Cerebrovascular accident
Neurological case study: Cerebrovascular accident
The purpose of this essay is to analyse and interpret the clinical manifestation present in the given case study of Mr. Sam Kwan. The initial diagnostic examination of cerebrovascular accident (stroke) is the general assessment of physical and neurological signs and symptoms. This paper also highlights the interprofessional care, and management plan during hospitalisation and after discharge which includes person-centred care, health education, and ethical and legal implications. The discharge plan varies with the severity of stroke and recovery which is based on the improved physical conditions, social and family history, and living arrangements. Mr. Kwan is assessed throughout the treatment in the hospital and placed on an appropriate treatment and care plan to stabilise his condition
Mr. Kwan was presented with several physical and neurological symptoms which could be the cerebrovascular accident. He has a medical history of hypertension, type 2 diabetes mellitus, congestive cardiac failure, and 40 years long smoking history which are the primary risk factors of stroke (Samad et al., 2018). Australian Bureau of Statistics, 2016 stated that around 40% of disability cases result from a stroke which also accounts for 5.2% of deaths in Australia. The aortic arch from the heart is divided into left and right carotid arteries, which are further divided into external and internal carotid arteries. The internal carotid arteries bifurcate into anterior and middle cerebral arteries in right and left hemispheres of the brain (Nogles& Galuska, 2020). The primary function of the middle cerebral arteries is to supply oxygenated blood and nutrition to the brain parenchyma. According to Nogles and Galuska, middle cerebral artery is involved in the acute stroke which supplies blood to the frontal, parietal and temporal lobes of the brain and the deeper tissues. In the given case study, the diagnostic CT scan without contrast; which is the primary diagnostic tool of stroke, shows increased density in the left middle cerebral artery. This increased density of the middle cerebral artery reflects the composition of a clot in which ‘the red blood cell’ rich vascular fluid changed in fibrin-based ‘white thrombus’ rich blood (Haridy, Churilov, Mitchell, Dowling, & Yan, 2015). It also stated that the team was unable to dissolve the clot, which might be significant to examine the cause of the cerebrovascular accident. Stroke caused by a blood clot is called ischaemic stroke which is further divided into two subtypes; embolic and thrombotic stroke (von Kummer, &Dzialowski, 2017). In an embolic stroke, a blood clot formed in other body parts such as the heart travels towards the brain and is stuck in the artery to stop the blood flow in the brain tissues. In contrast, a thrombotic stroke happens when plaque formation occurs in the inner wall of the artery which develops in thrombus and affects the arteries taking blood to the brain (Lai-Te& Chen-Yang, 2018). In Mr. Kwan’s case, the cause of stroke could be either embolic or thrombotic blockage of the artery. Brain oedema is a common symptom of acute ischaemic stroke caused by the disruption of the blood-brain-barrier which allows the influx of fluids and solutes into neurons. Similarly, the injured cells and artery initiate the injury cascade and release glutamate which opens the calcium and sodium ion channel of the blood vessel (Jha, 2003). This allows sodium influx in the brain cells and increases the cell volume resulting in oedema of the brain. These are the initial diagnostic findings concerning the given case study.
The stroke of the left middle cerebral artery is associated with several clinical manifestations. The injury in the left hemisphere of the brain affects the right side of the body. Mr. Kwan’s initial physical presentation is right-side hemiparalysis, aphasia, and facial drooping. Right-side hemiparalysis is the inability to move the right side of the body which is due to the deficient blood supply to the nerve centres of the brain. It occurs when communication between the spinal cord and brain fails due to the injury in the brain. The injured neurons cannot pass signals responsible for the motor control, thus dampened its functions that cause decrease movement of right limbs and droop the face muscle (Puig, Brenna, & Magnus, 2018) Aphasia is a language disorder that is also caused by damaged speech and language centre present on the left side of the brain. Although this cause difficulty in communication and act as a barrier in the assessment, stroke’s patient might preserve intellectual capability even though it is hard to understand their fragmented speech (Lee, &Pyun, 2014). Thus, Mr. Kwan can nod his head for closed questions and use the communication board. The cerebrovascular accident also damages the optic nerve which involves vision loss on the same side of both eyes (Goodwin, 2014). In the case study, it is difficult to identify if Mr. Kwan has lost his vision partially due to restrictive communication. Another common complication of stroke is dysphasia, associated with abnormal triggers for swallowing, lip closure, and lack of lingual control.Dysphasia and impaired consciousness together are risk factors of stroke associated pneumonia (SAP), as the patient might have a pre-existing infection, immunological alteration, and comorbidities like diabetes mellites (Matz et al., 2016). Hence, Mr. Kwan is nil by mouth after the admission and put for a swallow review for further investigations. SAP is the most common complication of dysphasia, which can be partially controlled by tube feeding. Mr. Kwan has basal crackles which might be the sign of SAP or due to the damage in the respiratory centre in the brain (Hoffmann et al., 2017). Though his oxygen saturation is 96% in room air, he is on 2 litre/minute oxygen via nasal prongs to reduce the respiratory distress and to increase the oxygen perfusion in the brain.
The acute and chronic management plan is placed for Mr. Kwan following the admission. The onset of the cerebrovascular accident is unknown as his family was not with him and found him late at night. He is hyperglycaemic and on oral hypoglycaemic agents which might be uncontrolled due to stroke and needs regular observations. Glucose levels should be monitored continuously in emergency stroke evaluation as too high and low glucose levels may be mistaken for the symptoms of a stroke (Otero‐Ortega et al., 2019). Elevated glucose also provokes the anaerobic metabolism and free radical production and initiate cell death of injured tissue. He is on 2 hourly turns to maintain normal blood flow and pressure injuries care. Stroke disturbs the harmony between blood, cerebrospinal fluid, and brain matter as the result of swelling due to brain injury which is progressive in the primary stage with an increase in neurological signs and symptoms (Telano, & Baker, 2020). Fluid maintenance in a patient with critical brain injury is routine care for swallow difficulties. Mr. Kwan is receiving IV crystalloid fluid which prevents dehydration, risk of infection, and deep vein thrombosis (Visvanathan, Dennis, &Whiteley, 2015).Isotonic fluid resuscitation is helpful to minimise the secondary brain injury derived from cerebral oedema (Thompson et al., 2018). The patient should be monitored for further deterioration and vital signs to identify the changes within the body.
Interprofessional care plan
The care and management plan for stroke patients involves an interdisciplinary team to address different concerns about symptoms management and post-hospitalization care. The team members include a nurse, neuropsychologist, physiotherapist, speech pathologist, occupational therapist, social worker, pharmacist, general physician and, in-home caregivers. The goal of the interdisciplinary involvement is to organise services, early assessment, and diagnosis, acute management, secondary prevention, rehabilitation, community participation for long-term recovery, and management of ongoing complications (Heiberger et al., 2019).
Nurses are involved from the onset of hospitalization to the post-discharged community management of stroke patients. During the hospital stay nurses can manage the neurological flow sheet including consciousness level, degree of voluntary and involuntary movements, eye sights and opening, communication level and, vital observations (Maxwell et al., 2019).Person-cantered care is achieved by working with the patient, as Mr. Kwan can communicate with the board and head nod, thus the nurse should gain consent before implementing management plans. If the patient cannot provide consent for a specific care plan the family should involve in the ethics of informed. The goal of the nursing care plan is to improve mobility, communication and, swallowing deficits, maintain hydration status and, glucose level, eliminate the risk factors such as hypertension. Nurses play a vital role in educating patients and families during hospital stay and rehabilitation to recommend change and explain the importance of lifestyle modifications.
Mr. Kwan has right-side hemiparalysis with a restriction on movement, which can be improved by regular physiotherapy. Physiotherapy sets goals depending on his need and gains consent from the patient and family. They also educate the family and carers on how to support the patient to move and walk and help to improve the ability to walk, get in and out from bed and chair and do optimum personal care (Cho, &Cha, 2016).Mr. Kwan should attend the recommended appointments and complete the exercises. A speech pathologist can address swallowing difficulties as they have vast knowledge about the muscles in the tongue, mouth, and neck (Berg, Rise, Balandin, Armstrong, &Askim, 2016). They provide speech therapy and assist patient to communicate alternatively if speech is lost. They also educate the family to learn communication techniques as the patient is aphasic. During the hospital stay, an occupational therapist assesses the patient’s motor function, cognition, and visual perception to identify the capability for the activity of daily living (Schiavi et al., 2017). This assessment aid to identify the area of personal and environmental difficulties and enable to person-centred goal setting with the involvement of family and patient. For instance, the occupational therapist assesses personal care tasks including toileting, showering, dressing, grooming, eating, laundry, and shopping; which allow them to develop plans to support the patient. Similarly, social workers can also get involved in the management plan of the post-stroke patient. They can be a member of the interprofessional group during in-patient rehabilitation and in the out-patient phase of the stroke. A social worker provides counselling to the patient and carer, liaison with other community-based services, and gives information on support services and medical doctors (Padberg et al., 2016). They assist the patient to become social, functional, and financially independent and work with the patient, family, and rehabilitation team to achieve the set goal for the patient (Lehnerer et al., 2019). Mr. Kwan is a 74-year-old man who can be assessed for rehabilitation at an aged care facility as he has lost a degree of independence.
When the patient gets back to the community the GP’s role becomes paramount as the physician helps patients to deal with the consequences of stroke and other comorbidities such as hypertension, diabetes, and infections. The patient should be educated for the importance of GP follow-up as they provide counselling on sexual and interpersonal challenges and vocational and creative activities (Pedersen, Petursson, &Hetlevik, 2018). GP works closely with the nurse and treats the patient to prevent secondary complications such as seizures and sleep apnoea. The rehabilitation physician also has an important role in the management of post-stroke anxiety and depression. A physician can manage the complications like spasticity and pain by pharmacological treatment along with a careful medical assessment of the patient (Monaghan et al., 2017). A neuropsychologist is an important member of a stroke management unit. Patients with stroke lose some extent of cognitive function in the form of impaired memory and difficulty in problem-solving. Neuropsychologists are specialists in assessing the brain function to plan treatments and detect progressive damage or improvement in the brain. They work together with allied health to uplift the physical, social, and psychological aspects of patients. Pharmacists are also involved in the care plan of Mr. Kwan as they provide education on medications to manage symptoms and comorbidities. They are also involved in both in-patient and out-patient settings and put interventions that reduce the modifiable risk factors of stroke and prevent relapse (Basaraba, Picard, George, &Mysak, 2018).
In-home caregivers are trained professionals competent to provide support to stroke patients and families. Mr. Kwan needs support as he has lost control over the right side of the body and has slurred speech. Caregivers usually implement and adapt the care plan developed by health professionals (Tsai, Yip, Tai, & Lou, 2015). As they spend more time with the patient, they are the primary source of the information about the health status of Mr. Kwan. Providing care to the paralysed patient might be stressful which can be reduced by appropriate knowledge skills and emotional support. Caregivers are abided by ethical and legal principles and also responsible for educating patients while there is disagreement in the care plan.
Criteria Led Discharge Form
NSW Government | Family Name: Kwan | MRN: 684421 |
Criteria Led Discharge |
Given Name: Sam | Male (74-year-old) |
Address: 526 Kemp street, 2233, NSW | Ward: X2 |
|
Diagnosis: Cerebrovascular accident
I agree for this patient to be discharged once the milestones in part B and C are met.
Please do not discharge until medical team review for the following reason (s):
Mobility and communication of Mr. Kwan
Name: P N. SignaturePreeti Time/date: 16/09/2020. 1400hrs
PART C: PATIENT CRITERIA | Y/N | Name | Signature | ||
All observations Between the Flags within the last 24 hours or within the documented Altered Calling Criteria for this patient | Yes | Preeti Neupane | Preeti | ||
If no, refer to senior medical clinician | |||||
Transfer of care (discharge) checklist completed | Yes | Preeti Neupane | preeti |
PART B: Specific patient interdisciplinary team (IDT) discharge criteria (to be completed by IDT) | ||||
IDT agreed specific milestones | Name | Designation | Contact | |
Discharged summary completed,
Follow-up plans documented and referrals made |
Dr. John Smith | Neurologist/
Medical Team |
04123456789 | |
Vital signs BTF,
Patient education provided, |
P N | Registered Nurse | 04123456781 | |
Patient able to maintain the movement with/without support
Manageable/No pain on movement |
Smiley Harrison | Physiotherapist | 04123456782 | |
Rehabilitation arranged for patient,
Community support in place |
Laurel McKey | Social Worker | 04123456783 | |
Swallow review completed,
Patient can drink normal/thickened fluid |
Tegan White | Speech Pathologist | 04123456784 | |
Patient at usual level of function or support at place | Tom Morrison | Occupational therapist | 04123456785 | |
Prescriptions completed with education on medications | Catherine Nelson | Pharmacist | 04123456786 | |
Responsible person: | CLD competent staff member | |||
Reason patient not discharged using CLD protocol: N/A
I confirm that the criteria I parts B and C have been met and are achieved:
Name: P N
Designation: Registered Nurse
Signature: p
Date/time: 16/09/2020. 1430hrs
Rationale for discharge
The discharge planning process should include the patient and family members. The team should discuss life at home be like after discharge, education for medications, possible signs and symptoms, and follow-up appointments. Mr. Kwan has improved; he can walk steady and unaided and has slurred speech which has been improved over time. The physiotherapist has educated him about the exercises that can improve his movement and physical function. The speech pathologist is also agreed to discharge but he has to consume thickened fluid till the next follow up appointment after two weeks (Cichero, 2013). The occupational therapist and social worker have reviewed and arranged the living environment which is suitable for Mr.Kwan and discussed with the family. The pharmacist has completed the script and educated the patient and his family regarding its uses and adverse effects. The nurse has recorded the discharge summary and educated the family about the care plan and medications (Ostwald, Davis, Hersch, Kelley, & Godwin, 2018). They are informed about follow up care and told to come to the emergency department or visit a GP if the health deteriorates.
To conclude, the cerebrovascular accident is the blockage of cerebral arteries with a deficient supply of oxygenated blood to the brain tissues. This leads to several clinical manifestations such as loss of voluntary and involuntary muscle function, impaired vision and, diminished cognition. Interprofessional involvement is necessary for developing care and management plan for a speedy recovery. Life after stroke is not the same thus the patient and family should be educated for ongoing management.

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