Integrated Nursing Practice

Contents

Case study.

Analysis and interpretation of assessment findings.

Legal and ethical implications.

Patient-centred care.

Health Promotion Strategies.

Discharge Plan..

References.

Case Study

The patient with aphasia, hemi paralysis and facial paralysis has various associated risk factors, for instance, confusion and depression. Moreover, if holistic care and interventions are not given to the patient then his mental and physical health condition can deteriorate. In the present case, Mr Kwon is 74 years old male patient was presented in the hospital with a chief complaint of facial drooping and aphasia. Further, he had right-sided hemi paralysis. These clinical symptoms are interlinked with the left side brain stroke that leads to the following clinical symptoms- speech problem, communication issue, anxiety and confusion. This case evaluation report will analyze and interpret the clinical findings of Mr Kwon. This will be followed by a thorough discussion on ethical and legal consequences, health promotion strategies and person-centred care. The detailed discharge plan will be also included.

Analysis and Interpretation of Assessment Findings

As per the clinical vital sign and symptoms evaluation, the patient had a body temperature within the normal range (36.1 to 37.2 degree Celsius). His temperature is 36.8 ° C that follows under normal temperature limits. Additionally, his heart rate is 98 beats per minutes, that also lies within the normal limits (60 to 100 beats per minutes). Mr Kwon has a higher respiratory rate that was 24/ minutes. For a normal healthy adult, the respiratory rate is 12 to 20 breaths per minutes. High respiratory rate is indicative of tachypnea (Htun et al., 2019), in the present case, the patient is suffering from tachypnea. In accord with Htun et al., (2019), tachypnea can be described as the rapid breathing. It is evident from the patient's blood pressure values that are 140/105 mmHg, he was suffering from high blood pressure that is hypertension. The patient's systolic pressure (140 mmHg) indicates hypertensive condition with stage 2, moreover, the diastolic pressure (105 mm Hg) also indicated hypertensive condition with stage 2 (Greenland & Peterson, 2017). The patient’s oxygen saturation at room air is 96 %. This value is acceptable in the old age group as in older age the oxygen saturation is usually lower than the young people. As per the past medical history of the patient, he is suffering from type 2 diabetes mellitus and hypertension. Moreover, he had an episode of cognitive cardiac heart failure. Further, his habit history reveals that he was a chronic smoker with 40 years of cigarette smoking. 

Additionally, the patient’s vital signs assessments indicated his vital signs are directly linked with his diseased conditions, including cardiovascular issue, hypertension and diabetes mellitus. In accord to Ormazabal et al. (2018), cardiovascular issues and diabetes mellitus are interlinked as high serum glucose levels lead to deposition inside the blood vessels that causes narrowing of the vessels and causing cardiac issues. The hypertensive condition causes an increased load on the heart and causes a functional and structural alteration in the cardiac tissue (Santulli, 2019). Therefore, it is evident that three of these health conditions, including diabetes, hypertension and cardiovascular disease are tangled together and present the interlinked clinical signs and symptoms (Tackling& Borhade, 2019). CT scans report of the patient are suggestive of left cerebrovascular accident and that can progress to edema. In the present case, edema can lead to a rise in intracranial pressure (Khatri et al., 2018). Increased intracranial pressure can resultant in the reduced blood flow in the brain tissue and eventually, less oxygen supply due to low blood flow leads to brain cell and tissue death (De Bernardo, Vitiello & Rosa, 2019). Increasing intracranial pressure can be fatal therefore it is vital to properly access the condition of Mr Kwon and plan interventions accordingly. On further clinical evaluation, the patient is suffering from homonymous hemianopia that progress into distorted sights and double vision (Chokron, Peyrin & Perez, 2019).

Legal and Ethical Implications

In the present case, CT scan was done for assessment of the brain tissue injury, though cerebral angiography was also needed for better evaluation. The cerebral accident must be assessing through cerebral angiography for effective evaluation of the brain stroke cause. Further, the physician can conduct the Trans-cranial Doppler ultrasonography to measure the velocity of blood in the brain blood vessels (Bonow et al., 2018). Additionally, it is paramount to prepare medical intervention based on the neurologic assessment. Neurologic assessment is necessary in the present case to evaluate the extension of stroke and its effect on the mental and physical health of the patient (Powers et al., 2019). Hemodynamic monitoring is another vital process in the present case to control bleeding and hypertension (Zhang et al., 2019). Though, no such interventions and assessments have been performed that can lead to ethical implications as lack of such assessments can affect the overall health condition of the patient.

Effective care and intervention plan must be developed through the inter-professional approach. It is an effective way to develop a care plan with the involvement of physiotherapist, physicians, nurses and other health care workers, along with the shared decision of the family members (Wittling et al., 2018). Although, in the present case, the patient was alone and no family member was there with him since morning. Further, there were no other health care professionals for rendering medications to manage the patient’s vital sign. Further, the patient was unable to communicate therefore no feedback was obtained from the patient. Therefore, the nurse must confirm therapeutic communications with the patient for effective comprehensive care and communication (McEwen et al., 2019). This could lead to legal implication as a family member must there with the patient during treatment. Further, the patient had diagnosed with homonymous hemianopia, therefore, it is essential to consult optometrists for further vision restoration techniques and correct glass (Palomar-Mascaró, 2018).

Additionally, the blood clot is still alarming and concerning the situation as it could lead to death. Clots in the brain tissues can cause body paralysis and associated with other risk factors like a heart attack that again lead to ethical and legal consequences (Abiodun, 2018). Therefore, the physician must provide neuro thrombectomy for a blood clot (Wittling et al., 2018). Though, no such intervention had been performed in the present case. Further, Mr Kwon was provided with the IV catheter, but not regularly monitored for the site infection risk. No such interventions and monitoring performed in this case therefore can lead to further ethical and legal implications (Rupp & Karnatak, 2018).

Patient-Centred Care

The patient must be provided with comprehensive, holistic and patient-centred care to meet all the requirement and individualized needs as per his health condition (Naylor et al., 2017).In the present case scenario, the patient may suffer from dizziness, depression and stress. Therefore, it is essential to render holistic care to the patient with the involvement of psychiatrist to deal with the patient's emotions and prevent the development of negative and low thoughts. Additionally, negative thoughts and/ or depression can deteriorate the blood pressure of the patient therefore it is paramount to calm the patient (Yang et al., 2018). Moreover, he is suffering from homonymous hemianopia that can lead to visual difficulties including blurred vision. Explorative saccade training and flicker stimulation training can be an effective procedure for Mr Kwon as these procedures would aid in the improvement of the blind side of the patient (Abiodun, 2018). The above-mentioned training procedure includes some eye movement exercise like rapid eye movement between the two fixed points, theses exercise will help the patient to remediate visual issues (Ghannam & Subramanian, 2017).

Moreover, Mr Kwon is not able to communicate and have visual troubles too. Therefore, it is vital to provide him with some communication techniques like blackboard/ writing board to understand his needs. Therapeutic communication can be an effective way to fetch the proper feedback from the patient as that will aid in formulating individualized care plan (Naylor et al., 2017). Further, the patient’s family member’s involvement enhances the whole caring process and the health care staff must explain the treatment and condition of the patient to his family. Mr Kwon must be provided with a physician, physical therapist, psychiatrists, vocational counsellors, neurologist, physiatrists, pharmacist and visual aids. Proper medication must be rendered to normalize the patient's vitals. Further, at this stage, proper nutrition intake and feeding is paramount for the patient, therefore, the catheter will be effective for maintaining the nutritional requirement of the patient (Mahoney et al., 2015). The physician must look for basal crackle sound and evaluate the associated risk, for instance, pneumonia and bronchitis. The patient Mr Kwon must be provided with the respiratory aid device for proper breathing. Vieten et al., (2018) stated that age-associated crackles can also interfere during the management of brain stroke patient therefore it is vital to look and evaluate the basal crackle in the present case.

Health Promotion Strategies

The health promotion strategies must be as per the need of the patient. The health promotion strategies for Mr Kwon are focused on his current physical and mental condition. Patient-centred care is a problem-solving approach to render comprehensive care to Mr Kwon. In the present case scenario, Mr Kwon is suffering from various interlinked health issues, for instance, hypertension, vision blurring, speech issues, stroke and basal crackles etcetera. Healthy diet and weight management strategies would be effective for Mr Kwon. Healthy meal and plenty of vegetables and fruits will help the patient to maintain his blood pressure issue. Further, eating food items with low cholesterol, Trans fat and saturated fat with high fibre can prevent high cholesterol levels (Chen et al., 2018). Limiting sodium will aid in maintaining blood pressure. It is vital to maintain the blood pressure and cholesterol level of the patient to reduce the risk of stroke in future. A healthy weight reduces stroke risk. Obesity or overweight can lead to various health issues including hypertension and high cholesterol (Ashraf et al., 2015). Physical activity including light exercise and yoga will aid in reducing stress and anxiety. Further, physical acidity help in maintaining cholesterol and body weight therefore reduce the risk of further stroke. In the present case, the patient is chronic smoker, therefore, it is paramount to motivate the patient for quitting smoking as tobacco either in chewing or smoking can lead to blood vessel thickening and stroke (von Martial et al., 2018). Further, other health promotion strategy includes health education and health promotion campaign. Health education and promotion campaign must include risk factors and management of stroke. In the present case, it is must to educate Mr Kwon about diabetes mellitus, hypertension and other health issues. Further, the patient must follow the medicine schedule as prescribed by the physician (Kalkonde et al., 2015).

Discharge Plan

After acute care management, the stroke patient may face the healing and recovery process. Rehabilitation process must start as early as possible during the recovery phase. The most communal effects of the cerebrovascular accident are depression reduced motor skill and a speech impediment. The extent and nature of `disability followed by a stroke depends on the stroke type and extend of brain damage. The rehabilitation phase must include goals related to gaining back the motor abilities, new skills and make the patient independent. In the present case, the restoration process is dependent on various factors, for instance, the availability of caregiver, living situation, disabilities, and resulting damage. Further, a good recovery process is associated with team efforts, the involvement of family members, patients, rehabilitation providers (Langhorne et al., 2017). The discharge of the plan of Mr Kwon will be based on his present situation. After 14 days, his gait is unaided and steady and his speech is slurred but improved. Additionally, there is some movement on the right side of the body. Further, the goal is to reduce the risk of stroke in future, maintain the blood pressure and blood glucose level. Further, to normalize the patient life by aiding in recovery from the paralytic attack including improvement in walking, speech and eating. Home care services can be an effective technique to help Mr Kwon to achieve his further milestone. Moreover, a checklist with the medication schedule, personalized intervention plan (diet, screening, monitoring and wellness) emergency signs and emergency contact number must be handover to the patient (Norrving et al., 2018).

References for Neuro-Ophthalmic Manifestations of Cerebrovascular Accidents

Abiodun, A. (2018). Stroke (Cerebrovascular Accident (CVA) or Brain Attack) and Its Management-Literature Review.

Ashraf, V. V., Maneesh, M., Praveenkumar, R., Saifudheen, K., & Girija, A. S. (2015). Factors delaying hospital arrival of patients with acute stroke. Annals of Indian Academy of Neurology18(2), 162.

Chen, L. Y., Chung, M. K., Allen, L. A., Ezekowitz, M., Furie, K. L., McCabe, P., ... & Turakhia, M. P. (2018). Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Stroke Council. Atrial fibrillation burden: moving beyond atrial fibrillation as a binary entity: a scientific statement from the American Heart Association [published online ahead of print April 16, 2018]. Circulation.

Chokron, S., Peyrin, C., & Perez, C. (2019). Ipsilesional deficit of selective attention in left homonymous hemianopia and left unilateral spatial neglect. Neuropsychologia128, 305-314.

De Bernardo, M., Vitiello, L., & Rosa, N. (2019). The utility of ocular ultrasonography to evaluate the influence of Tourniquet application on intracranial pressure. Medical Principles and Practice28(5), 499-499.

Ghannam, A. S. B., & Subramanian, P. S. (2017). Neuro-ophthalmic manifestations of cerebrovascular accidents. Current Opinion in Ophthalmology28(6), 564-572.

Greenland, P., & Peterson, E. (2017). The new 2017 ACC/AHA guidelines “up the pressure” on diagnosis and treatment of hypertension. Jama318(21), 2083-2084.

Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Scientific reports9(1), 1-10.

Kalkonde, Y. V., Alladi, S., Kaul, S., & Hachinski, V. (2018). Stroke prevention strategies in the developing world. Stroke49(12), 3092-3097.

Kalkonde, Y. V., Deshmukh, M. D., Sahane, V., Puthran, J., Kakarmath, S., Agavane, V., & Bang, A. (2015). Stroke is the leading cause of death in rural Gadchiroli, India: a prospective community-based study. Stroke46(7), 1764-1768.

Khatri, N., Thakur, M., Pareek, V., Kumar, S., Sharma, S., & Datusalia, A. K. (2018). Oxidative stress: major threat in traumatic brain injury. CNS & Neurological Disorders-Drug Targets (Formerly Current Drug Targets-CNS & Neurological Disorders)17(9), 689-695.

Langhorne, P., Baylan, S., & Trialists, E. S. D. (2017). Early supported discharge services for people with acute stroke. Cochrane Database of Systematic Reviews, (7).

Mahoney, C., Rowat, A., Macmillan, M., & Dennis, M. (2015). Nasogastric feeding for stroke patients: Practice and education. British Journal of Nursing24(6), 319-325.

McEwen, S. E., Donald, M., Jutzi, K., Allen, K. A., Avery, L., Dawson, D. R., ... & Quant, S. (2019). Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice. PloS one14(3), e0212988.

Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., ... & Brock, J. (2017). Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society65(6), 1119-1125.

Norrving, B., Barrick, J., Davalos, A., Dichgans, M., Cordonnier, C., Guekht, A., ... & Nabavi, D. (2018). Action plan for stroke in Europe 2018–2030. European Stroke Journal3(4), 309-336.

Ormazabal, V., Nair, S., Elfeky, O., Aguayo, C., Salomon, C., & Zuñiga, F. A. (2018). Association between insulin resistance and the development of cardiovascular disease. Cardiovascular diabetology17(1), 122.

Palomar-Mascaró, F. J. (2018). Rehabilitation of left homonymous hemianopia with adjacent palomar prism technique and visual therapy on line. J Intellect Disabil Diagn Treat6, 31-35.

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... & Jauch, E. C. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke50(12), e344-e418.

Rupp, M. E., & Karnatak, R. (2018). Intravascular catheter–related bloodstream infections. Infectious Disease Clinics32(4), 765-787.

Santulli, G. (2019). Cardiovascular disease and diabetes. Frontiers in endocrinology10, 314.

Tackling, G., & Borhade, M. B. (2019). Hypertensive heart disease. https://www.ncbi.nlm.nih.gov/books/NBK539800/

Vieten, C., Wahbeh, H., Cahn, B. R., MacLean, K., Estrada, M., Mills, P., ... & Presti, D. E. (2018). Future directions in meditation research: Recommendations for expanding the field of contemplative science. PloS one13(11), e0205740.

Vieten, C., Wahbeh, H., Cahn, B. R., MacLean, K., Estrada, M., Mills, P., ... & Presti, D. E. (2018). Future directions in meditation research: Recommendations for expanding the field of contemplative science. PloS one13(11), e0205740.

von Martial, R., Gralla, J., Mordasini, P., El Koussy, M., Bellwald, S., Volbers, B., ... & Sarikaya, H. (2018). Impact of smoking on stroke outcome after endovascular treatment. PloS one13(5), e0194652.

Yang, E., Schamber, E., Meyer, R. M., & Gold, J. I. (2018). Happier healers: randomized controlled trial of mobile mindfulness for stress management. The Journal of Alternative and Complementary Medicine24(5), 505-513.

Zhang, Z., Pu, Y., Mi, D., & Liu, L. (2019). Cerebral hemodynamic evaluation after cerebral recanalization therapies for acute ischemic stroke. Frontiers in neurology10, 719.

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