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A Comprehensive Nursing Care Plan for a Stroke Patient with Hypertension and Peripheral Oedema

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Developing a Nursing Care Plan for Stroke Symptoms, Hypertension, and Brain Swelling

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The present assignment is based on the given case study of a patient who has suffered from a stroke and needs urgent nursing care. The assignment deals with identifying the three major symptoms or health issues and their relevant discussion according to the existing literature. This assignment has also identified the comprehensive and logical arguments for ranking and prioritising persistent health issues. Lastly, a broad and detailed discussion on the role of the nurses in assessing the issues and implementing care plans is also presented. All the nursing care plans are based on the nursing health standards and policies of the “Australian Nursing and Midwifery Board (NMBA)”.

Identification of health issues

Ruby Stewart, a 66-year-old female, was diagnosed with Brain Stroke and has undergone “intravenous thrombolytic therapy Alteplase” three hours after the onset of Stroke. Based on the assessments, three critical clinical conditions have been detected, and these include the following

 Issue 1: Stroke

 Ruby Stewart was identified with Stroke. The condition is considered an interruption of the blood supply in any specific part of the brain that halts the normal functioning of the brain cells and leads to Stroke. The condition is also referred to as a brain attack in which the brain lacks blood, and that specific area of the brain is damaged, causing various problems related to speech impairment and nerve-related issues (Galego et al. 2018). In the current case scenario, the patient has no symptoms of nerve damage and speech impairment that have resulted from the brain stroke. Within three hours after the onset of the symptoms of brain stroke, the patient was administered intravenous "intravenous thrombolytic therapy Alteplase."

 Issue 2: Hypertension

Assessing the patient's case history, it can be demonstrated that the patient is hypertensive. The parent Blood pressure of the patient is 184/93 mmHg, whereas the normal BP is 120/80 mmHg. The result shows that the patient has higher blood pressure levels, which is the leading cause of brain stroke (Salinet et al. 2019). High blood pressure can cause blood clots to form within the arteries and result in blocking the normal blood flow within the brain. These gradually result in Stroke.

Issue 3: Peripheral oedema

The patient has represented symptoms of peripheral oedema. After the assessment, the symptoms of the conditions have been observed. The condition can be referred to as swelling of the legs due to the retention of fluid in the legs. Studies show that the movement of muscles and joints becomes difficult after a brain stroke (Neugebauer et al., 2019). Thus it has impaired the lymph flow as well as has to lead to the build-up of fluid within the affected tissue.

Heath issues prioritisation and rationale

The MCA stroke is one of the major internal carotid arteries that supply oxygen and nutrients to critical areas of the brain. One of the major reasons that cause heart attack includes heart disease and co-morbidities such as hypertension and diabetes. Based on the impact on patient condition after Stroke, the prioritised health condition list, along with the rationale, has been provided below.

  1. Stroke

The symptoms of the Stroke include symptoms such as regular bowel movements for the patient to maintain their nutrition level. The stroke patient has also lost complete activity and mobility in the left side of the muscles. This can be effective for creating an overall impact on mobility for the patients. It may be reflected through the increased flexion and pressure over the muscle points. The management of the stressor points is also associated with proper blood flow to the peripheral segments of the left side (Nogles & Galuska, 2021). Other major aspects of the Stroke include prevention of further coating and embolism of cloud, as the chances are high after the first time. The nurses are responsible for the assessment of the patient's condition. As per the case study, the patient has received “Thrombolytic Therapy Alteplase (TPA)” for the process. This can be effective for creating an impulsive factor for the overall management aspects. Another major factor for the strike includes proper sensory activities. The major factor affecting the patient includes speech ability. Hence consultation with the speech therapist is needed in this case. 

  1. Hypertension:

Hypertension is a common problem seen in older adults. In the case of hypertension, it is seen that it may be caused due to genetic causes or due to lifestyle changes. Hypertension, in this case, is put on the second prioritised list because, in order to control the further risks of Stroke, it is necessary to control the blood pressure of the patient (Li et al. 2022). Continuous monitoring and assessment of the blood pressure of the patient are necessary to avoid the relapse of Left MCA territory acute ischemic stroke. 

  1. Peripheral oedema:

The cause of peripheral oedema or retention of fluid in the legs is due to problems in venous blood circulation or kidney problems. In this case, this issue is considered the last priority because it is necessary to monitor the venous blood circulation of the patient. The removal of deoxygenated blood is necessary to maintain the proper flow of oxygen to the vital organs, including the brain and the heart (Tanaka et al. 2018). The risk of a second stroke remains persistent, and hence it is essential to eliminate the fluid accumulation from the legs. Along with that, the reduction in oedema will help in motility which further will be beneficial for implementing nursing care plans, including some exercises. Oedema is also effective for increasing the peripheral blood pressure within the arteries, which also increases the risk for internal bleeding and creates pressure on organs.

Role of nurses

Three distinct care plans have to be prepared in order to help the patient overcome the current health concerns. These care plans include the following.

Issue

Nursing care plan

Brain stroke

  1.  Improvement of the mobility
  2.  Managing the shoulder pain
  3. Helping the patient to do self-care
  4. Prevention of the aspirations
  5. Communicating with the patient to improve the problem related to speech impairment (Pan et al. 2020)
  6. Continence of the bladder and bowel
  7. Relieving the perceptual and the sensory deprivation (Anmf.org.au, 2022).
  8. Interaction with the patient to help them improve the thought process.

Hypertension

  1. The Nursing care plans for hypertension involve controlling and lowering the blood pressure of the patient as soon as possible, adhering to the therapeutic regime as prescribed by the doctor, and helping the patients to modify and improve their lifestyles (Cipolla et al. 2018)
  2. Prevention of the current complications.
  3.  On the other hand, it is important to help the patients to participate in different activities that can decrease the cardiac workload and decrease blood pressure (Anmf.org.au, 2022). In this context, the nurses have to help the patient maintain BP at an acceptable rate through proper medication.
  4.  A repeated assessment of cardiac markets, blood cell count, blood pressure, ABF+GS cardiac enzyme, creatinine and nitrogen to identify any additional health risks (Anmf.org.au, 2022).
  5.  Reviewing if the patient is at risk as described in the related factors and individuals with similar situations that can put a force on the heart. 
  6.  The monitoring can be done by recording the blood pressure in both arms as well as at the thighs three repeated times when the patient is resting.
  7. Noting the presence as well as the quality of the peripheral and central pulses.

Peripheral oedema

  1.  Closely monitoring the overall fluid intake of the patients. In this context, fluid shifting can lead to dehydration, although fluid consumption is sufficient. This can be caused due to reduced sodium levels. The concentrations of sodium must be monitored from time to time.
  2. Evaluating the patient to check for the presence of oedema in other places. In this case, the angles, tibia and sacrum can be checked to determine the signs of pitting (Cho, 2018).
  3. As instructed by the doctor, monitoring the patient is taking adequate sodium supplementation (Anmf.org.au, 2022).
  4. Communicating and encouraging the patients to engage in progressive activities.
  5.  Providing the patient with assistance for early mobility, planning activities, and modification of postal and physical activities.

Table 1: Role of nurses to addressing issues

Conclusion

From the above discussion, it can be concluded that the patient, named Ruby, needs to be monitored for the risk of Stroke along with hypertension and peripheral oedema. It is the duty of the nurse to proceed with a nursing care plan that is in standard with the NMBA of Australia. The nurse can work on the improvement of the mobility and management of the shoulder pain can help the patient to do self-care, provide prevention of the aspirations and can help in communicating with the patient to improve the problem related to speech impairment. It is to be concluded that with the help of proper nursing care and plan, the patient can easily recover from the current state and can avoid the risk of Stroke in future. The management of diabetes and hypertension is also essential for avoiding the future risk of Stroke and other complications. It can be done with self-care management, diet management and lifestyle management, which includes exercises, meditation etc.

Reference list

  • Cho, K. C., Kim, J. J., Jang, C. K., Hong, C. K., Joo, J. Y., & Kim, Y. B. (2018). Rete middle cerebral artery anomalies: a unifying name, case series, and literature review. Journal of Neurosurgery, 131(2), 453-461. DOI link: https://doi.org/10.3171/2018.2.JNS1832
  • Cipolla, M. J., Liebeskind, D. S., & Chan, S. L. (2018). The importance of comorbidities in ischemic Stroke: Impact of hypertension on cerebral circulation. Journal of Cerebral Blood Flow & Metabolism, 38(12), 2129-2149. DOI: 10.1177/0271678X18800589
  • Galego, O., Jesus-Ribeiro, J., Baptista, M., Sargento-Freitas, J., Martins, A. I., Silva, F., ... & Machado, E. (2018). Collateral pial circulation relates to the degree of brain oedema on CT 24 hours after Ischemic Stroke. The neuroradiology journal, 31(5), 456-463. DOI: 10.1177/1971400918769912
  • Li, S., Zhao, W., Liu, G., Ren, C., Meng, R., Wang, Y., ... & Ji, X. (2022). Chronic remote ischemic conditioning for symptomatic internal carotid or middle cerebral artery occlusion: A prospective cohort study. CNS Neuroscience & Therapeutics. DOI: 10.1111/cns.13874
  • Neugebauer, H., Schneider, H., Bösel, J., Hobohm, C., Poli, S., Kollmar, R., ... & Jüttler, E. (2019). Outcomes of hypothermia in addition to decompressive hemicraniectomy in treatment of malignant middle cerebral artery stroke: a randomised clinical trial. JAMA neurology, 76(5), 571-579. doi:10.1001/jamaneurol.2018.4822
  • Nogles, T. E., & Galuska, M. A. (2021). Middle cerebral artery stroke. In StatPearls [Internet]. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK556132/
  • Pan, J., Qu, M., Li, Y., Wang, L., Zhang, L., Wang, Y., ... & Yang, G. Y. (2020). MicroRNA-126-3p/-5p overexpression attenuates blood-brain barrier disruption in a mouse model of middle cerebral artery occlusion. Stroke, 51(2), 619-627.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136138/
  • Salinet, A. S., Silva, N. C., Caldas, J., de Azevedo, D. S., de-Lima-Oliveira, M., Nogueira, R. C., ... & Bor-Seng-Shu, E. (2019). Impaired cerebral autoregulation and neurovascular coupling in middle cerebral artery stroke: Influence of severity. Journal of Cerebral Blood Flow & Metabolism, 39(11), 2277-2285. DOI: 10.1177/0271678X18794835
  • Tanaka, M., Ishihara, Y., Mizuno, S., Ishida, A., Vogel, C. F., Tsuji, M., ... & Itoh, K. (2018). Progression of vasogenic oedema induced by activated microglia under permanent middle cerebral artery occlusion. Biochemical and biophysical research communications, 496(2), 582-587.https://doi.org/10.1016/j.bbrc.2018.01.094
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