This paper examines the acute care needs of ‘Tina Thomas ‘who has suffered a Haemorrhagic stroke. Moreover, range of factors such as clinical indicators of acutely deteriorating health associated with Tina, nursing acute care requirements and Tina and her family psychosocial needs as well as clinical tools to respond problems will be deployed in this paper.
Barkley and Myers (2015) explained that acute care involves time-sensitive and individual-orientated diagnostic along with remedial actions. The primary objective of acute care is to improve and monitor patient condition through rapid interventions. Furthermore, acute care services are used to treat sudden and unexpected injury or illness which could result in death or disability of patient without rapid actions. Acute care branches out of clinical health and deals with critical and trauma care, emergency medicine and short-term inpatient.
Tina Thomas aged 72 is married to Joe and has three children. Tina’s husband used to work at oil rig and now retired. After the retirement both have settled in their routine life and their children and grandchildren all live in the local area. Earlier today, Tina had complained about headache and took two Paracetamol to get rid of the pain. Afterwards, Joe found her wife asleep in the chair while taking coffee. When her husband tries to wake her up she was unable to speak as well as the left side of her body was flaccid paralysis. She was rushed to the hospital and has been admitted to hospital for treatment of Haemorrhagic stroke.
There are two types of stroke which are ischemic and haemorrhagic. According to American stroke association, Haemorrhagic stroke is accounted for only 13% of all strokes but it has a mortality rate of 40%. In case of haemorrhagic stroke, blood is spill around the brain which results in pressure and swelling on the brain (American Stroke Association, 2013).
The first involve carrying full clinical assessment of the Tina. According to Resuscitation Council UK, 2006, ABCDE (airway, breathing, circulations, disability and exposure) is most systematic approach in order to conduct clinical assessment. These are the universal indicator to assess the patient and methodology ensures that vital life signs are managed and assessed in logical manner. The three clinical signs of deterioration and critical health are cardiovascular, respiratory and numerological system (Jevon and Ewens, 2016).
The left side of Tina body is flaccid, therefore, the most like symptoms involve impaired speech, slow performance as well as impaired comprehension. One of the most common problem associated with Haemorrhagic stroke is airways problem patient develop over time (Fiebach, Schellinger and Sartor, 2015).
According to diagram present by Linton, 2015, a person experiencing left side brain damage range of factors such as impaired speech, slow performance, depression or impaired depression. Therefore, Tina is likely to experience these problems. Moreover, a patient who receive the treatment in the first couple of hours of treatment are less likely to develop neurological deterioration. (Kammersgaard et al., 2015)
Siegler and Martin-Schild (2015) explined that the pathophysiological of haemorrhagic stroke has long lasting impact on the patients. Early neurologic deterioration (END) in haemorrhagic stroke is generally happen due to development of the hydrocephalus and perilesional edema. The neurological deterioration in first few hours of the stroke is known as ‘stroke progression’ or ‘stroke in evolution’.
The deterioration is usually caused through combination pathophysiological, haemorrhage, brain damage, acute local recurrence and hydrocephalus.
Recent research shows that 20-40% of the patients develop neurological deterioration is common phenomena. The secondary injury caused by neurological damaged have worsen effect compare to stroke. There are wide range of problems that stroke patient can develop which include risk of pneumonia, urinary tract infection, digestive system bleeding or even risk of heart attack and bed scores. Therefore, effective nursing management is required to prevent further deterioration and complications in patient (Williams, Perry and Watkins, 2015).
According to Atluri (2016), nursing management is important aspect for neurological condition, especially to prevent and control secondary damage to the patient. The recovery of the patient is principle objective through facilitation of recovery of patient as well as to prevalent further neurological deterioration. The three principle aims for nursing involve
Harrison and Daly (2016) explained that in practice, nurses carried out assessment for the neurological function of the patient. The first test conducted is AVPU (Alter, Respond to voice and pain and unconscious level). This assessment can be completed on Tina through using ABCDE methodology to determine initial assessment. The track-and-trigger system for the scoring is useful to determine acute deterioration in Tina as well as it will be helpful to establish baseline for evaluate neurological condition and function in Tina.
The most significant indicator of neurological deterioration is consciousness. The level of consciousness could rapidly change in patient of Haemorrhagic stroke. The most commonly used tools for haemorrhagic stroke are ‘ICH score’ and ‘Glasgow coma scale’ (GCS). The ICH is useful to perform clinical grading based on patient characteristic, Neurological examinations as well as conducting initial neuroimaging. The neurological observation chart is attached in appendix 1 (Foster and Prevost, 2015).
Moreover, Glasgow coma scale is widely used tool to quantify patient level of consciousness after haemorrhage stroke. The initial tests conducted on Tina helpful to highlight the universal vital sign of life. Physiological observations of the patients should be managed hourly in ICU and increase of transitional care every two hours. The physiological observation includes examine vital signs such as respiratory and pulse rate, level of consciousness, oxygen and temperature (Chiu, Shyu and Liu, 2014).
Clarke and Ketchell (2015) added that for any type of stroke the initial assessment is same and conducting the ABCDE have high importance because of the neurological patients usually experience high unconsciousness and their inability to protect the airway. The wide range of duties performed by nurse involves observations, mobility, pain control, blood pressure and prevention of complications.
In order to conduct initial assessment blood pressure, temperature, disability, airway and circulation will be carried out. As Tina has had a haemorrhagic attack, i.e. it is likely to have airway problems, as well as physical disability of slur language or memory loss (Harrison and Daly, 2014).
Fiebach, Schellinger and Sartor (2015) explained that brain imaging is a most important step in order to evaluate the impact of haemorrhagic stroke and should be done on an immediate basis. This is helpful to determine the brain oedema and hydrocephalus. The two types of technology available in order to determine the magnetic resonance imaging (MRI) or computed tomography (CT). The diagram shows sample ICH score conducted on haemorrhagic patient on arrival in the emergency.
Moreover, the images below shows sample brain scans for the patient The ICH score for Tina will help to access the level of care and treatment required addresses the acute care needs of the patient (Jennifer L. Clarke et al., 2014).
Morrison (2014) elaborated that the device used to measure the pressure on the brain is known as ‘Ventriculostomy tube’. The device is used at area in the skull known as ventricle and in case of high bleeding, small portion of fluid known as cerebrospinal can be removed. It is important to conduct electrocardiogram (ECG), monitoring heart rhythm (telemetry) as well as blood testing of the patient. The most important factor to monitor is blood pressure and control seizure.
ECG is useful to determine the clotting and hyperlipidemia. Nevertheless, lumber puncture should conduct in order to obtain the spinal fluid (CSF) for examination to determine the early deterioration factors. Haemorrhage (bleeding) damages the brain because of increase pressure from amount of blood or even blood itself. Brain tissues are irritating to blood and when they come to contact, it results in swelling (Jennifer L. Clarke et al., 2016).
The assessment of the acutely patient like Tina, as well as management of the patient, is an important part of the role of the nurse. In order to conduct a good assessment of the Tina, right tools and communication are must and this allows observing social, physical and psychological needs of the patient.
The initial care of person with haemorrhagic involve number of components which are; i) outline causes of bleeding, ii) controlling blood pressure, iii) Stopping medication which could increase bleeding, and iv) measuring as well as controlling pressure inside the brain. It is important to perform wide range of neurological assessments in case of a patient with stroke. The nurses will maintain proper documentation and conduct detail assessment of the neurological function to ensure minimization of neurological deterioration in Tina (Kumlien and Axelsson, 2016).
The treatment of stroke is dependent on type and nature of the stroke. In case of haemorrhagic stroke of Tina, it might be necessary to perform surgery and this will be performed in the specialist neurological centre. The first hours for Tina are critical as in these hours risk of further attack, as well as treatment procedures, will be selected based on patient assessment (Atluri, 2015).
Based on the condition of Tina, a surgery could in next 48-72 hours or it could be delayed for the week because Tina condition get stabilised. The range of surgical procedure would involve aneurysm treatment, arteriovenous malfunction treatment or even decompresssive craniotomy. There is a concurrence with the multi-disciplinary group taking care of her care that the length of it is conceivable to exchange her securely. The decision is made the basis of medical condition, age and likelihood of recovery (Falvo, 2013).
Acute Nursing Care for Tina
|Potential Problems of Haemorrhage Stroke||Role of nurse for acute care|
|Deteriorating consciousness level||· Tina’s Head elevation should be 30˚ and positioning for airway|
· Arrange oxygen and anaesthetic referral based on GCS score
|Respiratory problems||· Monitor respiratory rate for Tina and supplementary oxygen in case of saturation level below 95%|
|Neurological deterioration issues||· Neurological assessment and maintain Tina’s head elevation to 30 ˚|
· Minimise the activities which are responsible for intracranial along with determining the need of analgesia
|Hypertension and Pyrexia||· Monitoring blood pressure and temperature|
· Blood pressure should be below 185/110
|Dehydration and blood glucose||· Maintain blood sugar level between 4-11 mmol because it effects intracranial pressure|
· Maintain fluid balance chart for Tina
The psychosocial factor attached with Tina and family could have long term impact on her and family. For example, treatment of Haemorrhagic could involve surgery. In case of surgery it would have long lasting impact on Tina and her family. The first 6 hours are most crucial as during this period Tina condition and future complication could be avoided. Moreover, it would mentally stressful for the family and children’s of Tina. The fear of operation, possible paralysis, feeling of fears, pain as well as anxiety could result in significant depression (Williams, Perry and Watkins, 2013).
The reassurance and information is important and imperative in case Tina. Timely and accurate information can help to improve the situation and decision making along with reduce anxiety for the Tina and her family. The psychological problems of the haemorrhage stroke present complication for both individual and her family.
The stroke results in psychological crisis to the family of Tina because of experience of stroke by the patient and functional manifestations associated with stroke. Moreover, the addition caregiving of family without support and training creates psychosocial stress for the family of Tina. The complexity and economic consequences associated with Tina stroke may pose difficulties for the family (Morrison, 2014).
Role of the interdisciplinary team
Harrison and Daly (2014) discussed the role of the interdisciplinary team is fundamental to offer stroke rehabilitation and interventions. The team for stroke involve physiotherapist, occupational and speech therapist, stroke nurses and physicians as well as healthcare assistance. According to the comprehensive critical care report, 2000, in order to provide effective and quality services, it important to shift from professionally focused to the need of patients.
As the nurse is the first source of contact, monitoring and recording of the results as well as communicating the initial finding with members of the Interprofessional teams. The interdisciplinary team work closely for both in-reach and outreach to continue care for the patient.
The acute phase of Tina’s Treatment requires visibility and empathy approach of health professionals. Tina requires continuous support from a various members of the team in order to recover the haemorrhage attack in terms of both physical and emotional recovery. The team can help both Tina and her family to recover from the shock and medical condition through delivery effective acute service (Barkley and Myers, 2015).
According to National Consensus Project (2009), palliative care involves both disease-alleviation and support for patients to relieve pain as well as addressing social, emotional and cultural need of the patients and their families. There has been a shift from traditional illness-cure model towards a more holistic approach which is focused on personal or individual with acute care needs. In case of Tina, it is important focus should be delivering the quality of care service to Tina as well as provide timely and relevant information to her family members (Moore, Turner and Todd, 2013).
In humanism approach, the focus is on interest, dignity and value of the patient. Tina is aged 72, i.e. feeling of helpless and fear of social and physical disability could result in the complication of the case. The three basic principles of ethics include autonomy, beneficence and fairness. In case of acute care, a wide range of the ethical issue could raise this involves withholding treatments, allocation of resources and technological challenging in order to deliver the service (Chiu, Shyu and Liu, 2015).
Peitzman, Barie and Jurkovich (2012) explained that different apprehensions patients is encountering incorporate, apprehension of unrelieved torment for which she has been instructed concerning the part of agony authority medical caretakers who will help in getting the right agony alleviation if we battle to discover the torment mitigate that works successfully for her. The cost and fear associated with the possible surgical procedure could raise ethical concerns. The acute ill patients are usually unable to make decisions for them and, therefore, they need the support of health care professionals.
Acute care requires continuing focus and attention of the nurse in order to deliver quality and lifesaving service to the patients. Tina Thomas has recently suffered from haemorrhage attack which has resulted in flaccid paralysis on the left side. The role of nurse could not emphasise less in such scenario.
The utmost issue in delivering the quality service include detail neurological and physiological assessment of Tina in order to determine the conditions of the patient. The psychological assessment will highlight the universal life indicator whereas neurological assessment will highlight the risk of health deterioration for Tina.
The nursing care for acute ill Tina is important. This is useful to control the further complication as well as control the secondary problem associated with haemorrhage attack. Nevertheless, acute care provided by the nurse is a most decisive factor in recovery and control of secondary problems.
At last, not least, the Interprofessional team could deliver the significant result to deliver quality services as well as help to resolve number of ethical problems.
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