Posted on 5/02/08
Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part-time. One of his co-workers called 9-1-1. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.
A stroke can often times be catastrophic, especially when medical attention is not received immediately after it occurs. Also known as cerebrovascular accident (CVA), stroke occurs when part of the brain is deprived of adequate oxygen due to an arterial blockage or rupture. It accounts for more than 160,000 annual deaths in the United States, making stroke the third leading cause of death, following closely behind heart disease and cancer. It is also the main cause of adult disability.
There are two kinds of CVAs or stroke: an ischemic stroke (occurs when the blood supply to the brain is interrupted, usually by a blood clot) or a hemorrhagic stroke (happens when there is bleeding in or around the brain). In some instances, people may also experience a “mini-stroke” (or transient ischemic attack), where symptoms only last for a short period of time. ALL strokes are medical emergencies.
The Case Continues
Upon Mario’s arrival to the hospital, the ER nurse proceeds to gather the patient’s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted as well as the oral hypoglycemic agents he was taking.
During the gathering of the patient’s medical history, the attending ER physician informs Lucinda that preliminary tests had indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario indicated there was no hemorrhage or early signs of ischemia. He tells Lucinda that Mario will be treated with thrombolytic therapy, and will be placed in the hospital’s intensive care unit for further monitoring of his condition.
Lucinda feels somewhat relieved and tells the nurse and attending ER physician that both of Mario’s parents passed away from myocardial infarctions when they were in their late 60s. She adds that Mario is a smoker, usually smoking about a pack and half each day. She explained that although he had tried to quit several times, he had trouble abstaining for longer than a week. Also noted in Mario’s medical history was that he led a sedentary lifestyle that had contributed to his excess weight. He disliked physical activity and his idea of “exercise” was watching sports on television. At 5’5 inches, Mario weighs 255 pounds.
When the nurse asks the wife if he had experienced any unusual symptoms prior to being admitted to the hospital, she tells her that Mario had complained of escalating migraines a couple of days ago. But she tells the nurse that this was not unusual since Mario had suffered migraines ever since his late thirties when he immigrated to the United States from his native Puerto Rico. When his grating headaches began intensifying, Mario and his wife chalked it up to the recent stressors in his life. He had just turned 66 and had been newly-diagnosed with diabetes mellitus.
Upon further questioning from the nurse, Mario’s wife recalls that the intensity of the migraines had been such that they were not alleviated by the usual triptans he was prescribed by his primary care physician.
The nurse tells Lucinda that it is crucial to recognize the signs of an impending stroke, which include:
* Numbness or weakness of the face, arms or legs
* Trouble speaking or understanding others
* Trouble seeing in one or both eyes
* Difficulty walking
* Loss of balance and coordination
* Severe headache (without a known cause)
* Paralysis of part of the body
She adds that immediate medical attention is imperative immediately following stroke symptoms. When patients are treated by medical professionals soon after a stroke occurs, permanent brain tissue damage or death may be avoided. The nurse informs Lucinda that the major identified risk factors associated with an increased risk of stroke include:
* Age (older than 65 yrs)
* Family or personal history of cardiovascular disease
Lucinda realizes that Mario meets the criteria for all of them.
The ER physician advices Lucinda that Mario will need to undergo stroke rehabilitative therapy, and that he is going to refer him to a cardiologist, nutritionist, and psychiatrist, and then discusses the case with the ER case manager. He asks the case manager to meet with Lucinda, and then with Mario when he is fully conscious.
When the attending case manager speaks with the wife, she asks about insurance coverage and verifies that the patient has adequate coverage through his employer’s health insurance plan. She lets her know that Mario’s health plan has experienced case managers and other professional staff that can provide useful information and additional assistance in stroke care management.
The case manager informs Lucinda that Mario’s stroke rehabilitative therapy will include physical therapy and speech therapy. She notifies her Mario will likely experience impaired movement and/or speech to some extent as the result of the stroke. The case manager also emphasizes that the sooner the patient begins therapy, the likelier it is that Mario will regain significant functioning. She adds that a healthy diet and lifestyle should be followed to assist in Mario’s recovery and prevent stroke recurrence, of which he is now at higher risk. The case manager tells Lucinda that it is important that both her husband as well as she, as a family unit, incorporate a healthy lifestyle indefinitely to aid in improving the patient’s BMI. She informs her that the patient’s health plan provides for coverage for a nutritionist as well as membership to a gymnasium, a pro-active habit the patient will find beneficial for his health and one that can promote a return to functionality. She adds that Mario should quit smoking and suggests using a nicotine patch or the antidepressant bupropion, which may be more beneficial in that it may also treat any underlying depression that is commonly experienced by stroke patients.
In addition, the case manager reassures Lucinda that she will follow-up with Mario’s assigned stroke care team and recommend that he be provided ongoing educational materials and patient reinforcement regarding medication adherence, lifestyle choices, dietary choices and rehabilitation options for stroke.
With the assistance and information provided by the ER case manager, Lucinda feels less anxious and more knowledgeable about how to help care for Mario, which can in turn, help propel the necessary action toward a critical and pivotal next step in the entire family’s plan of care.
Additional stroke facts
The focus of immediate medical care for patients who have suffered a stroke is to re-establish needed blood flow to the brain. But, when blood flow is restored to the affected area(s) of the brain, there is the risk that additional damage may occur. Returning blood carries white blood cells that may create a blockage in small blood vessels and may release toxins harmful to brain cells. Nevertheless, brain cells deprived of oxygen can die within minutes, causing long-term disability or death. Thus, re-establishing blood flow is a critical first step in emergency treatment of a patient who has had a stroke.
Prevention methods for stroke are aimed at eliminating or treating the risk factors. This can often times be accomplished by making lifestyle changes geared to that end: eating a heart-healthy diet and taking medications. Surgery for some patients also may be necessary.
The National Stroke Association http://www.stroke.org/site/PageServer?pagename=SAM Accessed on April 23, 2008.
Ramzan, M. et al; Headache, migraine, and stroke; http://uptodate.com/ Accessed on April 23, 2008.
Reuters Health; Stroke-Related Headache Usually Begins on First Day http://www.medscape.com/viewarticle/573471?sssdmh=dm1.347207&src=nldneAccessed on April 25, 2008.
The Internet Stroke Center at Washington University in St. Louis http://www.strokecenter.org/ Accessed on May 1, 2008.
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Cerebrovascular AccidentCerebrovascular Accident is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. Stroke, also called brain attack or ischemicstroke, happens when the arteries leading to the brain are blocked or ruptured. Whenthe brain does not receive the needed oxygen supply, the brain cells begin to die, astroke can cause paralysis, inability to talk, inability to understand, and other conditionsbrought on by brain damage.Four types of stoke:
Cerebral Thrombosis- caused by blood clots.
Cerebral Embolism- caused by blood clots.
Cerebral Hemorrhage- caused by bleeding inside the brain.4.Subarachnoid Hemorrhage- caused by bleeding inside the brain.Cerebral Thrombosis
The most common type of brain attack.
Occurs when a blood clot (thrombus) forms and blocks blood flow in an arteryleading to the brain arteries primarily affected by atherosclerosis and moresusceptible to blood clots.
Most often occurs at night or in the morning when blood pressure in low.
Often preceded by a transient ischemic attack (TIA) or “mini-stroke”.Cerebral Embolism
Occurs when a wondering clot (embolus) or some other particle forms in a bloodvessel away from the brain, usually in the heart. The clot then travels and lodges inan artery leading on the brain.Cerebral Hemorrhage
Occurs when a defective artery in the brain busts.Subarachnoid Hemorrhage
Occurs when a blood vessel on the surface of the brain ruptures and bleeds intothe space between the brain and the skull. The World Health Organization (WHO) definition of stroke is “rapidly developingclinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting24 hours or longer or leading to death, with no apparent cause other than of (1) Non-communicable disease. WHO Geneva (2) vascular origin” (3) By applying this definitiontransient ischemic attack (TIA), which is defined to less than 24 hours, and patients withstroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma, areexcluded.Based from the data gathered from TCGPH records section, there were 10 reportedcases of CVA as of January 2009 until December 2009 comprises of 2 mortality cases and8 morbidity cases.
Why this case?
We have chosen this case as our topic during the case presentation because wewould like that we, student-nurses, to be aware about CVA and also to broaden ourknowledge about the management and treatment of this disease.
Having awareness and gaining more knowledge about CVA would enhance ourskills and attitudes in handling patients suffering from this disease.