Scenario 1 The Neurological Patient
June Osakwe is a 79 year old woman. She has been admitted following a left hemispheric ischaemic stroke. June underwent thrombolysis with alteplase and has spent 24 hours in the acute stroke unit and has now been transferred to the stroke ward.
On assessment June has moderate expressive and receptive aphasia. She has a right hemiplegia and moderate dysphagia. She has been incontinent of urine on five occassions since admission. Her vital signs are all stable. June lives with her husband Greg who is 86. They have two adult children but they live in the USA.
|Airway||Airway is patent, June is awake. She has moderate dysphagia.|
|Breathing||Respiratory Rate 14bpm, SpO2 95% on room air|
|Circulation||Heart rate 86bpm, strong, regular pulse|
Blood Pressure 190/88mm/Hg;
Urine not measured as she is incontinent (Pt. weight 66Kg)
|Disability||GSC E4 M5 V3|
Severe right sided weakness in arms and legs
PEARL size 3
Blood Glucose 5.1
No complaints of pain
|Exposure/Environment||Hemiplegia and homonymous hemianopia Expressive and receptive aphasia|
On IV fluids as no nutritional support
No wounds or pressure sores.
Incontinent of urine and faeces
Suggested problems (for guidance only, you may choose to discuss other issues)
- Nutritional support
- Management of Dysphagia
PT SCENARIO GUIDLINE- Write essay in third person
Harvard reference style- 15 0r more
- OUTLINE THE SCENARIO YOU HAVE CHOSEN BRIEFLY, WHY THE PATEINT IS ADMITTED IN HOSPITAL and what you will be discussing in the essay.
- PUT ABOUT NMC CONFIDENTIALITY i.e CONFIDENTIALITY HAS BEEN MAINTAINED
- Also include that for the purpose of the essay, you have chosen to discuss two of patient problems i.e management of dysphagia and nutritional support. State the reason for chosen to discuss management of dysphagia and nutrition support
Note- relate all discussion with acute care
What is ABCDE ASSESSMENT?
- DEMONSTRATE THE A TO E ASSESMENT AROUND THE SCENARIO (A-AIRWAY, B- BREATHING, C- CIRCULATION, D- DISABILITY AND E- EXPOSURE
Briefly discussed what each stand for e.g A stand for airway……. and relate it to the essay and state what need to be done as a nurse. I included example below, do more research and add more…
YOU CAN USE THIS INFORMATION below AS PART OF YOUR DISCUSION BUT IT WILL NEED TO BE REWRITING PROPERLY AND ADD MORE INFORMATIONS.
ABCDE are initial assessment used to prevent deterioration and rule out critical conditions (Mayo, 2017).
Airway- In the scenario, patient airway is opened and maintained. When engage in conversation to observe any obstruction or noisy sounds (Smith and Bowden, 2017)
The normal respiratory rate is 12 to 20 breath per minute and the patient respiratory rate is 14bpm which is normal. It is important to check the depth, pattern and depth In assessing patient it is important to look, listen and feel.(Farrington, 2018) . To look out for use of accessory muscles, any sign of respiratory distress and unable to finish a sentence. Movement of the chest should be symmetrical and normal breathing should be quiet, effortless and rule out pneumothorax by looking out for any sign chest pain, shortness of breath and rapid heart rate (Peate and Dutton, 2013). Patient saturation is normal Spo2 >95% on room air and should be regularly monitored to prevent desaturation to rule out hypoxemia which is caused by lack of oxygen in the blood and (Farrington, 2018).
Mrs X heart rate is 86 within the range of 60 – 80 normal range. During assessment patient pulse is palpitated to know if it is weak or strong, thready or regular (Peate and Dutton, 2013). Blood pressure was higher than normal 190/88. At this stage, nurse should check to make sure if Mrs X has had any anti- hypertensive medication recently and if not might need to give her medication to regulate blood pressure which might need to be given through IV if patient cannot swallow (Peate and Dutton, 2013)
is assessing the patient level of consciousness by using AVPU. They are used to check if the patient is Alert, response to verbal, response to pain and unresponsive and if there is reduced in the level of consciousness Glasgow Scale Coma is used to assess the patient further. In the scenario, patient GSC show that E4- eye opening is spontaneous, M5- best motor response is in localized pain and V3- best verbal response is inappropriate. The total score is 11 which means that the brain injury is moderate. This might lead to long term cognitive impairment, physical skill and emotional functioning (Mayo, 2017). Patient blood glucose is within the range, it need to be assessed to know if it is hypoglycemia or hyperglycemia which might be a medical emergency (Peate and Dutton, 2013). Patient pupil are assess for the size, reaction to light and symmetry. During the observation, quick response indicate “+” and slow response indicate “-“. They are done to detect any medical condition such as developing intracranial lesion (Farrington, 2018)
The news score was 1 due to saturation that was 95%, patient will need to be regularly monitored to prevent desaturation.
Physical examination is very important to check for any additional factors such as allergy reaction, inflamed area, bleeding, rashes and skin integrity (Peate and Dutton, 2013). In the scenario, patient has right hemiplegia which is the condition that affect one side of the body due to stroke. Nurses supported patient by making them comfortable and regularly turning of patient and supporting the affected arm on adjustable base. She also has homonymous hemianopia which mean half a vision on both eyes. Patient might be supported by placing objects where they can see. Pain assessment is also carried out by locating the pain and intensity of the pain, if patient is in pain. Patient might need to be catheterized to monitor the urine output and prevent pressure sore. The IV fluid is for rehydration (Farrington, 2018)
Problem 1- Nutritional support
THESE ARE SUGGESTION ON NUTRITION i.e what you can work on, PLEASE DO MORE RESEARCH and develop the list below and reference it.
Why is it important for stroke patient and consequence of inadequate nutrition for stroke patient?
Nutrition screening i.e all patient admitted should have a nutrition screen by using the appropriate tool MUST, if more than 2 referred patient to dietician.
Dietician decide type of texture and if patient is at high risk of malnutrition and require high energy and high protein diet.
Oral nutrition supplements (ONS) e.g fortisip, ensure, fresubin and their benefit to patient with reduced oral intake.
Hydration i.e IV fluid should be administered if patient is having reduced oral intake.
Holistic care- to give regular oral care, maintain adequate oral intake by support patient to eat and drink, protect meal time etc
Management of dysphagia
Note these are only Suggestions on how to answer the question, please do more research…explain the point below and reference them.
What is dysphagia and relate it to the stroke patient with moderate dysphagia in the scenario
Steps to take as a nurse i.e assess patient within 4 hours after admission and if failed assessment referred patient to SALT i.e speech and language therapist and be kept nill by mouth (pls research and reference)
Patient with moderate dysphagia, do they need soft diet or NG tube.
Nutrition statue assessment
Refer patient to dietician
Treatment plan e.g thickened fluid, how to sit when eating, take small bite and sips, supplement need etc
What other things can be done as a nurse i.e holistic care…. how to support patient, carer and family member. Nurses are responsible for ongoing assessment, providing assistance during meal time if there is need for it and Patient weight monitoring
NEED TO DO MORE RESEARCH AND ADD MORE ON DYSPHAGIA
Managing psychosocial aspect of stroke
- Working with MDT in collaboration to support patient.
- Working with patient to help them develop skills
- Early involvement of family and friend in planning pathway
- Listening and providing solution
- SUMMARY OF WHAT’VE DONE TO THE PATIENT
- PULL TOGETHER ALL KEY POINT U’VE DISCUSSED
- WHAT CONCLUSION YOU’VE DRAW ON IT i.e LOOK INTO PRO AND CONS e.g NMC SAY THIS AND RCN SAID IT BETTER
- BRING IN YOUR LITERATURES, USE GOGGLE SCOLAR TO IDENTIFY EVIDENCE
- USE ROYAL COLLEGE OF NURSING
- ADVANCED JOURNALOF NURSING
- MIX WITH INTERNET, BOOKSAND JOURNALS
- USE CURRENT EVIDENCE WITHIN 5 YEARS.
- USE HAVARD REFERENCES
– what you are going to discuss mention two problems (200 words)
- Briefly discuss underlying pathology (respiratory, altered fluid balance or neurological) optional
- A-E assessment, NEWS and SBAR in connection to your patient, consider investigations (600 words)
MAIN BODY (1500 words)
- Problems must be patient problems
- Nursing management, evidence base for this care and analysis WHY?
- Discuss themes that have been covered on the course not something else
- Pick the obvious don’t make this too hard for your self