The purpose of this essay is to demonstrate care that is provided for an individual who has suffered an acute stroke . In this instance, the scenario that will be considered ; is about a 40-year-old lady, Amita; who has suffered a haemorrhagic stroke. A detailed handover has been given, discussing the background, possible contributing factors and a detailed ABCDE assessment of Amita on hospital admission. The reason for choosing this scenario is because in first placement of my second year of nursing, I was based on a stroke rehabilitation ward. During this time I had the opportunity to spend half a day on an acute stroke unit, this would be where our patients would be transferred from; once they had started recovery and were ready for rehabilitation. Acute care is defined by World Health Organisation (2013) as providing care for a patient, who has undergone a sudden commencement of a medical condition or an exacerbation of a known chronic disease; that lasts for a short duration of time. An acute episode can be described in 2 separate ways, these being minor, or serious; and the outcomes are determined on the severity of the clinical symptoms (Jones, 2010).
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The essay will present evidence-based practice, by prioritising risks that occur post stroke; and this will be in accordance of the Fundamentals of care (Welsh Assembly Government, 2002) and the Nursing Process (Lynn, 2018). The structure of this essay will commence with detailed interpretation of the handover, identifying how the stroke clinical symptoms are associated with Amitas presenting background. Moving on to identify, discuss and prioritise the identifiable risks; and be able to demonstrate what should be considered next, in order to provide the correct care. The ABCDE assessment will then be reconsidered, in order to detect any changes with Amita and her care; the ABCDE framework will be discussed and relevant literature will be evident in order to support the outcomes. Leading on to the final section, which will focus on the care and safety of Amita for the duration of an eight-hour shift; planned interventions will be discussed, in accordance to the welsh assembly fundamentals of care.
Agrawal (2017) suggests a haemorrhagic stoke either arises due to a brain aneurysm bursting under pressure, or when a blood vessel becomes weak and is caused to leak. Cells and tissues in the brain are then damaged, by spilt blood entering brain space, which is caused by swelling and pressure. A haemorrhagic stroke can be identified through 2 names, intracerebral or a subarachnoid. Stated by Stroke Association (n.d.) a haemorrhagic stroke is only at a 15% rate in the UK, in comparison of a ischaemic stroke, which stands at 85%.
Interpretation of handover.
It is stated that the reason for Amita’s admission, was due to a collapse at home; and it has been later discovered through a CT scan, that she has suffered a haemorrhagic stroke. The handover of Amita discusses multiple indications of things that could have possibly lead to the current situation that she is in, and through interpretation there are multiple clinical symptoms of stroke that correlate with her background. Amita appears to live a very busy and family orientated lifestyle. With Amita having three children that are still dependent on her, a husband that works away, a full time job and other worries such as work inspections and her daughters GCSE’s, it appears that she has a lot to balance; British Heart Foundation (n.d.) suggests that personal stress can be playing a part in her day to day living, and could be a factor that can lead to the stroke. Sundermann (n.d.) suggests that stress alone is not commonly seen as a risk factor of a haemorrhagic stroke, but if other risk factors are present such as hypertension; a stressful lifestyle or event is capable of increasing levels of cortisol and adrenaline, which then has an impact on blood pressure rise, which can then lead to a stroke.
Although the handover does not state the amount of physical activity Amita undertakes, it suggests that her life is occupied by other priorities such as home life and work; so, she does not have much time to fit in a regular and adequate amount of exercise. Healthlink (2019) states that by taking part in moderate exercise, for only 30 minutes a day would help maintain lower blood pressure and avoid the risk of obesity; which are both high risk factors of stroke. It is stated that Amita drives back and forth to work, to save time; this suggests that the distance is not too long and walking or cycling to work could be an option. Exercise encourages blood vessels to work more effectively and has a positive effect on the brain; this helps to prevent strokes by protecting any damage to the arterial systems (Harvard medical school, 2014). As stated, Amita has been gradually gaining weight over 3 years. Taking Amitas height, weight, age and amount of physical activity into account, the NHS (2018) states that Amitas BMI is 28.6, and it is suggested that she is overweight. Literature suggested by (Kotchen, 2010) due to Amita being overweight, the risk of hypertension is increased due to the fatty tissues encouraging vascular resistance, causing the heart to work faster to get blood pumping around the body.
It has already been identified that Amita has been diagnosed with hypertension in the past, during an appointment with her GP. Hypertension is one of the factors that has been identified throughout the handover, that has a massive impact on Amitas current state. Hypertension is one of the most vigorous risk factors for ischemic and haemorrhagic stroke, it has been estimated that 54% across the world are known to have been caused due to high blood pressure (Aiyagari & Gorelick, 2016).
Amita declined any intervention of medication, for high blood pressure and had been missing follow up appointments. It would be assumed that if medication was taken, Amita’s stroke could have possibly been avoided. National Health Service (2019) suggest that when Amita was diagnosed with high blood pressure, medication should have been taken as directed, even though medication may be prescribed for the foreseeable future; it would have lowered Amitas risk of stroke. It is suggested by ( Blood Pressure Association, 2008) that a satisfactory recovery is possible, Amita will be cared for by a range of health professionals; usually a stoke team. This may include professionals such as speech and language specialists, dietitans and occupational therapists. Amita was only able to make groaning sounds when found collapsed by her husband. This is suggested that there has been a possible effect on her speech, due to the stroke that she has suffered. This suggests that Amita has suffered from a left sided stroke, as in a high percentage of people, the left side of the brain; controls the ability for speech to be present, and the understanding of language (Allina Health, 2018). Through reading the handover, it seems that Amita may be suffering with an impairment of language, known as aphasia. This is condition that is caused by a brain injury, most common in stroke patients. The symptoms of aphasia are not always the same; it can be a single aspect of language use, including having the ability to say the names of items or it could affect the ability to speak or a read a sentence. However, more often than not, multiple aspects of communication become affected by this. This is suggested by the National Aphasia Association (n.d.) Suggested by O’driscoll (2016), critically ill patients who are being nursed outside of a specific critical care setting, such as ICU and HDU; should have their condition assessed and monitored through the popular physiological system, such as the National Early Warning Scoring system (NEWS). Through reading the handover, and using the NEWS system; it is calculated that Amita is scoring an 8. This score suggests that Amita is at high risk, as Hancock (2013) states that this score is an indicator that a patient will deteriorate quickly. Furthermore, NEWS is essential in the management of patients with suspected sepsis risk. If a high NEWS score is detected, in this case; 5 and above, sepsis screening must be done (Marsden, n.d.).
Discussion of the risks
Suggested by National Institute of Neurological Disorders and Stroke (2019) as Amita is neurologically compromised, an outcome of the stoke; her movement is limited, due to having a right sided weakness; which makes repositioning herself difficult and is now impacting on her airway remaining patent. A major risk that Amita may experience due to this, is airway obstruction. Many things could potentially cause this; blood, present fluid in airways, vomit, or the patients tongue ( Lloyd, 2000). As already discussed in handover, there was gurgling sounds were detected, when Amita was breathing. Suggested gurgling sounds are heard, it suggests that air is being forced to travel through fluid, which indicates that there is fluid partially obstructing the upper airway (Henry, Stapleton & Edgerly, 2012). If the airway was to be obstructed, it could cause Amita to become unresponsive, fastly. Wint (2018) supports this as she mentions that an airway that is obstructed, can prevent the passing of oxygen to the brain; and a lack of oxygen can lead to severe brain damage in a matter of minutes. As stated in handover, Amita’s respirations were 22 breaths per minute; although we do not know what the usual is for Amita; 22 is seen as high as the RCN (2016) suggests a woman should be taking between 16 to 20 breaths per minute. This suggests that Amita could be at risk of an upcoming infection, as it is the bodies way of suggesting that there may be a severe instability in a body system and could be a sign of potential risk to the patient, West and Luks (2016) supports this.
Another risk identified is Amita’s, GCS scoring and the ability to respond. Currently there is little response, although Amita responded to voice command, it does not state to what extent the response, she did not give feedback when questioned if pain was present. In accordance to Teasdale, (1974) and the Glasgow Coma Scale Amitas current score is 10/15. A risk of a drop in GCS score has been identified due to the handover stating that Amitas motor response was scored at 5, yet in contrast; also states that Amita did not respond when she was questioned about having pain, which suggests that pain was not localised. This could suggest that Amitas GCS score, could drop by this finding alone; causing Amitas score to drop to 8 or below, suggesting severe head injury (Nagalakshmi, 2018).
Another risk identified is Amita’s susceptibility of pressure damage, due to the severity of her stoke, she is currently bed bound and is currently unable to reposition herself; due to having no movement on the right side of her body (Lindgren, Unosson, Fredrikson, & Ek, 2004). Amita did not respond when asked if pain was present, her risk of pressure damage is; as she may not be able to feel pressure, ease it or locate her pain.
Focus of reassessment
Thim (2012) suggests that the ABCDE assessment was created with the aim of maintaining life with a critically ill patient, and to be able to achieve the first parts of patient improvement; encouraging a structure in finding potential deterioration. Key parts are outlined, for health professionals to make the best out of a critical situation. Using ABCDE is the first point of action, ensuring that the assessment and treatment is correct for each patient. The assessment suggests that potential life-threatening factors should be priority, before moving onto the next stage. Another key point is for professionals to be able to recognise when extra help is needed, and when other team members are involved; they should all be used, for any form of intervention to be carried out simultaneously (Resuscitation Council, 2014).
In order to anticipate any changes that could possibly occur with Amita, an initial re-assessment of ABCDE would be completed. This is in order to ensure that the risks Amita is exposed to, are prioritised and to encourage safe and effective continuous care; in an acute stroke situation.
A- Re-assessment of the airway would mean ensuring that the airway was maintained as clear and patent; this including any objects such as vomit, saliva or even the tongue; causing a partial or full obstruction. McGrath (2013) supports that measuring for an oropharyngeal airway and ensuring that is to hand in case of any sudden deterioration, as it could be a situation where suction may also be required. Resuscitation council (2015) implies that although currently, Amitas airway is seemingly clear and stable, the ‘look, listen and feel approach would be appropriate here, in order to recognise changes that could cause potential risks in the future.
B- To improve the respiratory rate of Amita, placing her in a position that helps regulate and ease breathing would be essential during re-assessment. Kelly (2018) made the link that a person’s respiratory rate is often spotted first, during the deterioration of a patient. Maindal (2016) supports that positioning is essential for breathing rate, as he suggests that for a patient whos breathing is abnormal, lying down and having the bed at roughly 30 degrees; encourages gravity to push secretions away, and encourages easier breathing. As stated, Amita’s bed is already in the 30-degree position, regular monitoring to ensure that breathing is easing, and is not getting worse or harder. A nurse should look for a change in Amitas vital signs, specifically in respiratory rate or a decrease in oxygen saturations, with regards to the safety of airway (Royal College of physicians, 2015).
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C- As already stated 180/90, was Amitas blood pressure reading on admission. During the re-assessment stage, it would be essential to take another manual reading of this and record it on the NEWS scoring system, and this would to be able to detect whether it is remaining the same, or whether the blood pressure is fluctuating. If during reassessment, the nurse found that the readings were staying around 180/90mmHg; suggested interventions such as the input of IV hypertensives would be considered (Elliott, 2016).
D- Re-assessment of Amita’s disability would detect any changes to her GCS score, and vital signs. She is currently responding to voice but did not give an answer when she was asked if any pain was present. This could potentially mean that she is slipping in and out of consciousness or is unable to locate or feel pain. The current GCS score could potentially change during the re-assessment, if Amita’s ability to respond, move and adhere to commands either increases or decreases. An important assessment tool that nurses should implement here, is the NEWS chart; which is an effective way of monitoring a patients vital signs, and quickly determine deterioration (1000 lives, 2013). As already mentioned, Amita is only responsive to voice, it would be essential for nurses to re-assess Amitas GCS score, in order to detect whether there is a level of improvement or deterioration of brain function and consciousness. Amita’s current GCS score is moderate, but if further deterioration was to occur; the score would decrease and become severe (Flinders University, 2013). It is stated by the Intensive Care society (2014) GCS assessments and NEWS scoring, would encourage the nurses to detect any important risks. The NEWS score and GCS score would be affected if for example, the patients oxygen levels were to decrease; this would then be detected through the usage of a oximetry machine. Nurses usually monitor physiological observations every 12 hours at lease; this being in regards to no decisions have been made to increase them. As abnormalities have been detected, nurses should increase the monitoring of Amitas NEWS score, to no less than every 2 hours for the first 4 hours of care (NICE, 2007). As Amitas pupils are both measuring differently, and she has suffered an injury to the brain, nurses should reassess this by implementing neurological observations; through the GCS assessment.
E- The nurses would need to reassess the IV cannula site, to ensure that it remains patent and able to use. Goossens (2015) suggests that reassessing the IV site, includes a flushing of the cannula with saline, before and after usage helps to reduce blockages of the site. A nurse should also monitor the bruising that has been detected on Amitas left shoulder, as a common issue from a bruise is a haematoma; which is commonly related to a significant trauma. A bruise may not heal so easily if a haematoma is present; as it slows the healing process down (Fletcher, 2018).
In order for Amita’s safety to be ensured for the duration of the acute phase of her stroke, nursing interventions are implemented, to help prevent further deterioration. The treatment and care of Amita here, will take into consideration her needs. For the duration of an 8-hour shift, good communication throughout the health care professionals, and including Amita as much as possible is vital. Any form of nursing interventions should be carried out in a holistic manor; and to ensure safety at all times towards the patient, in accordance to the FoC (Welsh Assembly Government, 2002)
Pressure care and Immobility-
Following a stroke, positioning is key when trying to achieve a high standard recovery; this is done by controlling muscle tone, try to provide adequate sensory input, and can also avoid other complications such as pressure sores, pain and respiratory issues (Ada, Goddard, McCully, & Bampton, 2005). The right positioning can avoid complications of the respiratory system, the suggested position would be expected here. The fowlers position, otherwise known as the standard patients position, was a technique implemented for patients who have difficulties in self-repositioning; and this encourages an easier talking, eating and breathing pathway, with the help of gravity, Funnell, Koutoukidis, & Lawrence (2009) support this. Due to having a stroke, Amita is feeling numbness or and has a loss of feeling sensation to the right side of the body. The implication of this, means an opportunity of other problems, as it can make a Amita unaware of possible harm, being caused to the body. Further complications such as chronic pains, possible dislocations and furthermore. If a patient is unable to move a part of their body, having help to reposition herself, Amita will avoid the risk of gaining a pressure sore. Suggested by University Hospital Southampton NHS Foundation Trust (2014) the most effective way of preventing pressure sores is by repositioning of the body, to relieve pressure from the at risk areas. Due to the severity of Amitas stroke, it is likely that she will have a decrease in her mobility for a long while. Pressure damage is a large concern in stoke patients, as they are unlikely to be able to repostion themselves, as and when needed. UPMC (n.d.) implies that , as a loss of sensation is usually lost; patients are more vulnerable, to not being able to feel any pressure applied, or may not be able to locate pain. According to Advanced Tissue (2015) it is suggested that Amita would benefit from being nursed on a pressure relieving mattress, and has assisted repositioning, as often as 2 hours; in order to relieve pressure on skin, and prevent a build-up of moisture, as this contributes to pressure sore development. Due to Amita having limited mobility, the nurse may need to intervene here and administer a form of blood thinning medication (NHS, 2011). Medication helps to prevent the risk of deep vein thrombosis, by encouraging blood proteins to work differently (Stroke Association, 2019). DVT is known to develop when a patient has been inactive for a number of days, and due to Amita’s situation, DVT could cause further issues if not treated or prevented. VTE prevention team (2016) states that not only is medication prescribed in order to prevent DVT, there are also other protocols such as; anti-embolisim stockings, which are designed to prevent blood clots through pressure to the legs, or alternatively specialist inflatable leg sleeves may be placed around the lower leg, whilst a patient is in the supine position in bed. These sleeves inflate automatically, also applies adequate pressure. In concern of Amita’s safety, even as she is deprived of her mobility, it is cautioned by using the Health and Safety Executive (2013) that a bed rail assessment would be conducted, to restrict the hazard of falls. This evaluation would then be reconsidered, when patients mobility status has improved.
When a patient suffers from a stroke, them achieving adequate nutritional value becomes compromised (Dennis, 2000). Amita may now be struggling with a condition that comes from a stroke, called dysphagia. This means that she may find it difficult to swallow; this meaning with foods, liquids, or even her own saliva. As a result of dysphagia, other complications such as malnutrition, rapid weight loss and can even higher her risk of pressure sores (Brown, 2013). As a nurse, it would be essential to make a referral to a speech and language therapist for a swallow assessment to be conducted. Suggested by Priory (2019) the first assessment of swallowing on a stroke patient, should be commenced at the acute stage of stroke; within 24 hours of diagnosis. The importance of this, is so that the risk of aspiration and chocking is minimised. Nursing care in relation to nutrition is conducting a MUST assessment; to determine Amita’s malnutrition risk (Bapen, 2011). The Malnutrition Universal Screening Tool (MUST) was introduced for health professionals to be able to screen patients who are at risk of malnutrition Stratton, Hackston, Longmore, Dixon, Price, Stroud, and Elia (2004). A MUST assessment that is implemented on a stroke patient, and with an outcome of a score of 2 and above; is then referred onto a stroke specialist dietitian for best outcome. Brown (2013) suggests that consideration of the patients current oral ability and intake, along with with calculated nutrition requirements will then be used to assess whether additional nutritional support will be needed; additional support could include, high calorie drinks or snacks, foods with added micronutrients, pureed diet or thickened fluids, this is supported by Wright, Cotter, Hickson & Frost (2005).
In conclusion from producing this essay, and researching the haemorrhagic stroke; it is evident that the acute care stage, is the determinant of how situations could improve or deteriorate quickly. From going through the essay structure and having to write it out; it has encouraged knowledge and understanding, in relation to the ABCDE assessment phase, handover interpretation and implemented nursing care. It has become evident that in the nursing role, having the knowledge and understanding to be able to interpret given information, and know what steps to take next; in order to prioritise risks and provide the right care. Being able to re-assess is vital, at the same time as working in accordance of the nursing process and taking the fundamentals of care into consideration. It is now made it evident that monitoring patients, taking ordinary observations and carrying out the appropriate risk assessments; is the way in which any anticipated changes, or apparent modifications should be detected. Being capable to recognise the deterioration of patients, is a quickly manner and can happen at any second during an acute phase. This is necessary as in an acute setting, as the distinct respondents in every individual, and each given intervention; affecting the different in distinct ways. All interventions and assessments should be safe, patient centred and applied holistically. After a stroke, it is necessary for a nurse to be aware of surrounding risks and threats to the patient. Being able to prioritise care in accordance to identified risks is vital for patient recovery. This essay has motivated the understanding of how vital the FOC and nursing manner are; when dealing with an acute episode, specially stroke; and being able to put into effect them and work critically for the period of one shift alone.
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