the recovery process. Only when a patient starts to absorb information about his illness and its subsequent treatment, would recovery become truly meaningful.

The stroke rehabilitation unit in a hospital setting is a major breakthrough in healthcare. Patients who have had a stroke are given another chance to become active participants in their activities of living. They also benefit from the skills and knowledge of highly-qualified members of the multi-disciplinary team. However, for the common good of both patients and staff, it is imperative that the nurse-patient ratio be strictly 1:2, with one healthcare assistant per bay. This is relevant in terms of time spent and quality of care being given to each patient. If the quality of service rendered is high, chances are, recovery will be a lot faster, which would ultimately mean early discharge for the patient and less cash output for the hospital.

Rehabilitation is every nurse’s responsibility, and as rehabilitators, nurses are bound to act as teachers and travelling companion of patients in their rehabilitation journey. Though recovery depends largely on the patient, it is still the nurse’s role to motivate, inspire and guide these stroke survivors to achieve the goal of being able to function again in the community. A nurse’s contribution, in terms of patient outcome is worth more than a thousand words. It is when patients start to live their lives once again in the way they have aspired for, that nurses truly feel that their hard work has finally paid off.

References
Alexander, M., Faucett, J. et al (2000). The Patient in Need of Rehabilitation. Full-text [online]. Nursing Practice: Hospital and Home: The Adult. [Accessed 23 November 2010].
Bernhardt, J., Dewey, H. et al (2008). A Very Early Rehabilitation Trial for Stroke (AVERT). Full-text [online]. American Heart Association. [Accessed 23 November 2010].
Cheow, C. (2010). Sleep is An Important Aid to Stroke Recovery. Full-text [online]. Ezine Articles. [Accessed 23 November 2010].
Department of Health (2004). National Service Framework for Coronary Heart Disease: Winning the War on Heart Disease. 16-20. Full-text [online]. Department of Health. [Accessed 02 December 2010].
Department of Health (2005). National Service Framework for Long-term Conditions. p.4. Full-text [online]. Department of Health. Accessed 01 December 2010].
Department of Health (2007). National Stroke Strategy. London. Department of Health
Esquenazi, A. (2008). Falls and Fractures in Older Post-Stroke Patients with Spasticity: Consequences and Drug Treatment Considerations. Full-text [online]. Clinical Geriatrics. [Accessed 12 November 2010].
Healthtalkonline (2010). Stroke Recovery: Communication disorders. Full-text [online]. Healthtalkonline.Org. [Accessed 23 November 2010].
Healthtree (2010). Stroke Rehabilitation: Home Management and Nursing Facility. Full-text [online]. Healthtree. [Accessed 23 November 2010].
Kerse, N., Parag, V., Feigin, V. et al (2010). Preventing Falls Important for Stroke Patients. Full-text [online]. Americam Heart Association. [Accessed 12 November 2010].
National Health Service - Greater Glasgow and Clyde (NHS-GGC) (2010). Rehabilitation After A Stroke: Getting Back to Work. Full-text [online]. National Health Service – Greater Glasgow and Clyde. [Accessed 23 November 2010].
National Institute on Clinical Excellence (2008). Stroke: Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack. Clinical guideline 68, 17-19. Full-text [online]. National Institute on Clinical Excellence. [Accessed 22 November 2010).
National Stroke Association (2009). Stroke Facts. Full-text [online]. National Stroke Association. [Accessed 23 November 2010].
Rhodes, M. (2009). Stroke Recovery: Coping With Eating Problems. Full-text [online]. WebMD. [Accessed 23 November 2010].
Roper, N., Logan, W. et al (2000). Model of Nursing: Based on Activities of Living. Churchill: Livingstone.
Royal College of Nursing (2001). Pressure Ulcer Risk Assessment and Prevention. p. 14. Full-text [online]. Royal College of Nursing. [Accessed 01 December 2010].
Royal College of Physicians (2000). National Clinical Guidelines for Stroke. Sudbury, Suffolk: The Lavenham Press Ltd.
Scottish Intercollegiate Guidelines Network (2002). Management of Patients with Stroke. Volume 1, p.13. Full-text [online]. Scottish Intercollegiate Guidelines Network. [Accessed 12 November 2010].
Sherrington, C., Lord, S. et al (2010). Development of a Tool For Prediction of Falls in Rehabilitation Settings (Predict First).: A Prospective Cohort Study. Full-text [online]. JRM Medical Journals. [Accessed 05 December 2010].
Stroke Foundation (2008). What is Stroke? Full-text [online]. Stroke Foundation. [Accessed 23 November 2010].
Stroke Recovery Association (2009). The Effects of Stroke. Full-text [ online]. Stroke Recovery Association of Barrie and District. [Accessed 23 November 2010].
Stroke Rehab Online (SRO) (2010). Hope in Stroke Recovery Prayer Wishes. Full-text [online]. Stroke Rehab Online. [Accessed 23 November 2010].
Subbe, C.P., Kruger, M. et al (2001). Validation of a Modified Early Warning Score in Medical Admissions. Vol. 94, Issue 10. Full-text [online]. QJMed. Oxford Journals. [Accessed 05 December 2010].
Timby, B.K., Smith, N.E. (2003). Introductory Medical-Surgical Nursing. Philadelphia: Lippincott, Williams and Williams.
Vega, J. (2008). Sexuality After Stroke. Full-text [online]. About. Com. [Accessed 23 November 2010].
Willacey, H. (2008). Cerebrovascular Event Rehabilitation. Document Version 21. Full-text [online]. Patient UK. [Accessed 24 November 2010].
Williams, J., Perry, L. et al (2010). Acute Stroke Nursing. London: Blackwell Publishing Ltd.