Introduction-
CVA i.e. cerebrovascular accidents are generally a
result of a blood flow interruption in certain areas of brain and are often
characterized with sudden onset of neurological disorders which continuous for
at least a period of 24 hours. There is a range of symptoms that occurs
includes weakness, speech impairment, tingling and also includes some severe
symptoms such as aphasia, loss of visual field etc. Several clinical
manifestations available which depend mostly on the factor such as area of
brain affected collateral cerebral circulation and extensiveness of cerebral
edemas. The classifications of cerebrovascular accidents are largely done based
in etiology. Ischemic and hemorrhagic are the major classification of CVA. Ischemic
CV is caused most frequently due to thrombosis or due to the formation of
embolus. In case of hemorrhagic CVA,
extreme hypertension, arteriovenous malformation and cerebral aneurysm play a
major role. The treatment if CVA is
mostly is determined with the etiology as well the neurological problems that
are present. This essay focuses on
designing a care plan on the elderly woman aged 79 with several sign and
symptom representing CVA. The care plan
mostly focuses on the common problems that are associated with CVA and also
provided with several interventions on the tabular format. (Mergenthaler,
2012)
Pathophysiology of Cerebrovascular Accident-
Types of Cerebrovascular Accident-
There are two major types of cerebrovascular accident
of which one is Ischemic and the other one is hemorrhagic. Ischemic stroke may
cause due to the presence of the deep vein thrombus that result in the blockage
of blood vein that carries oxygen to brain whereas hemorrhagic stroke occurs
due to severe hyper tension. In this case
the patient has the medical history of deep vein thrombosis as well as
hypertension and with the initial examination it was not found to be CVA but
later on a small CVA was observed of which these to reason can have a vital
role to play.
Symptoms of Cerebrovascular Accident-
It is recommended that as fast as the diagnosis is
done, the treatment can be started for a better prognosis to happen. It is
sparingly important to understand the general symptom of CVA for an early
diagnosis. The symptom includes-
·
Walking
difficulty
·
Dizziness
and Anxiety.
·
Facial
drooping
·
Difficulty
in speaking or understanding what overs are saying?
·
Paralysis
in any side of the body
·
Severe
headache and Nausea
Out of these symptoms the patient was having most of
them like facial drooping, difficulty in speaking, severe headache as well as
she was having severe weakness on the left side of the body. So the symptom was
clearly indication towards CVA.(Mergenthaler, 2012)
Diagnosis-
There are several diagnosis methods available
depending on the severity of the symptoms. The diagnosis includes CT scan, MRI,
blood test etc. Due to severe headache and symptomatic anticipation, a CT scan
was carried out to investigate whether the patient is suffering from CVA or
not. But the initial test doesn’t show any sign of CVA in brain. The blood
pressure was also controlled followed by normal ECG report. Later after 18
hours it was found that the patient was having minor CVA in the left hemisphere
of the brain. (Dorze, 2010)
Treatment-
The patient was already under the medication of
flecainide, hormone replacement therapy, amlodipine, aspirin, simvastatin and
trandolapril before the CVA has occurred. These medications are prescribed to
control the hypertension of the patient. But as far as the symptoms are
diagnosed in the patient, it seems that due to the presence of thrombus it
happened. So the patient was then prescribed with some clot busting medication.
The condition was not too severe so the medication was given intravenously and
not by directly injecting the clot buster to brain or by operating it.
Further, after the stroke, for the next 24 hours the
patient was also involved in rehabilitation protocol with the help of speech
therapy, neurologist, also there was an involvement of psychiatrist etc. The
following table will show the intervention and the rationale involved depending
on the symptoms of the patient as observed.
Nursing Diagnosis
·
Problem in Communication, Verbal
Droop, Aphasia, Hemiparesis
May be related to
·
It can be because of improper
cerebral circulation, impairment in neuromuscular region, loss of oral muscle control and weaknesses.
Possibly evidenced by
·
Impairment of Articulation., Cannot
able to speak or say anything(Dysarthria)
·
The patient was unable to modulate
the speech, naming and finding any word, object identification, comprehension
of any written communication is lacking.
·
Not able to produce any written
communication also.
Desired Outcomes
·
To provide an indication of
understanding the problems lies in communication.
·
To device a methodology of
communication that can be expressed.
·
To use all the resources properly
and very efficiently.
Nursing Care Plan
|
Nursing Interventions
|
Rationale
|
|
Assessment of the Dysfunction that
happened i.e. the patient is having problem in speech and communication
either in understanding words or having trouble in speaking or
self-understanding too.
|
It will help in the determination
of degree and the area of brain that is involved and also helps in assessing
the difficulty the patient is having in terms of communication process. The
patient was having receptive aphasia as well as damage in the Wernicke’s
speech area that can be easily understood by the way the patient was having
difficulty in understanding the communication. The patient was also having
difficulties in speaking which is also known as expressive aphasia or there
can be damage in the broca’s area in which the CVA patient feels difficulty
in uttering any word during speaking.The intervention was given on the basis
of impairment that was most extensive. The patient was suffering from
expressive aphasia so the intervention was given according to the symptom.
Due to the
facial droop and paralysis of the oral muscles the patient was also suffering
from dysarthric in which the patient are not able to pronounce any words due
to their It Itdifficulty in saying something. (Hackett,
2008)
|
|
Monitoring the neurological
complications
|
The neurological complications
were regularly monitored in order to know if there is any ease of left-sided hemiparesis
|
|
Regularly checked the Blood
pressure and Cardiac output
|
The patient has chronic
hypertension and its require regular monitor.
|
|
The patient was provided with
thrombolytic therapy with a minute dosage
|
It was very important for the
patient as there may be some other clots that may further affect the outcome
of the patient.
|
|
To chalk out any errors in
speaking as well as properly communication with the patient.
|
By taking the feedback from the
patient it will help the patient to realize why the nurses are not giving
proper response and also helps in let them know the exact meaning of the
conversation.
|
|
The patient was ask to perform
little task such as closing and opening her eyes followed by expressing her
feelings
|
It is done in order to test
whether there is any receptive aphasia along with expressive aphasia.
|
|
I pointed to some objects and
asked the patient to identify and name them
|
It was a test for the expressive
aphasia in order to see if the patient is able to even recognize any material
or not.
|
|
The patient was asked to make some
sounds that are simple and small such as sound of a cat, dog etc.
|
It is generally done to know
whether she is suffering from dysarthria due to the motor impairment of
tongue, breath control or the movement of lips that can generally affect the
overall articulation and may be another component associated with expressive
aphasia.
|
|
The patient was also asked to
write down her name as well as some short sentences. The patient was having
difficulty in writing due to weakness in left side (Hemiparesis) so she was
asked to speak a small sentence.
|
This test is done to check the
disability of writing or if there is any presence of reading comprehensions
which is also a part of the expressive aphasia.
|
|
The major thing that was done is
to provide a call bell near the table that will help the patient to seek
nursing attention in emergency. The bell can be activated by applying minimum
pressure on the switch..
|
It is very important for the
patient that the nurses must meet frequently due to the level of anxiety it
can occur in the patient suffering from CVA.
|
|
The patient was provided with
alternative method of communication.
|
Depending of the problems the
patient is suffering, it was important for the patient to be provided with
such ease of communication so that she can tell the problems easily
|
|
The problem anticipation of the
patients and provided with intervention required.
|
It is an
important aspect of nursing care when the caregivers understand the need of
the patient and provide it to them. This helps in lowering down the level of
frustration the patient have when he or she is not able to speak. (Smith, 2008)
|
|
The patient was asked with simple
questionnaires. The communication was short and soft so that the patient not
feels anxious on what has been asked.
|
It generally helps in the
reduction of communication gap between the patient and the nurses. It also
doesn’t give the feeling of aniety of having large number of information
gathering at a time. This helps in the stimulation of memory and further will
help in the association of ideas and the words that are spoken.
|
|
The communication with the patient
was done in a normal tone and U talked very slowly so that the patient can
understand and then respond. The patient was not forced for any answer.
|
It is not
necessary that the patient has some hearing problem, so there can be a cause
that if the nurse asks something in a loud voice the patient might feel
irritated and that may result into anxiety. If the patient is forced to give
responses for what has been asked they may feel frustrated and may lead to
automatic speech. (Ellis, 2010)
|
|
It was encouraged to the visitor
not to talk about her husband and talk to the patient very nicely, ask some
questions, read mails and also tell her some good happenings in the family
even if the patient is not replying or responding nicely.
|
This will
encourage the wellbeing of the patient and also doesn’t give her the feeling
of isolation and helps in promotion of effective communication which can give
a sense of connectedness with the family. (Dorze,
2010)
|
|
The patient was discussed with
very common topics such as about weather, cooking, about her past lovely
memories etc.
|
By promoting some of the
meaningful and sensible conversation, the patient can practice communication
nicely.
|
|
Consulted to the speech therapist
for further evaluation of the aphasia.
|
It is done in order to handle the
problem by the experts and not to mishandle the situation. The
physiotherapist can better understand the problem and can give remedies.
|
Evidence that supports the Nursing Intervention-
According
to Bronken et al (2012), it was observed that psychological adjustment in the
patient with CVA after the stroke is very protracted and complicated. Therefore
playing with the psychology of the patient is an important step for the
wellbeing of the patient. It is very important to keep them involved in
something that will make them feel good and not feel isolated due to their
inability to communicate with people. It was also mentioned that there must be
some support for the aphasia patient that will come from the family and
relatives itself. Speech therapy is also an important thing that can be
included for the patient in order to make them communicate. Braimah et al
(2008) involved thrombolytic therapy as an important step for controlling the
case for at least 24hours. (Bronken,
2012)(Braimah, 2008)
Conclusions-
CVA i.e. cerebrovascular accidents are generally a
result of a blood flow interruption in certain areas of brain and are often characterized
with sudden onset of neurological disorders which continuous for at least a
period of 24 hours. Therefore, acute care is required for regularly monitoring
the condition of patient firstly by correctly diagnosing and then giving
treatment to the patient. It is also important to check speech impairment and
blood pressure regularly in order to avoid another stroke.
References
Braimah.
(2008). Nursing care of acute stroke patients after receiving rt-PA therapy.
The NINDS rt-PA Stroke Study Group. J Neurosci Nurs. , 373-83.
Bronken,
B. A. (2012). Psychosocial Well-Being in Persons with Aphasia Participating in
a Nursing Intervention after Stroke. Nurs Res Pract.
Cruice.
(2007). Finding a focus for quality of life with aphasia: social and emotional
health, and psychological well-being. Aphasiology.
Dorze,
L. (2010). Needs, barriers and facilitators experienced by spouses of people
with aphasia. Disability and Rehabilitation, 1073–1087.
Ellis.
(2010). Stroke liaison workers for stroke patients and carers: an individual
patient data meta-analysis. Cochrane Database of Systematic Reviews.
Hackett.
(2008). Interventions for preventing depression after stroke. Cochrane
Database of Systematic Reviews.
Mergenthaler,
P. (2012). Do stroke models model stroke? Dis Model Mech.
Smith.
(2008). Information provision for stroke patients and their caregivers. Cochrane
Database of Systematic Reviews.
