This piece of assignment will discuss about a stroke patient that I have provided care for, it will describe the significance of epidemiological data of stroke, It will demonstrate knowledge and understanding on a nursing frame work that has been used to assess patient physical, psychological and social state it will also going to looking at the care that has been required to the patient based on the nursing assessment. I am going to use the
Roper Logan Tierney model
for assessing, planning, implementing and evaluating the patient need I am also going to be using Kaiser Model to manage and deliver a quality care for patient. In accordance with the Nursing and Midwifery Council Code of Conduct and Performance (NMC), (2008) to maintain confidentiality the patient’s name and hospital will be disclosed, he will be referred to as Mr P. Patient information must be treated as confidential and should only be used for the purpose intended for (NMC 2008).
Mr P is a 72years old black Caribbean origin admitted to the ward from accident and emergency with ischemic stroke. On arrival in accident and emergency Mr P had been assessed by using Glasgow coma scale (GCS) to find out his level of consciousness Robert (2008) the scale comprises of three tests eye, verbal and motor responses Mr P was unable to response to verbal sounds makes no movement and only opens his eyes to painful stimuli, checking his blood pressure which was high and he also had a CT scan to examine the various structures of the brain to look for stroke, area of bleeding or blood clotting in the brain and what type of stroke if it is hemorrhagic or ischemic Sophie Cottrell and Alex Davies (2006) the result showed that there was a blood clot in his brain which is called ischemic stroke. Mr P has a past medical history of diabetes and high blood pressure; he was initially found unconscious by his wife in his home and was taken to accident and emergency by ambulance. Mr p was used to work for a company as an accountant before he become retired, he lives with his wife and youngest daughter and does some voluntary job at his local elderly day centre he smokes five to eight packet of cigarette per day he is very friendly and quite popular in his local pub.
The rational of choosing stroke patient is because it is a huge public health concern According to stroke association (2008) stroke is the third largest cause of death in the UK it also mention that at least 450,000 people are severely disabled as a result of stroke in England with high morbidity and disability that raised my interest to know more about stroke and its management. It is also a life changing long term condition and a number one reason why people admit to nursing homes, as an adult student nurse I will definitely face a stroke patient in my future placement and career therefore I am required to have knowledge and skills on how to deliver a quality of care to chronically ill patients.
Ischemic stroke occurs when an artery to the brain is blocked. The brain depends on its arteries to bring fresh blood from the heart and lungs. The blood carries oxygen and nutrients to the brain, and takes away carbon dioxide and cellular waste. If an artery is blocked, the brain cells cannot make enough energy and will eventually stop working. If the artery remains blocked for more than a few minutes, the brain cells may die Kathryn et al (2006). The CT scan Mr P had in accident and emergency department also confirmed that the effect of the stroke is a left sides hemisphere stroke, the effect of a left hemisphere stroke include right-sided weakness or paralysis, sensory impairment, problems with speech and understanding language(aphasia), visual problems including the ability to do math or to organize, reason, and analyze items, behavioural changes such as depression, cautiousness and hesitancy, impaired ability to read, write and learn new information, and memory problems.
Stroke is the leading cause of disability; it is the third biggest killer in the UK and its one of the most expensive conditions to treat. Each year more than 110,000 people in England will suffer from a stroke which costs the NHS over £2.8 billion department of health (DOH) (2005). almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85 which Mr P are, the incidence of first ever stroke is expected to rise by 30% over the next decades from 1983-2023 due to ageing demographic, there are at least 300,000 people in England living with moderate to severe disabilities as a result of stroke. According to National Health Service (NHS) (2009) about 72-86%of strokes are ischemic. Each year in England over 130,000 people have a stroke, Mr p age is one of the factor that put him to have stroke, the estimated annual stroke incidence in England and Wales male aged 75+ is 26,269, people aged 75 years or older have nine-fold higher risk of suffering from a first ever stroke, and a 14- fold higher risk of suffering a recurrent stroke when compared to people to aged 45 to 64 years. Stroke causes over 60,000 deaths each year in the UK, in 2004 male who are aged 75 years or older the number of deaths caused by stroke was 16,596. Factors such as his ethnicity, hypertension and diabetics have contributed to Mr P stroke incidence. According to Graeme et al(2003) African-Caribbean people are twice as likely to have a stroke compared with Caucasian (white) people possibly because of a high prevalence of hypertension and diabetes which Mr p suffers from. According to NICE (2008) More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities. One of the risk factor which leads Mr p to have a stroke is his smoking according to Warlow et al (2001) cigarette smoking is associated with approximately double the risk of ischemic stroke in males and females. Warlow et al (2001) also mention that increasing age is associated with both increasing blood pressure and risk of stroke.
For the purpose of this assignment under the supervision of my mentor I used the Roper, Logan and Tierney model (1996) is widely used in nursing practice in UK. The advantage of using Roper, Logan and Tierney’s activities of living model of nursing it indicates 12 activities daily of living which are related to basic human needs, they are maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying,( roper et al.) by using this model I am able to produce a care plan for Mr p and able to carryout a nursing assessment on him. Royal college of nursing (2004) explains assessment is considered to be the first step in the process of individualised nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status.
Because of the word limits I am only going to looking at eating and drinking, mobilising and personal cleansing and dressing the reason I choose those is because they are essential for life if a person is not mobilising that means he is not able to do his personal care and eating and drinking which can affect him from socialising, give him depress and isolated from others.
About half of patients admitted to hospital following a stroke cannot swallow safely. Mortality in this group is high (rowan h.et al.2005). Mr P swallowing function evaluated before he was given any food, fluid, or medication by mouth. If he cannot adequately swallow he is at risk of choking. Patients who cannot swallow on their own may require nutrition and fluids delivered intravenously or through a tube placed in the nose. According to NICE (2008) on admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral foods, fluid or medication. Immediately after admission bed side swallowing test was done by the trained nurse he has been given a small spoon of water and different thickening drinks to listen his chest if he is able to swallow it with out any problem however Mr P was coughing and straggle to swallow, so the nurses referred him to the speech and language therapists they are responsible for assessing and treating swallowing and communication difficulties the salt suggested that Mr P require his drinks to be thickened up with thickening powder to a syrup or yoghurt consistency so it goes down slower.
Swallowing problems affect over a third of people after stroke www.esto-stroke.org when a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and into the lungs called aspiration which can lead to chest infections and pneumonia.
Ischemic stroke affect Mr Ps ability to swallow, problems of swallowing were in the past thought to occur only where both hemisphere were involved over the years by stroke damage. In the early weeks after stroke about one-third of patients with single hemiplegia suffer from swallowing problem (Gordon et al., 1987).
The plan was to feed Mr P, reemphasize proper positioning and thinking about swallowing. Allow him to see and smell the food in order to stimulate salivation, and place the food on the most sensitive mouth areas. When spoon feeding, pass the utensil below his chin to encourage neck flexion, give him only small portions, using verbal coaching to emphasize chewing, holding the food, and swallowing hard. Pause between feeding allow him to rest, and make sure all of the food was swallowed.
He also referred to dietitian for further ongoing assessment, to allow monitoring, the risk of malnutrition, to ensure his identified needs are referred for specialist advise, In meal time to assist Mr. P to seat up on his bed in a good position, Keep the surrounding area clean and free of unpleasant smells, remove bedpans, urinals and other such objects from Mr P’s sight. It is important that the patient’s room and table offer a pleasant environment for eating. As Mr P is unable to use his right side of his body when he is feed, put the tray on his right hand side just to remind him he can use his right hand to eat this will encourage Mr P’s ability to use his weaken side of his body, to provide a special tray and cutlery to help him not to spelt the food, and monitor quantitatively all food and drink consumed as accurately as possible on the food chart. Food record charts can provide the essential information that forms the basis of a nutritional assessment and help to determine subsequent treatment plans. They are therefore a valuable resource for dietitians, nurses and ultimately the patient. (Nursing times 2002).
Swallowing difficulty cause psychological effect on Mr P such as considerable distress for him and family and contribute to him loss of self esteem and self worth, loose his appetite and discomfort, less enjoyment of eating; embarrassment in social situations involving eating. As well as making difficult for family members to understand or communicate with him. According to Ebrahim, (1985) and Collin et al (1987) more severe psychological effects such as anxiety, agitation or clinical depression, requires more specific intervention. A patient who is severely depressed will lack motivation to perform even the simplest task such as maintaining posture, attempting communication etc. Physically he loses weight and start developing malnutrition include weakness, bedsores and urinary tract infection. Emotionally he become distress and become very angry in mealtime especially when he spelt food.
Washing is important not only for the reason of hygiene, but also for self esteem, the hemiplegic hand particularly can smell offensive if not washed regularly Robert Fawcus (2008) Mr p was unable to wash himself and dress due to his left hemisphere stroke the right side of his body is become paralyse.
The plan was as he requires full assistance from another individual for personal care. Personal hygiene is an important aspect of his daily living routine. To keep him remain fresh through the day, every morning to assist him brush his teeth, shower and deodorize him, to keep his skin, nails hair clean and to provide him clean cloth.
A break in this routine will give him a feeling of being dirty and cause depression and frustration. Unfortunately, personal hygiene may become an issue for Mr P, due to stroke.
Maintaining personal hygiene enhances an individual’s physical and emotional wellbeing. Mr P becomes dependent because of his long term condition; he can experience a deep loss of independence and self-esteem. On the other hand helping him to smell fresh and look his best can be a great booster to Mr P.
After brain damage by stroke, normal muscle tone is missing. First and foremost normal movement depends on normal muscle tone and without normal muscle tone the patient will never again normal movement Margaret (1987) after assessed by the manual handling advisor to evaluate his ability of moving and to determine how much assistance he needs in terms of movement due to weakness of right side of his body he is at high risk of developing pressure sore so he has been put on waterlow risk assessment chart The primary aim of this tool is to assist nurses to assess risk of patient developing a pressure ulcer.
The plan was to be given good skin care and light powder areas were skin touch skin to avoid friction, with two assistant using sliding sheet to turn him frequently to change position provides exercise for muscles stimulates circulation, helps prevent ulcers and comfort him and he has been provided pressure relief mattress to avoid any pressure sore also to give him dignity while doing personal care when he need bedpan.
According to NICE (2008) early mobilisation may have beneficial effects on oxygenation and lead to a reduction in complications such as venous thrombo-embolism and hypostatic pneumonia. There could be benefits in terms of motor and sensory recovery, and patient motivation.
Mr p is referred to physiotherapist to be assessed to his mobility to help promote his health and wellbeing and to assist the rehabilitation process by developing and restoring body systems, he also being referred to occupational therapist (OT) to assess his physical, mental and social challenges and devises, treatments, programs such as rehabilitation to increase the ability to tackle his difficulties independently.
At the result of lying on bed all the time due to his mobility and unexpected disability made Mr P depressed. This also affected his social life as he cannot go out and socialise with friends like he used to without assistance. This might make him isolated and frustrated and have a feeling of worthlessness.
At the centre of the health and social care long term conditions model is the Kaiser Permanente Health Care Model. This model builds a personalised vertical care continuum for patients with long term conditions. It also identifies the percentage of patients who will require delivery of care at different levels of the continuum through a risk assessment system. The Model provides a structured and consistent approach to help local health and social care partner’s shape the way they deliver integrated long term care locally. It details the infrastructure available to support better care for those with long term conditions as well as a delivery system designed to match support with patient need (department of health.,2007) according to Kaiser model Mr P is on level two This involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams Because of his vulnerability, simple problems can make his condition deteriorate rapidly, putting them at high risk of unplanned hospital admissions or long term institutionalization.
According to National Service Framework (NSF) (2005) anyone with a long term neurological condition who would benefit from rehabilitation is to receive timely, high quality rehabilitation service in hospital or other specialist settings when they need them, also People with long-term neurological conditions living at home are to receive a full range of rehabilitation, advice and support to meet their continuing and changing needs. This is to increase their independence and help them to live as they wish.
On the discharge date of Mr. P the multi disciplinary teams got involve because of his contentious care needs the social worker to provide career and to keep supporting him and his wife financially and for social net working such as a day centre, physiotherapist working with Mr. p to identify the physical problem, developing and reviewing treatment programs, to educate and advise Mr. P and his family how to prevent and improve his condition. He has been referred to occupational therapy which is important for him improves daily living activities and social participation, and to a district nurse to make regular home visits for example to arrange equipment such as wheelchair commode or hoist to be provided through social services and to take blood pressure measurements.
Mr. P and his family understood what foods he can and cannot eat. He has been told to eat slowly, and chew food thoroughly liquids or pureed foods than solids in order to swallow easily.
He has been advised for safety measures around the home to compensate for difficulties in mobility that are inherent with this problem. For example, avoid clutter, leave wide walkways, and avoid throw rugs or other objects that might cause slipping or falling.
Family members have been given advice to encourage Mr P to participate in normal activities and to have extreme patience because he suffers from poor coordination. Take time to demonstrate ways of performing tasks more simply. He has been advice to continue taking antiplatelet medication due to blood clot according to national clinical guidelines for stroke (2008) all patient with ischemic stroke who are not on anticoagulation should be taking an antiplatelet agent such as aspirin .Antiplatelet medication reduces the ‘stickiness’ of platelets. This helps to prevent blood clots forming inside arteries. He has been given advice to stop smoking and to have a regular check up for his blood pressure, to eat a healthy diet and to keep his blood sugar as near normal as possible to avoid further stroke, teaching him to perform specific tasks using repetitive drills in response to certain stimuli. For example, he was told to press a buzzer each time he hear a specific number. A variant of this approach trains him to relearn real-life skills, such as driving, carrying on a conversation, or other daily skills.
In conclusion the Roper, Logan and Tierney model of nursing I found it very useful in terms of assessing patient, to provide proper holistic care from admission to discharge, it allow multidisciplinary team to get involve in order to deliver quality of care for patients. The Kaiser model also helps me to identify in what stage my patient is and give me an idea of what kind of care he/she require. Overall doing this assignment I learnt so much about stroke the cause, symptoms and its management and it allow me to know the patient, how he felt and react about his illness and how it affect him psychologically, socially or emotionally.