Ischemic Stroke Management And Nursing Assessment

Ischemic stroke occurs when a blood clot blocks blood vessels that supply blood to the brain resulting in inhibited oxygen and blood levels. There are two types of ischemic stroke they include thrombotic stroke, whereby the clot forms within a given blood vessel in the brain and embolic stroke, which results from a clot originating from outside the brain that is lodged into blood vessels supplying blood into the brain where it stops thus preventing further flow of blood (Hui, Tadi, & Patti, 2018). Ischemic stroke can be attributed to; atrial fibrillation, atherosclerosis resulting from fatty components that accumulate around the blood vessels, thus tightening them and subsequently slowing down blood flow which clumps to form clots, heart disease, age (Robert is at 78), and high blood pressure. Clinical manifestations as presented by Robert include; aphasia (impaired communication), numbness (left upper and lower limb show weakness), loss of balance, loss of vision and confusion (conscious state score of 12). The management of ischemic stroke includes (Herpich, & Rincon, 2020); intravenous emergency medication; this therapy involves breaking the clots using drugs ( recombinant tissue plasminogen activator IV injection) through the veins. The IV injection works by dissolving the clot to create a way for blood to flow within the vessels toward the brain. In endovascular emergency procedures, there are three therapies that involve direct treatment of the blocked blood vessel. They include; clot removal by using a stent retriever inserted directly into the brain through a catheter to remove the clot from an affected vessel. The therapy works well in cases of more extensive clots in the blood vessels. Another therapy is the use of medications delivered directly to the brain through a catheter that runs from the arteries in the groin and to the brain to deliver tissue plasminogen activator drug to the point where the clot is situated. Angioplasty and stents involve passing a catheter through the arteries in the groin and inflating a balloon through the catheter to open and expand the tightened vessels. All these procedures aim at targeting the clot to either break or remove it to allow the proper flow of blood and oxygen.

This will involve;

• Positioning the head of the bed to at least 30⁰ This will help in increasing the blood flow and oxygen through blood vessels to the brain.
• Positioning Mr. Robert to the paretic side will facilitate induced communication and limit incidences of aspiration.
• Facilitate the proper sitting position.
• Encourage Mr. Robert to use a pillow or hand splint when coughing.
• Teaching Mr. Robert on how to use abdominal muscles to induce coughing.
• Teaching Mr. Robert the use of the quad and huff method in facilitating inspiration.
• Repeatedly consider safe ambulation procedures and change the patients’ position more often.  Causes And Clinical Manifestations Of Ischemic Stroke Example Paper

The rationale for positioning in facilitating airway and ventilation.

• The correct sitting position will initiate proper diaphragmatic contractions, movements and increased abdominal pressure, thus inducing coughing. Induced coughing mechanisms will force and clear secretions from the airways. Ambulation will facilitate lung movements and contractions, initiate secretions and reduce straining (Alexandrov et al., 2018).

Suctions are initiated in cases where the patients cannot voluntarily initiate coughing due to general weakness or increased accumulation of secretions. The process will include;

• Assisting Mr. Robert in understanding the whole suctioning procedure.
• Use of catheters.
• Assist the patient take a deep breath before and after the procedure.
• Inc case of bradycardia, withdraw the procedure and introduce an alternative oxygen source.

The rationale for suctioning in facilitating airway and ventilation.

• Suctioning aims at stimulating coughing. Catheters are used to remove secretions from the airways. However, they should be lubricated to reduce irritation and injuries to the mucus membranes. Deep breathing reduces the chances of hypoxia, while alternative energy provision will increase oxygen saturation levels (Rodgers et al., 2021).

Intubation is done when there is insufficient clearance of secretions along the airways. Intubation aims at removing the viscous secretions, thus reducing complications and facilitating a sufficient flow of oxygen. It includes;

• Monitoring the production of abnormal sounds from the airways and initiating intubation.
• Introduction of a saline solution when suctioning.

The rationale for intubation in facilitating airway and ventilation.

• To facilitate the removal of viscious mucus secretions by suctioning to promote breathing (Boling & Keinath, 2018).
  

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Lorazepam is a short-acting benzodiazepine drug used as a sedative to relieve symptoms related to anxiety.

Indications; It is also used in adults as anesthesia to relieve anxiety-related signs and treatment of short-term insomnia. It works by initiating GABA effects in the body (Bank, & Bazil, 2019).

Mode of action; Lorazepam binds to benzodiazepine receptors in the postsynaptic ligand-gated chloride channel in various parts of the brain. The resultant binding effect is an increased postsynaptic inhibitory effect, which presents as chloride ions flow increases in the surrounding cells. This causes cellular plasma membrane stabilization and hyperpolarization (Farrokh et al., 2018).

Management Of Ischemic Stroke

Anxiety related complications (orally);

• Initial; 2-3 mg once every 8-12 hours
• Maintenance; 2-6 mg/day once every 8-12 hours
• Geriatric; 2-6 mg/day once every 8-12 hour

• 2-4 mg at bedtime

Sedation (during intubation)

• 02- 0.04 mg/kg IV
• 02-0.06 mg/kg intermittent IV once every 2-6 hours
• 01-0.1 mg/kg/hour continuous IV and not more than 10 mg/hour

For IV, monitor respiration rates every 5-15 minutes and before the preceding IV.

• Fatigue
• Impaired memory or loss
• Depression
• Sexual dysfunction
• Distortion of sleeping patterns
• Gastrointestinal complications like loss of appetites, nausea, constipation or bowel load and antidiuretic hormone imbalance
• Skin allergic reactions
• Headaches
• Coma
• Respiratory complications
• Confusion
• Tremor
• Blurred vision
• Heartburn
• Dizziness
• Loss of coordination
• Fever
• Jaundice
• Lethargy
• Diarrhea
• Increase in weight
• Rashes
• Tolerance
• Spinning sensation
• Seizures
• Suicidal thoughts
• Difficult in talking
• Hypersensitivity complications
• Behavior change
• Drug over-dependence

• Acute narrow-angle glaucoma patients
• Hypersensitivity complications
• Sleep apnea
• Decreased respiratory function
• Intra arterial administration

After lorapezam intravenous administration, evaluation should be made on inconsistencies in breathing patterns like breathing rates, labored breathing, any sound produced during breathing like wheezing or moaning, oxygen saturation levels, cyanosis, level of confusion, sleeping patterns and intensity, incidences of headaches, abdominal movements during breathing, diaphragmatic contractions and mucus secretions that may block the airways. Check on pulse rate and its consistency (Almarzooq et al., 2021). In case of any abnormal clinical manifestation, a physician is engaged to prevent further deteroriatiation of the patient’s condition.

Monitor the instances of cardiac arrest-related complications after lorazepam intravenous medication. Signs of cardiac arrest may include unwarranted abdominal and chest pains, irregular breathing patterns, drowsiness, dizziness, depression, anxiety, shortness of breath, blurred vision, loss of coordination, loss of consciousness, nausea, hypertension, abnormal breathing sounds, difficulty in breathing, labored breathing, low levels of oxygen saturation rates, fainting, fatigue, abnormal temperatures with chilling and sweating and restlessness (Wainwright, 2018). Any abnormal deviations from standards should be notified to the physician in charge. Airways and ventilation protocols may be followed to ensure there is enough oxygen flow in the blood vessels.

Lorazepam is associated with incoordination. Therefore, there is a need to evaluate Mr. Robert on the levels of drowsiness, uncoordinated gait and posture as a result of ataxia, dizziness, loss of consciousness, vision loss or blurred vision, staggering, impaired physical mobility, ability to perform duties on his own, loss of memory, loss of communication, tremor, a spinning sensation among others (Siegel, & Besbris, 2020). Suppose there is no considerable improvement, or these physical signs are at adverse levels. In that case, a report should be made to the doctor or practitioner in charge of Mr. Robert for further medical attention. Carers should also be notified to keep a close watch over Mr. Robert to reduce the chances of falling off and subsequent consequences associated with falling off, like injuries and death. This will help in containing his situation.

Family patient care is an approach in nursing that involves the planning, delivering, and evaluating the health of patients with chronic medical conditions (Banerjee et al., 2018). It involves a partnership between a multi-agency team of health care workers, the patient and the family or caregivers. Family patient-centered care upholds and appreciates the role of the patient and the family by accommodating them in the whole medication and treatment process through the decision making and promotion of their physical, social and mental well-being. The multi-disciplinary team may include doctors, nurses, therapists, psychologists, and social workers. The goal is to achieve timely health outcomes, improved family-patient relationships and recommendable recovery rates. In this case, the team will support Agnes through;

• Appreciating and understanding her perspective and choice preferences as a caregiver, her knowledge, values, background, and cultural beliefs and how they can contribute to the planning and delivery of health care.
• Share health information and any developments about her husband’s state. Any progress made and a way forward. This will give her ultimate reassurance and hope.
• The team should also incorporate and support Agnes to fully participate in decision-making processes at all levels in her husband’s care.
• The team should also link Agnes to other healthcare professionals like psychologists and therapists to take care of her psychological needs, social workers to guide and counsel her as well as linking her to community programs like community groups that advocate for such illnesses where she can learn caregiver roles, get emotional and social support.

Patient family-centered care’s ultimate goal for the caregiver is to address their social, emotional, mental, and psychological well-being (Arabiat et al., 2018).

References

Alexandrov, A. W. (2019). Acute stroke nursing management. Stroke Nursing, 75-102.

Alexandrov, A. W., Tsivgoulis, G., Hill, M. D., Liebeskind, D. S., Schellinger, P., Ovbiagele, B., … & Alexandrov, A. V. (2018). HeadPoST: rightly positioned, or flat out wrong?. Neurology, 90(19), 885-889.

Almarzooq, A. H., Alshahrani, N. F., Al-Hariri, N. A., Alobaid, J. M., Alshurafa, Z. H., Abdulmajid, T. J., … & Alotaibi, I. M. (2020). Evaluation of Acute ischemic stroke management approach in the emergency department: Literature review. Archives of Pharmacy Practice, 11(4).

Arabiat, D., Whitehead, L., Foster, M., Shields, L., & Harris, L. (2018). Parents’ experiences of family centred care practices. Journal of pediatric nursing, 42, 39-44.

Banerjee, J., Aloysius, A., Platonos, K., & Deierl, A. (2018). Family centred care and family delivered care–What are we talking about?. Journal of Neonatal Nursing, 24(1), 8-12.

Bank, A. M., & Bazil, C. W. (2019, February). Emergency management of epilepsy and seizures. In Seminars in neurology (Vol. 39, No. 01, pp. 073-081). Thieme Medical Publishers.

Boling, B., & Keinath, K. (2018). Acute ischemic stroke. AACN Advanced Critical Care, 29(2), 152-162.

Farrokh, S., Tahsili-Fahadan, P., Ritzl, E. K., Lewin, J. J., & Mirski, M. A. (2018). Antiepileptic drugs in critically ill patients. Critical Care, 22(1), 1-12.

Herpich, F., & Rincon, F. (2020). Management of acute ischemic stroke. Critical Care Medicine, 48(11), 1654.

Hui, C., Tadi, P., & Patti, L. (2018). Ischemic stroke.

Liao, X., Ju, Y., Liu, G., Zhao, X., Wang, Y., & Wang, Y. (2019). Risk factors for pressure sores in hospitalized acute ischemic stroke patients. Journal of Stroke and Cerebrovascular Diseases, 28(7), 2026-2030.

Richardson, K., Loke, Y. K., Fox, C., Maidment, I., Howard, R., Steel, N., … & Savva, G. M. (2020). Adverse effects of Z-drugs for sleep disturbance in people living with dementia: a population-based cohort study. BMC medicine, 18(1), 1-15.

Rodgers, M. L., Fox, E., Abdelhak, T., Franker, L. M., Johnson, B. J., Kirchner-Sullivan, C., … & American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. (2021). Care of the Patient With Acute Ischemic Stroke (Endovascular/Intensive Care Unit-Postinterventional Therapy): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke, 52(5), e198-e210.

Siegel, C., & Besbris, J. (2020). Shared Decision-Making in the Setting of a Large Ischemic Stroke. In Palliative Skills for Frontline Clinicians (pp. 53-61). Springer, Cham.  Causes And Clinical Manifestations Of Ischemic Stroke Example Paper