CASE STUDY 10
Case Study: Amelia Middleton
July 23, 2011
Case Study: Mrs. Amelia Middleton
Stroke is considered as a significant threat on one’s health. The World Health Organization’s data indicates the existing 15 million of stroke cases every year. Five million of these lead to mortality while the other five million fall on unsuccessful treatment and rehabilitation leading to dead-like situation. On these cases, families involved seem to take it as a burden. Now, the awareness about the risk factors such as hypertension and smoking is heightened and resulted in decreasing stroke incidence. However, the number of stroke patients continues to increase due to ageing populations and increased life expectancy.
Mrs. Amelia Middleton entered the hospital and the doctor gave the provisional diagnosis of stroke. The provisional diagnosis based on symptoms seen which are paralysis and loss of sensation of her right arm and face and her difficulty in speaking. There several symptoms of stroke such as confusion, loss of memory, numbness, loss of balance, loss control of bowel movement, or any conditions wherein the normal function of the body is altered. But clinical signs of stroke are not enough to determine what type of stroke it is. Stroke can be caused by a blood clot (ischemic stroke) or bleeding (hemorrhagic stroke). Thus, she was asked to undergo CT scan that indicated ischemic stroke as her sickness. Further tests must be taken to pinpoint the main responsible of the strokes. These tests are: CT angiography to check abnormal blood vessel in the brain; echocardiogram to check if there is blood clot from the heart; carotid duplex to check the narrowness of the neck arteries; and electrocardiogram to check irregularity in the heartbeat. On Mrs. Middleton’s result of ECG it is found out that she has atrial fibrillation. This may be the main reason of her stroke.
Ischemic stroke is caused by blood clots and is accounted for 80% of all strokes while hemorrhagic stroke is caused by bleeding. Ischemic stroke’s clot is classified as a cerebral thrombosis or a cerebral embolism. On the other hand, the bleeding is caused by either a cerebral hemorrhage or a subarachnoid hemorrhage.
Her brain blood supply is interrupted decreasing the amount of oxygen and glucose reaching the brain cells. Oxygen and glucose are needed for the brain cells to function well. This type of stroke is caused mainly of blood clot formation in a small or large artery known as thrombosis. Other cases show that the embolism is the main reason of ischemic stroke.
Accumulation of fatty plaques inside extracranial or intracranial arteries will result to cerebral thrombosis. The formation of thrombosis slows down the blood flow on the extracranial arteries and intracranial arteries but the circulation on the collateral arteries remains unaffected. When this fails, death of cell occurs. A cerebral embolism is caused by a moving clot which is usually comes from the heart and makes its way to the brain. Cerebral embolism is sudden occurrence while cerebral thrombosis takes time to build up. Both prevent the blood flow to the brain.
After taking her CT scan, the doctor disregard of hemorrhagic stroke as a possible cause of her right face and arm loss of sensation and paralysis. In hemorrhagic stroke, cerebral hemorrhage or subarachnoid hemorrhage may be the cause. In cerebral hemorrhage, blood is released inside the brain due to bursting of an artery. The bursting of artery is caused by aneurysm or a head injury. Subarachnoid hemorrhage occurs between the brain and the skull. In here, the blood doesn’t leak directly into the brain. The two types of hemorrhage release blood that causes intense pressure on the brain. Both also cut the blood supply resulting for malfunction of the brain.
Precipitating factors can increase the possibility of forming hemorrhagic stroke should be taken in consideration in the case of Mrs. Middleton. Her age is a main factor since adult are more prone to stroke. In addition, her high blood pressure can trigger the happening of of cerebral or subarachnoid hemorrhage. Other risk factors are gender, ethnicity, smoking, diabetes, obesity, and high cholesterol level. Genetic composition, stress and depression may be responsible of having a hemorrhagic stroke. In studies, it shows that history of stroke or other related disease can attribute to the chance of having a stroke.
Mrs. Middleton experiencing terrible headache during that morning is considered as precipitating factor of ischemic stroke. Risk factors of ischemic stroke are grouped into two the non-modifiable and modifiable. Non-modifiable meaning it cannot be avoided or prevented. Under non-modifiable risk factors are age, race, sex, ethnicity, history of migraine, sickle cell disease, fibromascular dysplasia and hereditary. Old male people are most likely the victims of stroke but it doesn’t mean that women are not susceptible of acquiring the sickness. Any people who have states fall under the risk factors have an equal chance of having it. Stress and depression are also risk factors. Mrs. Middleton’ history of depression is treated by Sertraline. Conditions that can be prevented such as hypertension and diabetes increase the chance of having ischemic stroke. Cardiac diseases like valvular disease, atrial fibrillation and mitral stenosis trigger the occurrence of the stroke. Furthermore, unhealthy lifestyle where there is excessive alcohol intake, uncontrollable smoking, lack of exercise, use of drugs and even contraceptives fall under the modifiable risk factors. Modifiable risk factors can be prevented by having a healthy lifestyle. Moreover, those who are diagnosed of stroke like Mrs. Middleton it is important that they also avoid more risk factors so that their condition is not worsened. Therefore, proper treatment should commence from the first day the patient is admitted.
After the diagnosis, Mrs. Middleton is under the treatment of curing ischemic stroke. Her first twenty-four hours is the most critical part and needed a good nursing management. The patient should be positioned with the head midline. The head of bed elevated 30 degrees to decrease risk of aspiration and increase cerebral perfusion. If the patient must lie flat, turn the patient on his or her side to minimize aspiration of secretions (Hickey, 2003). Some stroke patients suffer from brainstem lesions that cause difficulty in swallowing and controlling secretions. In such a situation, intubation should be considered to prevent the risk of aspiration, which can lead to further complications such as pneumonia and atelectasis.
Patients with acute stroke like Mrs. Middleton are subjected for 24-hour monitoring. The monitoring will use telemetry to detect potentially life-threatening arrhythmias. The monitoring includes regular checking of the airway and ensuring the equipment is always available. The nurse is also responsible on maintaining the oxygen saturation using oximetry. It must be greater than 90%. Since there is a possibility of respiratory failure when there is an increase on the intracranial pressure (ICP), assessment of the patient’s respiratory status must be performed. This includes monitoring respiratory rate, lung auscultation, and continuous oxygen (O2) saturation. If the patient cannot have an O2 saturation greater than 90%, supplemental oxygen of 2–4 L should be used. The nurse is obliged to monitor the patient’s vital signs, neurological deficits, oxygen saturation, and cardiac rhythm frequently. The patient’s cardiac rhythm must be evaluated. If abnormalities were found on cardiac rhythm immediate treatment is necessary. It is because cardiac arrhythmias can lead to decreased cardiac output and decreased cerebral perfusion pressure (CPP). A cardioembolic stroke should be suspected. An ECG should be performed in the ED to rule out myocardial ischemia. Myocardial infarction is the third leading cause of death for patients with acute stroke, and it is the leading cause of death 30 days after the occurrence of a transient ischemic attack (TIA). And according to Mrs. Middleton her father died because of AMI (Anterior Myocardial Infarction. The nurse must also check the urinary retention of Mrs. Middleton with a bladder scan at least once within first 24 hours.
It is also the job of the nurse to start the rehabilitation of Mrs. Middleton as soon as she has been settled in the hospital. An early rehabilitation means an early discharge. The nurse must execute range of motion (ROM) exercises as part of rehabilitation. In addition, it is the nurse’s task to encourage Mrs. Middleton. Psychological treatment is an effective way to have a fast recovery.
In the case of Mrs, Middleton, thrombolysis is indicated. Thrombolysis is the breaking down of clots using drugs called thrombolytics. It is the treatment given to those who suffer thrombosis preventing further damage and the main treatment for acute ischemic stroke. Thrombosis is the formation of clots inside the blood vessel due to the accumulation of plaque. The clots prevent oxygen from reaching tissues so there is lack of oxygen on the tissue causing for its malfunction and even its death. Coronary arteries are the usual target for clot formation causing heart attacks. Patients who diagnosed of having thrombosis get an immediate treatment which is thrombolysis. Since Mrs. Middleton didn’t get this treatment, her condition is not caused by thrombosis. Cerebral embolism caused Mrs. Middleton’s ischemic stroke.
Four main thrombolytic agents are now used in emergency situations. These are alteplase, reteplase, tenecteplase and urokinase. The thrombolytic agent, tenecteplase is modified form of tissue plasminogen activator (tPA). It binds to fibrin convertinf plasminogen into plasmin. It is use to decrease death rate caused by acute myocardial infarction. Mrs. Middleton’s father died because of AMI.
Along with proper nurse management, prescribed drugs shall be taken in consideration and must not be overlooked. Patient’s present condition and medical history must guide the prescription. Doctor of Mrs. Middleton is considering giving aspirin, carvedilol and atorvastatin as part of her medication. The question is, are these drugs needed or suitable for Mrs. Middleton?
Aspirin is under the group of salicylates. Its work is to decrease substances that cause pain, fever and inflammation. In some cases, it is used as treatment or preventive measure for heart attacks, strokes and angina. If it is used for cardiovascular conditions, supervision of a doctor is needed. Taking this drug with alcohol will result to bleeding of stomach. Thus, it is not recommended for intake if you have history of gastrointestinal bleeding. And for that matter, prescribing this to Mrs. Middleton who has history of gastrointestinal bleeding is disagreeable.
Another drug used to treat heart failure and hypertension is carvedilol. It is also prescribed after a heart attack. Intake of this drug is continuous since a stop can result to a worse condition. Once Mrs. Middleton starts her carvedilol intake for her high blood pressure she must continue drinking it without missing. Stopping or missing drinking it can worsen her condition.
The doctor also thinks of giving atorvastatin in addition to Mrs. Middleton medications. This drug is a treatment for high cholesterol and reduces the risk heart complications as well as heart. Atorvastatin are not suggested for medication in people who is pregnant, diabetic, has thyroid disorder or a history of kidney or liver disease.
Based on Mrs. Middleton’s medical history, aspirin is not an option for her prescription. Carvedilol and atorvastatin can be used to treat her hypertension and prevent heart attack.
After ECG, it is founded that she has atrial fibrillation. It is a common type of arrhythmia or a heartbeat disorder. People having this condition may have a too fast, too slow or irregular heartbeat rhythm. It occurs when there is a disorganized electric signals cause the two upper chambers of heart to fibrllate. Fibrillate means irregular contraction of the heart. Symptoms are not seen or felt but can increase the possibility of stroke.
Mrs. Middleton has history of depression which may be the factor of atrial fibrillation occurrence. This condition can lead to complications like stroke and heart failure manifest by Mrs. Middleton. Since she is diagnosed of ischemic stroke, the treatment for atrial fibrillation would focus on controlling her heartbeat and not on decreasing the occurrence of stroke. Medicines under the groups of: beta blockers like metoprolol and atenolol; calcium channel blockers like diltiazem and verapamil; and digitalis like digoxin are used to normalize the rate. If Mrs. Middleton doesn’t show any good sign after taking the treatment for rate control she will be taking the rhythm control treatment. Also, it is common that patients admitted in the hospital receive this treatment to have monitor on their hearts. Medicines used to control the heart rhythm include amiodarone, sotalol, flecainide, propafenone, dofetilide, and ibutilide.
The period she will spend in the hospital is the time for freeing herself from any stress. This will avoid heart attack. She is also not allowed to drink alcohol, caffeine or any stimulant causing her rate to increase or decrease.
Stroke patients need more attention since the risk factors can worsen the condition or even cause death. Proper nurse management is the key to stabilize vital signs. It is also recommended that the family of the patient avoid unnecessary things that will cause stress. Furthermore, doctor’s prescription and decision must consider the patient’s medical history. Lastly, encouragement from the people surrounding her during rehabilitation can help for fast recovery.
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