Case study paper stroke

STROKE

(Case study paper)

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Critical care Nursing (NUR-418)

FAZAL RAHMAN

BScN02161010

Ms Sana Saher

Date: April 04, 2019

LAHORE SCHOOL OF NURSING

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THE UNIVERSITY OF LAHORE

(2016 – 2020)

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 Case study paper stroke

Guidelines of Case Study Paper Writing 10%

Section Information to Include Total Marks
(100)
1. Introduction:  Explain who the patient is (Age, 10 Marks
(Patient and Problem) gender, etc.)
 Explain what the problem is (What was
he/she diagnosed with, or what
happened?)
 Introduce your main argument (What
should you as a nurse focus on or do?)

2. Pathophysiology  Explain the disease (What are the 10 Marks

symptoms? What causes it? And
what’s pathological mechanism
behind disease)
3. History  Explain what health problems the 10 Marks
patient has (Has she/he been diagnosed
with other diseases?)
 Detail any and all previous treatments
(Has she/he had any prior surgeries or
is he/she on medication?)
4. Nursing Physical  List all the patient’s health stats in 10 Marks
Assessment sentences with specific numbers/levels
(Blood pressure, bowel sounds,
ambulation, etc.)
5. Related Treatments  Explain what treatments the patient is 10 Marks
receiving because of his/her disease
Nursing Care Plan
6. Nursing Diagnosis  Explain what your nursing diagnosis is 10 Marks
& Patient Goal (What is the main problem for this
patient? What need to be addressed?)
 Explain what your goal is for helping
the patient recover (What do you want
to change for the patient?)
7. Nursing  Explain how you will accomplish your 20 Marks
Interventions nursing goals, and support this with
citations (Reference the literature)
8. Evaluation  Explain how effective the nursing 10 Marks
intervention was (What happened after
your nursing intervention? Did the
patient get better?)
9. Recommendations  Explain what the patient or nurse 10 Marks
should do in the future to continue
recovery/improvement

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1. Introduction
Explain who the patient is (Age, gender, etc.)
Patient’s Name: Mrs. Bashiran Bibi Age: 60 years
Sex: Female D.O.A: 25-03-2019
Religion: Islam Occupation: Housewife
Marital status: Married Medical Diagnosis: Stroke
Surgical Procedure: Nil
Address: Lahore
Explain what the problem is (What was she diagnosed with, or what happened?)
Two days prior to admission, the patient experienced generalized weakness, decrease power in
all four limbs, Increase BP, and Aphasia. A complaint of dizziness was noted. He was responsive
and slurring of speech is noted. He was brought to emergency department of University of
Lahore Teaching Hospital at 3:30 P.M.
The patient was admitted on March 25, 2019 at 3:50 P.M. with vital sign of Temp: 36.8°C, PR:
85bpm, RR: 19/min, BP: 150/80 mmHg. The patient was diagnosed with Ischemic Stroke.
Introduce your main argument (What should you as a nurse focus on or do?)
As a Nurse I will focus on
1. To obtain the knowledge to enhance skills and to develop the attitude towards caring of
the patient with cases regarding ischemic stroke.
2. Demonstrate stable vital signs and absence of signs of increased ICP.
3. Observation for developing complications.
4. Provide information about disease process, prognosis, and treatment needs.

2. Pathophysiology:

Definition:

Stroke is defined by the World Health Organization as

“A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in
case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death
with no apparent cause other than a vascular origin.” (WHO, 2016).

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The damaging or killing of brain cells starved of oxygen as a result of the blood supply to part of
the brain being cut off. Types of stroke include Ischemic stroke caused by blood clots to the
brain or hemorrhagic stroke caused by bleeding into/of the brain (Tony Rudd, 2016).

Pathophysiology:

A Stroke is a sudden impairment of cerebral circulation in one or more blood vessels. It

occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood vessel
breaks, interrupting blood flow to an area of the brain (Mergenthaler, Dirnagl, & Meisel,. 2015).

Regardless of the cause, the underlying event is deprivation of oxygen and nutrients.
Normally, if the arteries become blocked, auto regulatory mechanisms help maintain cerebral
circulation until collateral circulation develops to deliver blood to the affected area. If the
compensatory mechanism becomes overworked, or if cerebral blood flow remains impaired for
more than a few minutes, oxygen deprivation leads to infarction of brain tissue (Tony Rudd,
2016).

Stroke interrupts or diminishes oxygen supply and commonly causes serious damage or
necrosis in the brain tissues. When either of these things happens, brain cells begin to die. When
brain cells die during a stroke, abilities controlled by that area of the brain are lost. These include
functions such as speech, movement, and memory. The specific abilities lost or affected depend
on the location of the stroke and its severity (Caplan, 2016).

There are two types of “brain attacks”

 Ischemic Stroke: a blood clot blocks or plugs a blood vessel in the brain.
 Hemorrhagic Stroke: a blood vessel in the brain breaks or ruptures.

An ischemic stroke can occur in several ways – embolic, thrombotic, Transient ischemic attack,
and lacunar infarcts (Caplan, 2016)

Embolic stroke occurs when a blood clots forms in the body (usually the heart) and travels
through the blood stream to the brain. Once in the brain, the clot eventually travels to a blood

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vessel small enough to blocks its passage. The clot lodges there, blocking the blood vessel
causing a stroke.

Thrombotic stroke, blood flow is impaired because of the blockage to one or more arteries
supplying blood in the brain. Blood-clot strokes can also happen as the result of unhealthy blood
vessels clogged with the build up with fatty acids and cholesterol.

Transient ischemic attacks, or TIAs, are brief episodes of stroke symptoms resulting from
temporary interruptions of blood flow to the brain. It can last anywhere from a few seconds up to
24 hours.

Lacunar infarcts are small (1.5 to 2.0 cm) to very small (3 to 4 mm) infarcts located in the deeper
non cortical parts of the brain or in the brain stem. They are found in the territory of single deep
penetrating arteries supplying the internal capsule, basal ganglia, or brain stem. They result from
occlusion of the smaller branches of large cerebral arteries, commonly the middle cerebral and
posterior cerebral arteries and less commonly the anterior cerebral, vertebral, or basilar arteries.
In the process of healing, lacunar infarcts leave behind small cavities, or lacuna. Six basic causes
of lacunar infarcts have been proposed: embolism, hypertension, small-vessel occlusive disease,
hematologic abnormalities, small intracranial hemorrhages, and vasospasm (Caplan, 2016).

Causes:

Stroke is a disease that affects the arteries leading to and within the brain. It is the No. 5 cause of
death and a leading cause of disability in the United States. Each year in England, approximately
110,000 people have a first or recurrent stroke and a further 20,000 people have a TIA. More
than 900,000 people in England are living with the effects of stroke (Great Britain, 2018).

Risk factor:

Uncontrollable risk factor Controllable risk factor

Increasing age. Stroke affects people of all High blood pressure. This is the single most
ages But the older have high risk. important risk factor for stroke because it’s the
leading cause of stroke
• Gender. Women have a higher lifetime risk of

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stroke than men do. Use of birth control pills • Smoking. Smoking damages blood vessels.
and pregnancy pose special stroke risks for
• Diabetes
women.

• High cholesterol. High cholesterol increases

• Heredity and race. People whose close blood
the risk of blocked arteries.
relations have had a stroke have a higher risk
of stroke.
• Physical inactivity and obesity.

• Prior stroke. Someone who has had a stroke

• Carotid or other artery disease.
is at higher risk of having another one.
• Excessive alcohol intake.
(Silva, Koroshetz, González, & Schwamm, 2017).

Sign & symptoms:

Followings are the sign and symptoms of stroke.

 Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body
 Sudden confusion, trouble speaking, or difficulty understanding speech
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance, or lack of coordination
 Sudden severe headache with no known cause
Acting F.A.S.T. is key for Stroke
 Face Drooping
 Arm Weakness
 Speech Difficulty
 Time to call 911
(Tony Rudd, 2016).
3. History
PERSONAL DATA
Patient initial is Bashiran Bibi. She is 60 years old. She was born on June 5, 1960. She
currently resides at Lahore City. She was married and has 5 children. Educational attainment was
high school graduate. She was a housewife and her sons and daughters support him. My source

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of reliability of information is her eldest son and his 3rd child. And the date of interviewed was
March 25, 2019.
REASON FOR SEEKING CARE
Loss of power in all four limbs.
HISTORY OF PRESENT ILLNESS
Two days prior to admission, the patient experienced generalized weakness, decrease
power in all four limbs, Increase BP, and Aphasia. A complaint of dizziness was noted. She was
responsive and slurring of speech is noted. She was admitted on March 25, 2019 at 3:50 P.M.
with vital sign of Temp: 36.8°C, PR: 85bpm, RR: 19/min, BP: 150/80 mmHg.
HISTORY OF PAST ILLNESS
It was known that she is hypertensive and have Diabetes Mellitus. The patient doesn’t have any
allergies in medications, foods and environment. She didn’t go in any surgery.
CURRENT MEDICATION
For now, she has current medication which includes inj oxidil 1g, inj Teph 40 mg OD, inj
mulamid, Losartan 50 mg/tab 1 tab OD hypertension and Metformin 500 mg 1 tab OD for her
Diabetes Mellitus.
LIFESTYLE
She is non-smoker and non-alcoholic drinker.
FAMILY HISTORY
As verbalized by the son, she has familial history of Hypertension and Diabetes Mellitus.

4. Physical assessment & laboratory findings

VITAL SIGNS
Patient’s Temp: 36.8°C, PR: 85bpm, RR: 19/min, BP: 150/80 mmHg.
GENERAL APPEARANCE
The client is in medium frame with stooped posture, the client is bedridden since she was
admitted to the hospital last March 25, 2019. Well groomed and has no body odor. He doesn’t
have any deformity.
MENTAL STATUS
The client is conscious and cooperative. The client can’t talk because she was stroke.
SKIN

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The client’s skin is of normal racial tone which is brown. It is dry and smooth. The skin turgor is
wrinkled and loss of elasticity. The body hair is evenly distributed. She doesn’t have any edema.
But she has popular lesion and pigmentation on her skin.
NAIL
The client’s nail shape is convex clubbing, the nail is rough and the nail bed is pink. The
capillary refill is within 3 seconds and there is an absence of beau’s line.
HEAD AND FACE
The client’s skull is proportionate to the body size; there were no tenderness in the scalp. There
were no presence of nodules, and infestation. Her hair is evenly distributed and the strands are
thin and brittle. The color of her hair is a mixture of white and black. Her head is round and
symmetrical its consistency is hard. She can’t control her head and the shape of her face is round
and asymmetrical and its consistency is soft.
EYES
The condition of her eyes is straight normal; the eye brows are evenly distributed. The blink
response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral
conjunctiva is pink and the sclera is white. The color of her eyes is brown, the shape is equal, it
is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and
accommodation.
EAR, NOSE AND TROAT
The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of
the pinna is symmetrical. The pinnas are elastic and recoil when folded. Her septum is in the
midline. The mucosa is pink; nostrils are both patent, nasal flaring is absent. There is an NGT in
her left nostrils. The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is
pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue
movements are not that smooth.
NECK
The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is
in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable.
CHEST AND LUNGS
Chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90.
Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal.

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The lung expansion is normal. When percussed the sound is resonance. When auscultate
brondual is absent. No adrentition sound.
HEART
The rhythm is regular. PMI is located in the apical pulse. Heart rate is 85 beats per minute.
ABDOMEN
The bowel sound is normo active and no bruits. When percussed the sound is tympany. The liver
is not palpable.
UPPER AND LOWER EXTREMITIES
The patient cannot resist force when asked to resist.
Laboratory and radiographic findings
Her hemoglobin level is 10.8 g/dL, with a hematocrit of 32%. His WBC count is 8.8
cells10µ/L, and 28% lymphocytes. Her platelet count is 399cells10µ/L. The results of a
multichemistry screen are unremarkable.
Abdomen Ultrasound documents gall bladder is partially contracted and shows multiple
calculi collectively measuring 3.5cm. No evidence of abnormal wall thickening or
pericholecystic fluid is seen.

5. Related treatment
Drug Therapy
Ultrasound abdomen revealed that gall bladder is partially contracted and shows multiple
calculi collectively measuring 3.5cm. The treatment for her in hospital is IV antibiotic treatment,
received azithromycin and oxidil with improvement in his symptoms. Malin lotions apply at
night below the neck all over the body to treat popular lesion and pigmentation on skin. Tab
Ivermite to treat certain parasitic roundworm infections. Curing parasitic infections helps to
improve your quality of life. Telfast 120 mg is used in adults and adolescents of 12 years and
older to relieve the symptoms that occur with hay fever (seasonal allergic rhinitis) such as
sneezing, itchy, runny or blocked nose and itchy, red and watery eyes.
6. Nursing Care Plan
NURSING DIAGNOSIS
 Ineffective Cerebral Tissue Perfusion May be related to Interruption of blood flow to the
brain as evidence by Changes in motor and sensory responses;

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 Impaired Physical Mobility May be related to neuromuscular involvement: weakness as

evidence by patient decrease power in all four limbs.
 Impaired verbal Communication may be related to impaired cerebral circulation as
evidenced by impaired articulation; patient cannot speak.
 Deficient knowledge may be related to Cognitive limitation as evidence by Development
of preventable complications.

PLANNING

1. Demonstrate stable vital signs and absence of signs of increased ICP.

2. Maintain/increase strength and function of affected or compensatory body part.
3. Indicate an understanding of the communication problems.
4. Provide information about disease process, prognosis, & treatment.
5. Verbalize understanding of condition/prognosis and potential complications.

7. Nursing Interventions
INTERVENTIONS RATIONALES
1. Closely assess and monitor neurological 1. Assesses trends in level of
status frequently and compare with baseline. consciousness (LOC) and potential for
increased ICP and is useful in
determining location, extent, and
progression of damage.
2. Monitor Heart rate and rhythm assess for 2. Changes in rate, especially bradycardia,
murmurs.
can occur because of the brain damage.

3. Evaluate pupils, noting size, shape, equality,

3. Pupil reactions are regulated by the
light reactivity.
oculomotor (III) cranial nerve and are
useful in determining whether the brain
stem is intact.

4. Position with head slightly elevated and in 4. Reduces arterial pressure by promoting
neutral position. venous drainage and may improve
cerebral perfusion.

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5. Maintain bed rest, provide quiet and relaxing 5. Continuous stimulation or activity can
environment, restrict visitors and activities. increase intracranial pressure (ICP).
6. Change positions at least every 2 hr (supine, 6. Reduces risk of tissue injury.
side lying) and possibly more often if placed
on affected side.
7. Position in prone position once or twice a day 7. Helps maintain functional hip extension.
if patient can tolerate.

8. Place pillow under axilla to abduct arm. 8. Prevents adduction of shoulder and
flexion of elbow.

9. Assess extent of dysfunction: patient cannot 9. Helps determine area and degree of
understand words nor has trouble speaking or brain involvement and difficulty patient
making self-understood. Differentiate aphasia has with any or all steps of the
from dysarthria. communication process.
10. Speak in normal tones and avoid talking too 10. Patient is not necessarily hearing
fast. Give patient ample time to respond. impaired and raising voice may irritate
Avoid pressing for a response. or anger patient.
11. Consult and refer patient to speech therapist. 11. Assesses individual verbal capabilities
and sensory, motor, and cognitive
functioning to identify deficits/therapy
needs.
12. Discuss plans for meeting self-care needs. 12. Varying levels of assistance may be
needed to be planned for based on
individual situation.
13. Monitor vital signs. 13. Monitor Alterations
14. Provide safety measures. 14. Prevent falls and injury
8. Evaluation

After effective nursing interventions the patient was partially able to:

1. Demonstrate stable vital signs.

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2. Complications are prevented or minimized.

3. Daily needs are met either by himself or others
4. Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
5. Patient report in information about disease process, prognosis, & treatment.
9. Recommendations

The care and services that are provided to the individual after the stroke, should include
the following preventive strategies.

1. Lower blood pressure: "High blood pressure is the biggest contributor to the risk of
stroke in both men and women,"
2. Lose weight: Increase the amount of exercise with activities like walking, golfing, or
playing tennis, and by making activity part of every single day.
3. Treat diabetes: Having high blood sugar damages blood vessels over time, making clots
more likely to form inside them.
4. Exercise training recommendations and physical activity programs, can serve as
important opportunities to implement effective and lasting behavioral and medical
interventions that would improve overall health and might prevent the future occurrence
of cardiovascular events such as subsequent stroke or myocardial infarction. The patient
receives instructions regarding activity level, vaccination information, and instructions
about what to do if symptoms worsen. She has been given an appointment for follow-up
after discharge (Yusuf, 2018).

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References

Caplan, L. R. (Ed.). (2016). Caplan's stroke. Cambridge University Press.

Mergenthaler, P., Dirnagl, U., & Meisel, A. (2015). Pathophysiology of stroke: lessons from

animal models. Metabolic brain disease, 19(3-4), 151-167.

National Collaborating Centre for Chronic Conditions (Great Britain). (2018). Stroke: national

clinical guideline for diagnosis and initial management of acute stroke and transient

ischaemic attack (TIA). Royal College of Physicians

Silva, G. S., Koroshetz, W. J., González, R. G., & Schwamm, L. H. (2017). Causes of ischemic

stroke. In Acute Ischemic Stroke (pp. 25-42). Springer, Berlin, Heidelberg.

Tony Rudd Intercollegiate Stroke Working Party. ‘National clinical guideline for stroke’, fith

edition. London: RCP,October 2016.

Yusuf, S., Diener, H. C., Sacco, R. L., Cotton, D., Ôunpuu, S., Lawton, W. A., ... & Bornstein,

N. (2018). Telmisartan to prevent recurrent stroke and cardiovascular events. New

England Journal of Medicine, 359(12), 1225-1237

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