Medical and Nursing Management of an Ischemic Stroke

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MEDICAL AND NURSING MANAGEMENT OF AN ISCHEMIC STROKE

Introduction

Maria Carr, a former teacher, aged 67, was admitted at the accident and emergency department about 4 hours ago, presenting with left-sided arm and facial weakness, which started about an hour before admission. C.T. scan was done, and the diagnosis was an ischemic stroke. Alteplase 900 micrograms/kg was administered by the nurse as prescribed. Maria has been moved to the acute stroke unit and put under the nurse’s care in charge. The essay is about the medical and nursing management of Maria’s condition in the next 24hours.

Addressing the patient, confidentiality, and dignity, seeking consent, and maintaining infection control

The nurse will reassure Maria and gain consent to do history taking. During this phase, communication with Maria’s family is essential to ensure the nurse gets the correct information to make a properly informed decision concerning her care. In Maria’s case, she is drowsy and cannot respond verbally. The nurse chooses her words carefully to ensure the patient’s dignity is maintained during all the nursing process phases. The patient will be moved to a comfortable and private environment to ensure privacy.

Acute ischemic stroke (AIS) commonly occurs when the cerebral artery is blocked, leading to a permanent brain injury (Life after Stroke, 2013). An ischemic stroke occurs when the brain’s blood supply is blocked, and brain cells are blocked from the glucose and oxygen they need to function correctly. The ischemic stroke commences when the brain blood flow reduces to less than 25 mL/100 g / min. At this stage, there are no neurons to maintain aerobic respiration. The mitochondria, then, breaks glucose down without oxygen, which produces massive quantities of lactic acid that induce a pH transition (Cheever and Hinkle, 2014)

During the acute process, the nurse maintains the neurological flow sheet, which provides data on the following critical clinical status indicators for the patient:

A change in the level of consciousness
Resistance to be moved
Response to stimuli
Orientation to person, location, and time (Belleza, R. 2018)

The nurse checks for the presence of movements of the extremities

Head position and body posture
Neck stiffness
The opening of the eyes
The comparative size of the pupils, the responses of the pupils to the light, and the ocular location
Body temperature, blood pressure, the ability to speak, amount of fluid consumed or administered, amount of urine excreted every 12hours. The nurse will observe for the presence of bleeding, maintain blood pressure within the normal range, and check Maria’s mental state (memory, attention span, vision, orientation, impact, speech). The nurse may also check for the patient’s ability to move, level of consciousness, ability to feel and touch, and their nutritional status (Belleza, R., 2018)

The Tests to be done for further investigations include;

T. scanning; Demonstrates systemic defects, edema, hematoma, ischemia, and infarctions,
PET scan; to show cerebral blood flow,
Angiography of the brain; to identify the cause of stroke, for example, obstruction of the artery, laboratory research to identify systemic causes
platelet and clotting research
X-ray of the skull may show cerebral thrombosis and partial calcification of the aortic walls (Belleza, R, 2018).

Medical interventions

Medical interventions for patients that have undergone a stroke include; secondary prevention medical care.

Administration of t-PA is recommended, and the bleeding should be controlled.
Increased intracranial pressure (ICP) may be controlled by administering osmotic diuretics.
Position the patient to prevent hypoxia by raising the head.
Intubation may be done if required to create patent air passages.
Continuous hemodynamic testing may be carried out to prevent blood pressure rise and determine any acute complications.
Surgical management may be performed to prevent and relieve her from ICP. Also, hemicraniectomy may be done to control ICP and brain edema in severe cases of stroke. (Cheever and Hinkle, 2014)

In drug administration, the patient will be weighed to determine the dosage of t-PA. The starting dose is 10% of the measured amount and is administered slowly. The remainder of the dosage is given over 1 hour through an infusion pump. The line gets flushed with 20 mL of normal saline after the procedure is done (Cheever and Hinkle, 2014). The side effects of t-PA administration include; bleeding; thus, the patient will be closely monitored for any orifices (Scroggins, 2000). Cerebral bleeding is a significant complication that occurs in approximately 6.5% of patients. The patient is admitted to the acute stroke unit, where continuous cardiac monitoring is carried out. Then the nurse will continue administering all medications as prescribed by the doctor and observe for any reactions.

Vital signs are collected every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour for the next 16 hours. Blood pressure is controlled at a systolic of less than 180 mm Hg and a diastolic of less than 100 mm Hg. Airway management is done based on the clinical condition of the patient and arterial blood oxygen. (Belleza, R, 2018)

Nursing care plan

The nursing care plan will aim at;

Improving mobility
Preventing shoulder pain
Encouraging self-care performance
Give the patient sensory and visual deprivation relief.
Prevent aspiration
intestinal, and urinary continence,
Improving reasoning processes
Achieving communication
Maintaining the skin’s integrity.

Nursing interventions

Nursing interventions include;

Positioning the patient to prevent abnormal muscle contraction.
Relieve pressure
Ensure good body positioning
Apply a splint to prevent bending of joints of the affected extremity.
Prevent the pressure on the affected limb with a pillow placed underneath the arm.
Raise the affected arm to control edema

After the interventions, the nurse will evaluate to assess whether the process is effective;

The nurse will evaluate the skin periodically for signs of breakdown, emphasizing joint areas and bony parts of the body.
He/she will then evaluate for enhanced mobility, absence of pain in the upper arm, sensory, and visual deprivation relief.
Prevention of aspiration, intestinal and urinary continence,
Improved cognitive processes
Achievement of the patient’s verbal communication
Improved the quality of the skin and
Absence of any complications.

Conclusion

In conclusion, the nurse will document all personal findings, services and adaptive devices available, results of clinical examinations, behavioral or cognitive assessment, support and involvement of the family, care plan and the nursing team involved, teaching and actions taken, and achievement or success towards the desired outcomes.

References

Belleza, R.N., 2018.’Cerebrovascular Accident (Stroke) Nursing Care and Management’: A Study Guide. [Online] Nurseslabs. Available at: <https://nurseslabs.com/cerebrovascular-accident-stroke/#nursing_care_planning_goals> [Accessed 9 October 2020].

Belleza, R.N., 2018. ‘Pneumonia Nursing Care Management’: A Study Guide. [Online] Nurseslabs. Available at: <https://nurseslabs.com/pneumonia/#aspiration_pneumonia> [Accessed 9 October 2020].

Cheever, K., and Hinkle, J., 2014. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 13th ed. Wolters Kluwer, pp.531-536, [Accessed 9 October 2020].

Mattila, J., Fine, M., Limper, A., Murray, P., Chen, B., and Lin, P., 2014. ‘Pneumonia. Treatment and Diagnosis’. Annals of the American Thoracic Society, 11(Supplement 4), pp.S189-S192.