Stroke, Its Pathophysiology and Nursing Management Technique

A stroke occurs when there is a blockage in the flow of oxygenated blood in the certain portion of the brain. When the oxygen supply is barred, the brain cells begin to die. It mainly happens if there is a rupture of the blood vessel that supplies oxygenated blood to the brain (Brunner et al., 2017). The other school of thought suggests that the stroke occurs if there is sudden bleeding in the brain. When the brain cells start dying due to stroke, a series of symptoms start appearing in the body that are being previously controlled by those damaged cells in the brain. There may be a sudden weakness, numbness or paralysis in an arm, face, legs, etc., trouble in understanding or speaking, trouble watching something. It is undoubtedly a severe chronic condition that requires immediate medical attention and nursing care. The longtime complication of stroke may include long-term disability, brain damage or even death (Cedambaur, 2017). According to the reports, stroke is known to be the fourth major cause of death in Singapore, with a rate of 50 people in every 100000 people and with a prevalence rate of about 3.65%. It is known to one of the top ten causes of hospitalization among elderly people. About more than half of the cases in stroke is hemorrhagic and hospital-associated care will approximately cost $5000. Although there is a provision of subsidized medical care both in primary and secondary care along with rehabilitation services, however, most of the people aren’t aware of it or not have the capability to use it.

There has been an establishment of national stroke group as with an increase in the aging population; there is a risk associated with a high prevalence of stroke in the community. It has been estimated that the disease burden will increase dramatically because of the lifestyle and the aging population, there is a need for health promotion and prevention program. The national authorities are planning a high quality of care and supporting research that will be essential for a better outcome for disease prevention (Winstein et al., 2017).  In the given case, Mr. Ali is an older adult (age-78) have a medical history of type II diabetes, hyperlipidemia, and hypertension. He is reportedly a chain smoker with 20 cigarettes per day. He was rushed to the hospital because of a fall and with a complaint of inability to move his right arm and leg. Also, there was specific impairment in speech and severe mouth paralysis. The blood pressure was quite high with 160/89 mmHg. He was immediately admitted to the hospital and was there for few weeks for rehabilitation. Because of his illness, there was undoubtedly mood swings, loss of motivation and irritation in the behavior of Mr. Ali. He was also reportedly kept him socially isolated because of a fear of getting another episode of stroke. His behavior towards his family members was also affected. The scope of this essay is to understand the pathophysiology of the disease, best assessment technique possible and finally the nursing management that can help Mr. Ali to recover from his current condition (Wall et al., 2015).

Pathophysiology of Stroke

As discussed in the introductory section of this article, the stroke occurs followed by a series of event that significantly disturbs the oxygenated blood flow in the brain. It is considered to be one of the major disorders associated with the blood vessels, however, the evidence shows that the biological processes involved in stroke are having a high interaction of glia, neurons, matrix components, and vascular cells that participate equally in the brain tissue injury and their repair. Stoke is a severe neuronal disorder, and it may lead to disability and death among the people. The pathophysiology of the disease is quite complex and involves a range of different mechanisms such as oxidative damage, inflammatory pathways, ecotoxicity mechanism, apoptosis, ion imbalances, and angiogenesis. The results of the ischemic cascade are indeed linked to the acute stroke, and it leads to neuronal death and irreversible loss of specific neurological function. Hyperlipidemia and hypertension have been one of the common cause of underlying stroke within several patients.

The stroke is the result of cellular depletion of oxygen and the depletion of ATP within the cell. At the cellular level, with loss of ATP, the energy and function of the cells in maintaining the ionic gradient are altered. Due to a passive flow of water and the influx of high concentration of sodium leads to edema. Because of a rise in the blood pressure significantly, there is damage in the blood vessel, and the local blood flow with oxygen in the brain gets affected. With a blood flow of 10mL/100 g in the cerebral regions are profoundly affected — the cells in these areas as assumed to be dead within a while after the onset of the stroke. There are zones with peripheral perfusion or decreased perfusion, and the place is called ischemic penumbra. The brain tissues in these regions can remain alive for a few hours because of the supply of oxygenated blood on a limited basis.

There has been a strong association of type II diabetes with the occurrence and pathophysiology of stroke. There are undoubtedly several modifiable risk factors such as diabetes, hypertension, lipidemia, etc. associated with the presence of stroke. It may also cause certain pathological changes in the blood vessel in several locations and further lead to stroke if there is a deleterious effect in the cerebral blood vessel. Diabetes is also having a strong relationship with the increase in the blood pressure because of it mainly constrict the blood vessel and increase the pressure on the heart. Whether or not the control of hyperglycemic condition can be associated with the better outcome of the patient with a stroke is not yet appropriately understood. However, the control of diabetes and other associated risk factor can certainly a way out to prevent stroke among the vulnerable patients. Mr. Ali’s case can be strongly related to the pathophysiology of the disease mentioned above, and he needs a proper management intervention to minimize the risk factors associated with stroke.

One primary symptom in stroke-

Numbness or Paralysis of the arm, leg, and face- Mr. Ali after getting the stroke episode developed weakness, numbness, and paralysis on the arm, leg and face. It happened in the one side of the body. It is important to assess this properly as it affects the health of the patient drastically.  Face drooping is another issue that occurs when there is a paralysis in the mouth of the patient.

Effect of the symptoms on the patient

The patient with such health issue where one side of the body is numb or paralyzed completely may have difficulties in completing their activities of daily living. There will be complications associated with the movement of the body and its function, and there are chances that the patient becomes completely dependent on others. In certain cases, living with paralysis may be equivalent to the loss of control in the bowel and bladder, sexual function and temperature. There are certain secondary complications of paralysis where the life quality and health of the person gets compromised heavily (Wadell et al., 2016). There are times when the secondary complications may lead to death as well. The people living with paralysis after a stroke lose the ability to have optimum control over the functioning of bowel, bladder and finds difficulty in completing their task as well. The patient gets psychologically distressed as they aren’t able to walk by themselves as well. The secondary complication may also result in the impairment of cognitive function, and their independence is wholly lost. It also causes tremendous pain and suffering for the patient as well.  For instance, if the stroke has resulted in the paralysis of the dominant hand may highly affect the person able to do their daily activities.

The activities of daily living mostly involve the use of the upper body part, and it gets severely restricted among the patient with stroke. Because their dominant body part has been disabled, their activities get diminished certainly. The patient starts feeling socially isolated and lacks the motivation of living their life (Standden et al., 2017). They become significantly dependent on others even for their hygiene which is sometimes quite embarrassing for them. Their motor task is also reduced increased body weight which can be another issue as the risk factor of diabetes and associated cardiovascular diseases increases.  The patient will feel fear, anxious, frustrated, sense of grief, anger and sadness because of their physical disability. The above-mentioned feelings are nothing but the response they generate because of the psychological trauma they got after the stroke episode. There will be emotional disturbances and change in personality that may cause after the damage in the brain and physical disability. The patient may enter the phase of depression where they will have a sense of hopelessness that will disrupt the social interaction with their family members. There will be lack of sleep, change in the pattern of eating and that will result in sudden weight gain or loss, fatigue, irritation, and suicidal thoughts as well. Further, the patient may also suffer a post-stroke depression and requires counseling (Fakuda et al., 2015).

Assessment Tool-

The name of the tool is Glasgow coma scale for measuring the level of consciousness of the patient

The development of the Glasgow Coma Scale is used to describe the level of consciousness among the patient suffered a stroke or head injury. It helps in measuring the motor function and verbal response of the patient who suffers numbness and paralysis of the limb and mouth due to a stroke. The score has been highly validated for the inter observer reliability and helped the physiotherapist and the nurses for improvement in training experiences of the patient. It is widely understood that the assessment of consciousness level of limbs is highly essential among the patient suffered from stroke for the clinical management (Duret et al., 2015). As given in the case study, the patient will be assessed for three major things that are the verbal response, motor response, and the eye response. The stroke may result in a certain deficit in the speech, language and the motor function of the patient and their conscious level will also get affected due to this. Among the patient having issues with verbal, the verbal score may get affected as it will lower down the level of consciousness level(Nishimoto et al., 2018)-

Eye response- Level of eye-opening and closing in response to the stimulus

Verbal response- How the patient is communicating verbally and if it is comprehensive or not?

Motor function- Movement of the limb with response to the stimulus will be assessed.

Eye response (E)

The numbers will be given according to the response-

• No opening of eyes- 1
• Eye only getting opened only response to pain-2
• An opening of the eye due to speech-3
• Spontaneity in eye-opening-4

Verbal response (V)

• No verbal response will be given score 1
• Moaning or lack of sound-2
• Random speech or sound-3
• State of confusion and coherence in speech-4
• Oriented speech-5

Motor function (M)

• No movement of limb- 1
• There is an extension with response to certain stimulus-2
• Flexion of muscles in response to pain-3
• Withdrawal of flexion in response to pain-4
• Obeying the command- 5

Advantages and disadvantages of Glasgow coma scale

The assessment tool has been widely recognized to be used for assessing the level of consciousness among the patient — the data achieved through this highly reproducible if it is assessed by the trained staff. It is quite easy to perform, and there is no requirement of any extensive training. The tool also has face validity. The tool provides the value of prognosis as the motor score generated through this can have a significant impact on the prognosis of the patient. The findings of motor function will be having a significant co-relation with the pathophysiology. It also helps in the categorization of the brain injury that has occurred on a scale of severe, moderate or mild. It can also help in measurement or indication of the trauma depth and tell whether or not there is a change of regaining the motor function. The tool has also been attached to the APACHE scoring system (Coloman et al., 2016).

There is the certain disadvantage of the tool as well. Firstly, the tool wasn’t designed for the assessment of trauma. The tool is quite unreliable on the patient with middle range, i.e., from 9 to 12.  Most of the people are unaware of the technique, and it has been reported that only 15% of the military physician has the ability to calculate it properly. There are chances of high inter observer variation because even with the trained staff, they tend to achieve a different set of scores in most of the cases. Because of the inter observer variation, the report does not tend to be reliable, and therefore another tool is used in alternative to confirming the score. The tool is not capable of assessing the reflexes in the brainstem, and it can’t be used as the part of the trigger for further intubation.  Most of the time, the eye response score is significantly unreliable if there is a damage in the eye. The total score is sometimes meaningless as well. The components of this tool are used well independently, and more importantly, the prognosis may be different sometimes for the patient having an issue with the same total score. The results are highly affected by the drug, smoke, and alcohol. The score is also affected by a possible barrier to communication and language (Dunover et al., 2017).

Nursing Management of the patient

Nursing management is the key aspect of care for the patient recovering from the post-stroke condition to gain a healthy and superior quality of life. The role of the nurses is sparingly important because they help in maximizing the self-management and reduces the dependency of the patient on others. The nurses take a holistic approach towards providing care to the patent and their family members to get the best outcome possible (Koh et al., 2015).

The scope of this nursing management will involve both family-centered and multidisciplinary team-oriented care where the patient will be supported by the family members and a team of a dietician, physiotherapist, counselor, an endocrinologist, and the general physician. Each team member will have a unique role to play in achieving a proper outcome for the patient. As the patient might have some financial difficulties in managing the expenses incurred in the management of stroke, there will be involvement of social activist who can help the patient to get funding for their treatment and can facilitate a regular follow up of the patient with the team of allied healthcare (Huang et al., 2017).

Role of physician-

The primary responsibility of the physician will be to manage the long-term care for strike and recommend the patient for the rehabilitation program to their best of the knowledge. They will appoint a local nurse who can take care of the general health of the patient and provide guidance regarding controlling blood pressure, diabetes, smoking, weight gain, etc. which are the highest risk factor associated with stroke. The role of the neurologist will be to lead the team of acute care and check the patient at the time of follow-ups. They will also participate in the long-term care and rehabilitation of Mr. Ali (Hatem et al., 2016).

Nurses-

The rehabilitation nurses will help the survivor to learn the basic techniques that can help the patient to carry out their activities of living. Their role will be to educate the patient regarding the importance of education and routine healthcare. They will also involve the family members regarding providing the patient with food on time, medicines; maintain personal hygiene, use of wheel chair and diets after consulting the dieticians. In the beginning, they will also support the patient to take a bath, control of inconsistencies, etc. They will also facilitate the appointment with a physiotherapist and the counselor for the wellbeing of the patient (Kwakkel et al., 2017).

Physiotherapist-

The physiotherapist will help the patient in emphasizing practicing the isolated muscle movements and ask the patient to perform a repeated movement of the muscles. They will train the patient in achieving greater coordination between the limbs and help them in maintaining the balances. Training will be given so that the patient can easily bear their weight and practice the repetitive movement at the time of therapy. The recent trend in the physiotherapy also emphasizes the goal-directed activities like games that promote the coordination. They also employ a selective stimulation of sensation that will help in encouraging the use of impaired limbs and hence regain the consciousness of the limbs.

Counselor-

As the patient has lost his hope and motivation of living a healthy life in the future, they will need an active counseling session that will help in regaining their confidence and motivation. The patient will be asked to perform recreational activities to the best of their ability as it will help the patient in maintaining a quality of life. The patient will be asked to interact with his friend and grand children as they will make the moments joyful and keep the negative thoughts away from the mind of the patient (Winters et al., 2015).

Endocrinologist- The patient has type II diabetes, and it is important that it should be controlled. The nurse will collaborate with the dietician and endocrinologist to get a healthy diet plan for the patient that may help in reducing the level of blood glucose of the body.

These nursing intervention and management will be a holistic approach to provide emotional, physical and psychological well-being of the patient.

Summary and Recommendation

Because of his illness, there was certainly mood swings, loss of motivation and irritation in the behavior of Mr. Ali. He was also reportedly kept him socially isolated because of a fear of getting another episode of stroke. Along with the nursing intervention, nurses may also involve certain occupational therapist who will particularly help in the improvement of sensory and motor ability of the patient. They will make sure the patient is safe after the post-stroke period. They will help the patient to perform certain self-directed activities such as preparation of meals, cleaning house, grooming, etc. This therapist will also help the patient to perform recreational activities such as drawing, painting, reading books, etc.  They will also help the patient in making a change in the home environment to make it more safer, removing barriers and facilitate the physical function of the patient such as the installation of bars and grabs in the bathroom, removing the sharps from the room, etc. The patient will be checked regularly for any injuries and bedsores as there are high chances that the patient may experience fall from somewhere and that may result into the fracture or severe injuries (Winters et al., 2016).

Conclusion-

A stroke occurs when there is a blockage in the flow of oxygenated blood in the certain portion of the brain. When the oxygen supply is barred, the brain cells begin to die in a while. It happens if there is a rupture of a blood vessel that supplies oxygenated blood to the brain. Mr. Ali is diagnosed with stroke with a series of associated complication. He was rushed to the hospital because of a fall and with a complaint of inability to move his right arm and leg. Also, there was certain impairment in speech and severe mouth paralysis. The blood pressure was quite high with 160/89 mmHg. He was immediately admitted to the hospital and was there for few weeks for rehabilitation. The Glasgow coma scale will help in measuring the motor function and verbal response of the patient who suffers numbness and paralysis of the limb and mouth due to a stroke. The score has been highly validated for the interobserver reliability and helped the physiotherapist and the nurses for improvement in training experiences of the patient. Nursing management is the key aspect of care for the patient recovering from the post-stroke condition to gain a healthy and superior quality of life. The role of the nurses is sparingly important because they help in maximizing the self-management and reduces the dependency of a patient on others. The nurses take a holistic approach towards providing care to the patent and their family members to get the best outcome possible.