Patient Presentation

The case study is about Brian Nolan, an 80-year-old man who left-sided cerebral vascular accident (CVA) at home. His medical history showed that he has Chronic Obstructive Pulmonary Disease (COPD). However, he continues to take one pack of cigarettes each day. The patient presents with severe right-sided hemiplegia impairing his basic life activities. He has slurred and gurgling speech and drooling of saliva. He is unable to eat or use the toilet.

Examination of Brian showed a swollen, tender, and hot right calf. The right calf measured 36cm compared to the left one, 33cm at the same level 39cm above the heel toward the bend of the knee. The vital signs are within normal range. The current patient’s problem is a pronounced right-sided hemiplegia and tender right calf.

The patient present with an inability to use the right side of both his upper and lower limbs. The hemiplegia has progressed to involve his face, and the patient presents with slurred speech with gurgling sounds. The patient’s mouth is deviated, leading to saliva drooling from the right side.

The hemiplegic patient condition follows the development of atherosclerosis due to prolonged smoking. According to Pan et al. (2019), smoking leads to an increase in inflammatory responses in the patient, leading to the destruction of the patient’s lung parenchyma, leading to COPD development. Inflammation in the blood vessels leads to the destruction of the patient endothelial cells leading to an increase in fatty acid infiltration and hardening of the vessel leading to atherosclerosis (Linton et al., 2019). Inflammation of the vessel also leads to disruption of the patient Virchow’s triad, which usually protects the patient from developing vascular thrombosis (Kushner et al., 2021).  Case Study: Brian Nolan And Ischemic Stroke Essay Paper

According to Al-Nasser (2020), smoking greatly contributes to arterial thrombosis. Prolonged smoking in the patient leads to arterial thrombosis, most likely on the left common carotid artery (Ashorobi et al., 2021). The thrombi enlarge following a continual inflammatory process triggered by smoking which accelerates the growth of the patient’s thrombi. The thrombi finally break off, leading to the generation of the emboli. The emboli are carried by blood into the patient’s cerebral arteries. The emboli block cerebral arteries, cutting off blood supply to the parts of the cerebrum (Konan et al., 2021). According to Hui et al. (2021), the middle cerebral artery is the commonest artery involved in ischemic stroke. Following blockage of the patient middle cerebral artery, the patient will have reduced blood flow to the motor and somatosensory areas of the brain (Nogles & Galuska, 2021). Reduction of blood supply to the motor areas leads to death of the motor segment of the brain. The areas that are not completely perfused undergo ischemia and cell body deaths. Areas with dual blood supply are spared ischemic but undergo oligemia and reduced blood supply, leading to loss of functioning (Hui et al., 2021). Loss of blood supply in the brain segment leads to an increase in radiolucency and can be detected through the radiological examination. A head CT scan was conducted on the patient, which showed increased radiolucency on the left hemisphere consistent with findings of an ischemic cardiovascular accident.

Smoking And Atherosclerosis

Embolism of the cerebral vessel leads to a decrease in blood flow to the affected segment in the brain, which appears as areas of ischemia on a CT scan. Blockade of the left side of the brain leads to loss of motor and sensory sensation in the contralateral side, right side following decussating of the nerves at the thalamus. The patient’s presentation follows the clinical feature of the left-sided ischemic thrombosis. The patient presents with right-sided hemiparesis, right-sided facial paralysis, and impairment of the patient’s speech. According to Hui et al. (2021), the patient may present with dysarthria and neglect some vision sections. The patient presented with slurred speech and gurgling of words, and dysarthria. Effects on the patient’s speech indicate impaired functioning of the Broca’s area (Acharya & Maani, 2021).

Effective, prompt management of ischemic stroke is essential to restore cerebral perfusion quickly. Quick restoration of the blood flow will salvage the oligemic areas and reduce the deterioration of the patient health conditions. Hui et al. (2021) recommend using thrombolysis such as alteplase to help thrombolysis any emboli causing vessel blockade. According to Hui et al. (2021), pharmacological use of thrombolysis such as alteplase should be done within the first three hours after the patient develops signs of stroke. Use of alteplase after three hours has been found to have minimal benefits. After the three hours, surgical procedures such as mechanical thrombectomy and embolectomy should be considered.

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Brian Nolan presented three hours after the initial signs of the ischemic stroke. He thus cannot be managed using the alteplase. Hui et al. (2021) recommend high-quality patient optimization and management of the patient symptoms to improve the patient’s outcome. It is always important for healthcare providers to arrest the possibility of the thrombi and emboli progression by inhibiting any further coagulation in the patient. The use of antiplatelet provides effects inhibition of the emboli progression without causing a risk of bleeding (Wang et al., 2020). Since the patient has lost effective motor function of his dominant hand and lacks coordination in speech and swallowing, there is a need for the nurses to ensure that patient feeding is enhanced through the use of a nasogastric tube.

Nasogastric feeding is nursing initiated treatment and is essential in addressing the patient’s nutrition needs (Ojo and Brooke, 2016). The patient is unable to eat following hemiparalysis. Implementation of the nasogastric feeding allows the healthcare providers to avoid severe complications such as dysphagia and possible aspiration of the food into the lungs. Slurred speech and gurgling sounds indicate paralysis of the patient’s nasopharyngeal muscles (Sabbouh and Torbey, 2018). Paralysis of oral and nasopharyngeal muscles leads to loss of swallowing reflex, which increases the risk of aspiration during feeding. The use of nasogastric feeding allows the bypass of the swallowing reflex. For Brian Nolan’s conditions, implementation of nasogastric feeding with probing of the patient is the best option for improving his nutritional status. Nasogastric feeding ensures that the patient does not become hypoglycemic or develop any malnutrition and thus promotes quick recovery of the patient. The success of the nasogastric tube will be evaluated by the positive nutritional status of the patient and the absence of feeding complications such as aspirations. (Ojo and Brooke, 2016).

Arterial Thrombosis And Ischemic Stroke

According to Hui et al. (2021), implementing antiplatelets such as junior aspirin prevents secondary thrombi and emboli development. There is a higher risk of developing a secondary ischemic stroke for the patient. The role of antiplatelet therapy allows for the reduction of the additional emboli formation (Kamarova et al., 2022). Its effectiveness will be passed through a gradual decrease in the resolution of the patient’s symptoms and a decrease in the areas affected by the ischemia.

The patient presents with swollen, tender, and hot right calf. The clinical presentation indicates a possible diagnosis of deep venous thrombosis of the lower right limb. Following the patient history of prolonged smoking, there is a higher risk of the condition being deep venous thrombosis. According to Al-Nasser (2020), smoking increases blood vessel endothelium inflammation and damage. Endothelial damage and prolonged immobility following the development of the patient’s stroke increase the Virchow triad, leading to deep vascular thrombosis. Smoking and obstructive lung diseases such as COPD greatly contribute to the development of deep venous thrombosis (Waheed et al., 2021).

Deep venous thrombosis develops following impairment of the Virchow’s triad leading to damage of the blood vessels endothelium, increase in blood turbulence, and hypercoagulability. For the patient, smoking leads to endothelium damage following the production of reactive oxygen species. Following the stroke development, the patient was immobile, which led to stagnation of the blood vessels, and the platelets and leucocytes then adhered to the blood vessel walls (Budnik & Brill, 2018). Additional damage to blood vessels leads to cytokine generation, which leads to an increase in white blood cells influences and initiation of the coagulation process (Waheed et al., 2021).

The coagulation process at the blood vessel walls leads to the trapping of the red blood cells under the fibrin, facilitating its growth and increase. As the thrombi propagate, there is an increase in occlusion of the venous outflow from the low legs, leading to an increase in venous hydrostatic pressure (Gardella & Faulk, 2021). Increase venous hydrostatic pressure that leads to extraversion of fluid, causing swelling. Congestion of the vessels and the tissues leads to a reduction of the blood flow into the leg, causing tissue ischemia and pain. Although clinical features of the patient suggest that the patient has deep venous thrombosis, NICE recommends that the patient be evaluated through investigation of the D-dimers, coagulation profile and proximal leg vein ultrasound (Al-Khafaji & Schierbeck, 2020)

The patient should be managed using anticoagulants such as heparin and warfarin. Implementation of graduated stocking help improves blood flow and increase venous return. An increase in venous return reduces stasis and propagation of deep venous thrombosis (Badireddy & Mudipalli, 2021). Anticoagulants such as heparin will help arrest further thrombosis formation and allow the body’s fibrinolytic system to degrade the remaining thrombi. The patient should be initiated on heparin which is fast-acting, followed by maintenance on warfarin. Although thrombolytic agents such as alteplase can address deep venous thrombosis it can lead to severe complications such as bleeding, especially postoperative intracranial bleeding, and perforated peptic ulcer disease (Grant et al., 2019). Waheed et al. (2021) use alteplase and other thrombolytic agents only in cases of severe deep venous thrombosis with imminent risk of emboli. Severe iliofemoral deep venous thrombosis is the main indication of the alteplase use in managing deep venous thrombosis (Grant et al., 2019).

Management Of Ischemic Stroke

Healthcare providers should initiate the use of graduated compression stockings (Sachdeva et al., 2018). The patient has right-sided hemiplegia, which limits his movement. An increase in immobility due to stroke contributed a lot to the progression of the thrombus formation and thus the progression of the DVT (Waheed et al., 2021). In addition to compression stocky, regular lower limbs massage and physiotherapy help increase blood flow and reduce stasis which helps reduce the development and progression of deep venous thrombosis.

The effectiveness of the anticoagulation and the compression stock will be assessed by a decrease in the patient leg swelling and pain, indicating a decrease in the size of the thrombi. Additional ultrasound can monitor the size of the thrombi and any emboli (Baker et al., 2021). A decrease in the size of the deep venous thrombus indicates effective anticoagulation.

Conclusion

Patient-centered care should be when addressing patient issues. For a patient with both right-sided hemiplegia following left-sided ischemic stroke and right deep venous thrombosis, there is a need to address both health issues wholesomely. Since the patient has exceeded the recommended three hours for using a thrombolytic agent, the main mode of treatment will be the use of antiplatelets to reduce the development of further thrombi formation and thus emboli. The patient cannot manage to eat independently, and there is a need for aspiration due to paralysis of the nasopharyngeal muscles. Thus the patient should be initiated on the use of nasogastric feeding.

Anticoagulants are the first management line; the patient should be started on low molecular heparin and warfarin. The patient should then continue on the use of warfarin. Heparin and warfarin help reduce thrombi formation, allowing body-mediated thrombi destruction to be effective. Since the patient is paralyzed, there is a need to implement an additional preventing measure, such as the use of compression stocking.

References

Acharya, A. B., & Maani, C. V. (2021). Conduction Aphasia. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537006/

Al-Nasser, B. (2020). Influence of tobacco smoking on the perioperative risk of venous thromboembolism. Turkish Journal of Anaesthesiology and Reanimation, 48(1), 11–16. https://doi.org/10.5152/TJAR.2019.08683

Ashorobi, D., Ameer, M. A., & Fernandez, R. (2021). Thrombosis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538430/

Badireddy, M., & Mudipalli, V. R. (2021). Deep venous thrombosis prophylaxis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534865/

Gardella, L., & Faulk, J. (2021). Phlegmasia Alba And Cerulea Dolens. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK563137/

Grant, P. J., Courey, A. J., Hanigan, S., Kolbe, M. S., Kronick, S. L., Obi, A., Jacob Seagull, F., Sood, S. L., Wakefield, T. W., Williams, D. M., Froehlich, J. B., Fontana, R., Haft, J. W., & Sonnenday, C. J. (2019). Special topics in venous thromboembolism. https://www.ncbi.nlm.nih.gov/books/NBK544377/

Hui, C., Tadi, P., & Patti, L. (2021). Ischemic Stroke. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499997/

Kamarova, M., Baig, S., Patel, H., Monks, K., Wasay, M., Ali, A., Redgrave, J., Majid, A., & Bell, S. M. (2022). Antiplatelet use in ischemic stroke. The Annals of Pharmacotherapy, 10600280211073008. https://doi.org/10.1177/10600280211073009

Konan, L. M., Reddy, V., & Mesfin, F. B. (2021). Neuroanatomy, Cerebral Blood Supply. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532297/

Kushner, A., West, W. P., & Pillarisetty, L. S. (2021). Virchow Triad. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539697/

Linton, M. F., Yancey, P. G., Davies, S. S., Gray Jerome, W., Linton, E. F., Song, W. L., Doran, A. C., & Vickers, K. C. (2019). The role of lipids and lipoproteins in atherosclerosis. In Endotext [Internet]. MDText.com.

Nogles, T. E., & Galuska, M. A. (2021). Middle cerebral artery stroke. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556132/

Ojo, O., & Brooke, J. (2016). The Use of Enteral Nutrition in the Management of Stroke. Nutrients, 8(12), 827. https://doi.org/10.3390/nu8120827

Pan, B., Jin, X., Jun, L., Qiu, S., Zheng, Q., & Pan, M. (2019). The relationship between smoking and stroke: A meta-analysis: A meta-analysis. Medicine, 98(12), e14872. https://doi.org/10.1097/MD.0000000000014872

Sabbouh, T., & Torbey, M. T. (2018). Malnutrition in Stroke Patients: Risk Factors, Assessment, and Management. Neurocritical care, 29(3), 374–384.  Case Study: Brian Nolan And Ischemic Stroke Essay Paper