Mr Sam Kwon Case Study Sample

Effects of Early Mobilization After Acute Stroke

Assessment Findings

Patient in the case study is suffering from multiple comorbidities. He is having a history of hypertension, congestive cardiac failure and type-2 diabetes mellitus.

• Hypertension can be noted to be one of the leading causes of development of stroke in patients. Due to continuous high blood pressure the arteries can undergo a permanent damage. This makes them vulnerable to weaken, clot more easily or even burst. These weakened arteries are at a higher risk of being subject to develop stroke due to insufficient functioning. In case of a stroke the blood vessel either blocks or tend of burst. This happens when the blood supply to the artery reduced evidently (Pistoia, 2016). In cases of hypertensive patients, there is an increased pressure observed in these arteries, leading to circulatory insufficiency. Thus, hypertension can be direct cause leading to the development of stroke in the patient.
• Congestive heart failure can also be considered as another major risk factor for the patient. Patients having a history of congestive heart failure are at an increased risk of developing thrombus. This can be deemed due to cardiac insufficiency observed in these patients, due to reduced cardiac output. The patient might have developed stroke secondary to this condition as well.
• Assessing for the risk of diabetes mellitus is also vital. It has been a well-established risk factor for development of stroke in the patients. Diabetes has been found to bring about various pathologic changes in the blood vessels, that might directly result in stroke, especially when the cerebral arteries are the one affected directly (Tun, 2017). This mainly happens due to uncontrolled blood glucose levels in the body.
• CT-Scan findings can be useful source of assessment. The CT scan report highlights on the increased density of left middle and cerebral artery along with possible signs of oedema (Munich, 2016). Usually the contralateral side of the brain is affected, from the main artery in the formation of clot. Possible signs of oedema can be reflective of reduced circulation in the artery, leading to the reduced functioning of the contralateral side.
• Patient is having a loss of vision as well. Homonymous hemianopia is observed to be one of the main symptoms reflected in patients suffering from occlusion of middle cerebral artery (Yamamoto, 2017).
• Aphasia of the patient should also be closely evaluated for underlying risk. With an injury to the middle cerebral artery, the patient might experience Wernicke’s conduction aphasia. Thus, the patient is reflecting on the signs of aphasia and requires a board to communicate.
• Assessing for the high blood glucose levels for the patient (Breitenstein, 2017). This is another major risk factor along with patient having a history of diabetes. Hyperglycaemia has been found close to be related with worsening outcomes of development of ischemic stroke in patients. It can also aggravate the clinical symptoms of the person suffering for ischemic stroke.
• Presence of basal crackles can also be crucial for the patient. The patient can be observed to have basal crackles on auscultation. Stroke brings about a difficulty in breathing due to insufficiency of working of respiratory muscles. This can be an underlying cause for the patient to develop respiratory complications and thus, accumulation of secretion in the lung passages.

Interprofessional Care Management Plan

The management of the patient will require a multidisciplinary approach to enable a holistic care model for the patient as per his current medical requirements. The following team members can play a vital role in enabling care to the patient in a methodical and schematic manner:

• Vitals monitoring- The nurse can play a crucial role in managing care for the patient. they can help by observing the changes in the patient’s condition and noting his vitals on an hourly basis. Main vitals to lay emphasis upon can include, heart rate, blood pressure, oxygen saturation and so on. The blood glucose levels of the patient should be monitored as well, so as to avoid any complication pertaining to the diabetes status of the patient. They can also help in carrying out a detailed neurological assessment of the patient to acknowledge for any deficit to be noted on early basis for early intervention (Liljehult, 2016). They can also help in monitoring and preventing subacute complication for the patient, that can be caused due to this condition. The close monitoring can also be done to note for the conscious level of the patient. The assessment can also be done for bladder and bowel movement of the patient.
• Positioning of the patient- Patient can be helped with changing his position on frequent basis. He can be helped to sit with desired support. This will avoid any complications from prolonged bed rest. With minimum movement of the patient, there are an underlying risk of complication such as formation of contractures, respiratory complications, development of pressure sores. Physical therapist can help the patient, along with the support of nursing staff in this process.
• Managing oral care- The patient can also be assessed for ability to swallow. Testing of gag reflex for the patient should also be monitored, so that a suitable nutritional support can be defined for the patient. swallowing in the patient should be carried out in the most suitable posture that can help in facilitating easy feeding. Gastrotomy feeding should be practiced for the patient, till he starts to gain strength around the face muscles (Ajwani, 2017). This can be done for dysphagia management for the patient as well. Both occupational therapist as well as physical therapist can help in promoting dysphagia management for the patient.
• Promotion of early mobilization- The patient can be assisted with early bed mobilization, so as to maintain joint range of motion and integrity. For initial phases, passive full-range of motion exercises can be carried out. The role of physical therapist can be deemed as the most vital in this process. This can be carried out within the next 48 hours of admission, after noting for the vitals of the patient (Li, 2018). The physical therapist can help in initial mobilization of the patient to reduce bed side complications.
• Treatment prophylaxis- Patient is having a paralyzed limb. There are chances for the patient to develop deep vein thrombosis. Early mobilization can help in prevention of deep vein thrombosis. Along with mobilization the patient can be provided with prophylactic medication management. Compression stocking can also be provided to the patient to ensure no formation of blood clot in extremities (Schwarz, 2016). Medication management for the patient can also be delivered with the help of general physician.
• Bladder and bowel care- Till the time the patient’s vitals are not stabilized, he can be provided with an indwelling catheter. Another use can be made of intermittent catheterization, which can be helpful in avoiding development of urinary retention or urinary incontinence. Portal ultrasound can also be used to asses the post-void residual urine in patients (Theofanidis, 2016). Patient can also be provided with drugs that can help in preventing constipation. Fluid intake should also be closely monitored for the patient. Other drugs can be in the form of oral or rectal laxatives, if the complication arises any further. Gastroenterologist can work along with the nurses aligned in patient care, to ensure sound medical management for the patient.
• Infection control- The patient is found to be having basal crackles. Given the case history and patient’s advancing age, he might develop respiratory complications. Patient should also be closely monitored for development of fever secondary to respiratory infection, pneumonia or development of urinary track infection. Prophylactic antibiotics can also be administered to the patient, to prevent the complications developing from infection.
• Ethical consideration- The involvement of family in the process plays a vital role. Being an emergent care, it is vital that the family is kept in a close loop, well-informed about the progress of the patient’s condition. This can also include informing the family about the clinical issues pertaining to the patient’s condition and explaining and planning intervention management in accordance with the same. The family can also be part of clinical decision-making process for the patient’s health. They can be informed and educated on the required lifestyle modifications aspired from the patient, post discharge (Mahanes, 2020). Nurses can play a vital role in keeping the family closely engaged in the process of patient care.
• Promoting autonomy- The healthcare professionals assigned in patient care should work with the patient and his family before taking any clinical decisions for promotion of health. Keeping the patient in a close loop will help in providing the patient with an autonomous status and will help in establishing a collaborative approach (Hedman, 2019). This will be helpful in fetching improved health care outcomes for the patient, by the means of integrated care approach and specific to the patient’s medical requirements. The medical team can allow the equal participation of the patient and his family in the decision-making process, through a collaborative approach.

Criteria Led Discharge

As per the findings observed in the patient after days of the incident, the following team members can help and support the patient in his journey of rehabilitation:

• Nurse- The role of nurse can be vital in the process. She can assist in a collaborative approach between the patient and the healthcare professionals. Nurse can also teach the family about various methods and techniques by which the patient can be provide both mental as well as physical support. Nurses can also help in regular follow-ups of the patient to the care center and can thus, help in keeping a close tab on the patient’s progress (Obana, 2019).
• Neurologist- The doctor can help the patient by assessing his overall physical progress. They can also help the patient in the process of medication reconciliation so that the medication adherence can be attained for the patient. They can also help the patient with scans to note on the progress of the condition in terms of improvement of the clinical status.
• Psychiatrist- The patient’s impairments are likely to be permanent. This can be a demotivating factor for the patient. they can help in promotion of emotional well-being of the patient. Patient can be provided with proper counselling to help support him with his progress. Information on various support groups can also be provided to the patient, so as to ensure mental health promotion along with physical health.
• Physical therapist- The physical therapist can help the patient in developing muscle strength and endurance. They can help the patient with promoting his activity of daily living through motivational methods. They can also help the patient, by having a physically active lifestyle so that joint range of motion can be maintained for longer duration and can also be sustained (Dyer, 2019).
• Dietician- Nutrition also playa s major role in rehabilitation of the patient. As the patient is having multiple comorbidities, he can be advised on a diet plan to manage these conditions. This can help can be administered to the patient, keeping in mind the high blood glucose readings and increased blood pressure. A balanced diet will also help the patient in preventing any further incidences like this and thus, reducing the underlying risk factors marginally.
• Speech therapist- Patient is having an improved speech, then he had at the time of incident. However, the slurring of speech is still to be rectified. Speech therapist can help the patient is correcting this minor deficit left and thus, imparting a positive reinforcement for the patient (Obana, 2019).
• Respiratory therapist- The condition of the patient can result in muscular deficiency. This condition affects the respiratory muscles as well. With the advancing age of the patient, the chances of development of respiratory track infection also progresses. Respiratory therapist can help in promoting normal ventilatory pattern and help in strengthening the respiratory muscles, which can be good for improved speech as well.
• Occupational therapist- They can help in the promotion and improvement of upper motor control of the affected limb. This way they can be assistive in improving the patient’s capability to undertake tasks such as self-care management. They can also help the patient in developing learning strategies to manage the cognitive, perceptual and behavioural changes of the person, that might present secondary to the development of stroke in patients (Ranford, 2019).
• Family- The family can be educated on the post-discharge management of the patient. they can also be imparted knowledge on the required lifestyle modifications for the patient. The interdisciplinary team members can work in a collaborative approach with the family and the patient, to enable care as per the clinical goals set for the patient. Family can also help in providing desired emotional and psychological support to the patient (Mahanes, 2020). This will help in promoting overall well-being of the patient, through holistic care management.

References for Mr Sam Kwon Case Study

Ajwani, S., Jayanti, S., Burkolter, N., Anderson, C., Bhole, S., Itaoui, R., & George, A. (2017). Integrated oral health care for stroke patients–a scoping review. Journal of Clinical Nursing, 26(7-8), 891-901. DOI https://doi.org/10.1111/jocn.13520

Breitenstein, C., Grewe, T., Flöel, A., Ziegler, W., Springer, L., Martus, P., ... & Abel, S. (2017). Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting. The Lancet, 389(10078), 1528-1538. DOI https://doi.org/10.1016/S0140-6736(17)30067-3

Dyer, L. (2019). The impact of a physiotherapist in the role of clinical matron within the stroke service of Hampshire Hospitals Foundation Trust. Physiotherapy, 105, 125-126. DOI https://doi.org/10.1016/j.physio.2018.11.113

Hedman, M., Häggström, E., Mamhidir, A. G., & Pöder, U. (2019). Caring in nursing homes to promote autonomy and participation. Nursing Ethics, 26(1), 280-292. DOI https://doi.org/10.1177%2F0969733017703698

Li, Z., Zhang, X., Wang, K., & Wen, J. (2018). Effects of early mobilization after acute stroke: a meta-analysis of randomized control trials. Journal of Stroke and Cerebrovascular Diseases, 27(5), 1326-1337. DOI https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.12.021

Liljehult, J., & Christensen, T. (2016). Early warning score predicts acute mortality in stroke patients. Acta Neurologica Scandinavica, 133(4), 261-267. DOI https://doi.org/10.1111/ane.12452

Mahanes, D. (2020). Ethical Concerns Caring for the Stroke Patient. Critical Care Nursing Clinics, 32(1), 121-133. DOI https://doi.org/10.1016/j.cnc.2019.11.001

Munich, S. A., Shakir, H. J., & Snyder, K. V. (2016). Role of CT perfusion in acute stroke management. Cor Vasa, 58(2), 215-224. DOI https://doi.org/10.1016/j.crvasa.2016.01.008

Obana, M., Furuya, J., Matsubara, C., Tohara, H., Inaji, M., Miki, K., ... & Maehara, T. (2019). Effect of a collaborative transdisciplinary team approach on oral health status in acute stroke patients. Journal of Oral Rehabilitation, 46(12), 1170-1176. DOI https://doi.org/10.1111/joor.12855

Pistoia, F., Sacco, S., Degan, D., Tiseo, C., Ornello, R., & Carolei, A. (2016). Hypertension and stroke: epidemiological aspects and clinical evaluation. High Blood Pressure & Cardiovascular Prevention, 23(1), 9-18. DOI https://doi.org/10.1007/s40292-015-0115-2

Ranford, J., Asiello, J., Cloutier, A., Cortina, K., Thorne, H., Erler, K. S., ... & Lin, D. J. (2019). Interdisciplinary stroke recovery research: the perspective of occupational therapists in acute care. Frontiers in Neurology, 10, 1327. DOI https://doi.org/10.3389/fneur.2019.01327

Schwarz, S. (2016). Prophylactic antibiotic therapy for preventing poststroke infection. Neurotherapeutics, 13(4), 783-790. DOI 10.1007/s13311-016-0466-y

Theofanidis, D., & Gibbon, B. (2016). Nursing interventions in stroke care delivery: an evidence-based clinical review. Journal of Vascular Nursing, 34(4), 144-151. DOI https://doi.org/10.1016/j.jvn.2016.07.001

Tun, N. N., Arunagirinathan, G., Munshi, S. K., & Pappachan, J. M. (2017). Diabetes mellitus and stroke: a clinical update. World Journal of Diabetes, 8(6), 235. DOI https://dx.doi.org/10.4239%2Fwjd.v8.i6.235

Yamamoto, T., Ohshima, T., Sato, M., Goto, S., Ishikawa, K., Nishizawa, T., ... & Kato, K. (2017). A case of acute isolated posterior cerebral artery occlusion successfully treated with endovascular clot aspiration. NMC Case Report Journal, 4(2), 55-58. DOI https://doi.org/10.2176/nmccrj.cr.2016-0214

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