Nursing Crisis Intervention: Stroke

Stroke is a global problem of the increasing elderly population. According to the Department of Health (2007a), stroke is the third leading cause of death in the UK, with more than 110,000 individuals falling victim to a stroke each year at a cost to the National Health Services exceeding £2.8 billion. The Stroke Association (2007) places this number at 130,000 with a mortality rate at 67,000 per year, including indirect costs of £1.8 billion and costs for informal healthcare following stroke at £2.4 billion. Incidence of stroke is equally as prevalent elsewhere, such as in the United States where, as the third leading cause of US deaths (Becker & Wira 2006; Nolan & Naylor 2003) stroke is the leading cause of disability (Becker & Wira 2006; Stroke Association as cited by Amber 2003, p. 316; Stroke Association 2007). Becker and Wira (2006) state the incidence of stroke within the United States is 400,000 individuals per year with an anticipated growth to over 1 million yearly stroke victims by 2050. The American Stroke Association (as cited by Amber 2003, p. 316) states “every 45 seconds, someone in America has a stroke. Every 3.1 minutes, someone dies of one.”

Nolan and Naylor (2003) state an average of 35,000 individuals suffer strokes when hospitalized for other unrelated illnesses. Such was the case for Ms. C., who suffered an ischemic stroke while hospitalized for a pacemaker implant.

As the unit nurse assigned to care for Ms. C., subtle signs of her stroke were noticed and reported to the Code Gray^[1] team for immediate response. The many roles of a unit nurse in the presence of a crisis are vital in providing adequate care to her patient, including the need to maintain a calm demeanour in the face of chaos. A number of rapid physical assessments must be performed including the use of the FAST criteria^[2] (Mathiesen et al, 2006), response teams must be alerted and the nurse must keep the patient calm and oriented throughout the flurry of activity that can easily upset an elderly individual. While all emergencies call for rapid response, it is even more critical in the case of stroke when, if the patient is eligible for recombinant tissue plasminogen activator (t-PA)^[3] a detailed physical history and examination, a neurological assessment, computed tomography (CT) scan and additional blood work must be performed before irreparable damage from the stroke occurs.

With a focus on patient impact and nursing interventions, this paper will present the case study of Ms. C.

Case presentation

Ms. C., a 78-year-old, ambulatory, Caucasian female was admitted to the hospital for the replacement of a cardiac pacemaker. Ms. C. was widowed 5 years prior to her current hospitalization and lived alone having two married children living in Scotland and Wales. Prior to admission Ms. C. was diagnosed with high blood pressure (HBP), high cholesterol, was diabetic, and was on pharmaceutical medication for all three conditions. In spring 1995, Ms. C. had recurrent bouts of tachycardia alternating with bradycardia. Following an attempt to control the situation through pharmaceutical intervention, her cardiologist recommended she receive a cardiac pacemaker; which was implanted without complication the same year. She reports remaining in good health since that time; although additional medical notes indicate the onset of dementia, as she appears confused at times.

Upon admission, vitals were normal, with the exception of her blood pressure (BP) which was 175/95. Her physician ordered Ms. C. be started on Losartan^[4]. Subsequent vitals indicated a fluctuation in BP ranging from a low of 170/90 at 1AM to a high of 195/110 at 10AM. As Ms. C. was not responding to medication or fluid balancing recommended by her physician and her BP continued to climb, her cardiologist postponed surgery until her BP was brought under control. At 11:48am, when taking Ms. C.’s vitals, she appeared confused, her speech was slurred, there was slight facial droop and she could not extend her arm for the blood pressure cuff. At 11:50am a Code Gray alert was sounded.

Impact on the patient

When assessing the impact to the patient when a stroke occurs, the nurse must be aware of the implications on a variety of levels, including biological, psychological and sociological. In the case of Ms. C., there were additional implications for each of these due to the combination of her low-level, yet progressive dementia.

Biological changes in an ischemic stroke (confirmed by the CT scan as opposed to hemorrhagic) were the result of a thrombolytic occlusion at the cerebral artery branch point due to atherosclerosis. On the cellular level, neuronal damage occurs when neurons become depolarized and allow for inordinate amounts of calcium to cross the cellular membrane that ultimately leads to a destruction of said cellular membrane and other structures within the neuron (Becker & Wira 2006). Becker and Wira (2006) also comment on the neuronal damage caused by free radical, arachidonic acid and nitric acid generation that takes place during the ischemic cascade^[5]. Genetic activation also takes place and leads to the production of cytokines in response to and as a cause of inflammation that can “consume” the ischemic penumbra (Becker & Wira 2006). If one can limit the degree of injury to the ischemic penumbra located within the origami, the degree of permanent damage due to the ischemic episode is limited and is the goal of immediate stroke response (Becker & Wira 2006).

A combination of diagnostic laboratory tests^[6] and rapid nursing assessments would be required to assess the level of damage. Although the Code Gray approach is geared towards rapid response to allow for administering t-PA within the three-hour window, Ms. C. was not eligible for t-PA treatment due to her uncontrolled hypertension (Bonnono et al. 2000, p. 300).

The psychological impact on Ms. C was the most dramatic as her post-stroke status left her more confused and fearful than one might find in a strike victim due to the comorbid dementia. In addition to being frightened of the unknown and feeling very alone as a widow and without her children present, Ms. C. felt betrayed by her body and didn’t understand what was happening to her or why. Psychologically Ms. C. had to be kept calm and be reminded of what was occurring and why, with such orienting comments as “You are going to be examined by Dr. X” or “You are going to have a test done that won’t hurt you. There is no need to be afraid; I’ll be with you to assure you’re safe.” With the unknown of any comprehension deficits caused by the stroke it was also important to remind other team members that Ms. C. had problems with confusion and that it was important “for patients with dementia in particular to understand what is about to happen to them” (Cunningham & McWilliam 2006, p. 14). Cunningham and McWilliam (2006, p. 14) suggest that nursing staff must compensate in their communication with dementia patients and that this often requires nurses to re-prioritize their tasks and sense of immediacy in order to offer the patient the greatest level of psychological and/or emotional support. Lipley (2005) states one of the most important nursing tasks is offering support to a stroke patient.

The sociological impact relating to Ms. C.’s crisis was limited for the immediate future while hospitalized, although she indicated that she wanted her children contacted and requested they come to the hospital. The biggest sociological change and challenges facing Ms. C. would be following her discharge from the hospital. Depending on the amount of total damage suffered from her stroke and the subsequent progress with therapy to regain lost functionality, it was probable that Ms. C. would relocate to either live with one of her children and/or settle in a home for the aged. This required the nurse to contact a social worker to help Ms. C. with her adjustment.

Implications for the organization

One of the six strategic goals established by the Department of Health’s National Stroke Strategy (2007b) is to “accelerate the emergency response to stroke and improve coordination between different agencies and professionals involved including through improved access to CT scanning.” Fortunately, the hospital where Ms. C. suffered her stroke complied with this goal and had a Code Gray team assembled. National Health Services (2007) approximates 90 percent of hospitals in England as prepared to administer specialized stroke services.

The number of stroke victims is increasing every year. The nurses must be aware of required interventions. This paper has highlighted the ischemic stroke and patient impacts, as well as those on the organization and nurse. The charts below presents required nursing interventions in response to an inpatient stroke.

Reference

Amber, R., & Watkins, W., 2003. The community impact of Code Gray. Critical Care Nursing Quarterly, 26 (4), pp. 316-322.

Becker, J. U. & Wira, C., R. 2006. Stroke, Ischemic [Online]. Available from: http://www.medscape.com/emerg/topic558.htm [cited March 16 2007].

Bonnono, C., Criddle, L. M., Lutsep, H., Stevens, P., Kearns, K., & Norton, R., 2000. Emergi-paths and stroke teams: An emergency department approach to acute ischemic stroke. Journal of Neuroscience Nursing, 32 (6), pp. 298-305.

Cunningham, C. & McWilliam, K., 2006. Caring for people with dementia in A&E. Emergency Nurse, 14 (6), pp. 12–16.

Department of Health, 2007a. Stroke [Online]. Department of Health. Available from http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Stroke/index.htm [cited March 16, 2007].

Department of Health, 2007b. Developing a national stroke strategy [Online]. Department of Health. Available from http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Stroke/DH_4132138 [cited March 16, 2007].

Department of Health, 2007c. Good practice examples and case studies: standard five (strokes) [Online]. Department of Health. Available from http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Olderpeoplesservices/Olderpeoplepromotionproject/DH_4002291[cited March 16, 2007].

Lipley, N., 2005. Different strokes… Emergency Nurse, 13 (5), p. 5.

Mathiesen, C., Tavianini, H. D., & Palladino, K., 2006. Best practices in stroke rapid response: A case study. Medsurg Nursing, 15 (6), pp. 364-369.

Nolan, S., Naylor, G. & Burns, M., 2003. Code Gray: An organized approach to inpatient stroke. Critical Care Nursing Quarterly, 26 (4), pp. 296-302.

Spilker, J., Kongable, G., Barch, C., Braimah, J., Bratina, P., Daley, S., Donnarumma, R., Rapp, K. & Sailor, S., 1997. Using the NIH stroke scale to assess patients. Journal of Neuroscience Nursing, 29 (6), pp. 384-393.

Stroke Association, 2007. Facts and figures about stroke [Online]. The Stroke Association. Available from http://www.stroke.org.uk/media_centre/facts_and_figures/index.html [cited March 16, 2007].

Wojner, A. W., Morgenstern, L., Alexandrov., A. V., Rodriguez, D., Persse, D., Grotta, J., 2003. Paramedic and emergency department care of stroke: Baseline data from a citywide performance improvement study. American Journal of Critical Care, 12 (5), pp. 411-417.

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Footnotes

^[1] The term generally accepted in the medical community for multidisciplinary stroke response teams. The typical composition of a Code Gray team includes a primary care RN, charge RN from the Stroke/cardio care unit, an ICU RN, ICU resident, a neurologist, CT technologist and an individual responsible for telecommunications (Nolan & Naylor 2003, p. 297). The Department of Health (2007c) reports that other Code Gray teams also include occupational therapists, physiotherapists, speech and language therapists, dieticians, pharmacists, a clinical psychologist and social worker.

^[2] FAST criteria is the acronym also known as the Cincinnati Pre-hospital Stroke Scale, such that F = Facial Droop, A = Arm drift, S = Speech and T = Time (Mathiesen et al. 2006; Lipley 2005).

^[3] t-PA must be administered within three hours of the first onset of symptoms (Amber 2003).

^[4] Losartan is an angiotensin receptor blocker. The choice was made to use this type of intervention based on the muscle relaxing nature of the medication rather than incorporating those that lowered BP through a modification of electrical activity within the nervous or cardiac system due to the reliance on her pacemaker and the potential other such forms of medication might have on recurrent tachycardia or bradycardia.

^[5] Ischemic cascade is the term referring to the chain of events that takes place following an ischemic stroke.

^[6] Although a variety of diagnostic blood work was already performed on Ms. C, a CBC, chemistry panel and cardiac biomarkers were ordered following the stroke for comparison against pre-stroke values along with coagulation studies (Becker & Wira 2006).