Stroke Case Study | Pathophysiology and Care Delivery Plan

This paper will discuss the case study relating to the patient, Mrs Amelia Middleton, and answer a series of questions relating to the pathophysiology of stroke, nursing care of the patient, and response to pharmacological issues with her treatment
Question 1
Farrell & Dempsey (2014b) define the pathophysiological characteristics of an ischaemic stroke as being the disruption to cerebral blood supply due to an obstruction in a blood vessel (p. 1649). This disruption can be described as an ischaemic cascade, which commences with a fall in cerebral blood flow to less than 25mL/100g/min (p. 1649). When this occurs, neurons are unable to maintain aerobic respiration, causing a decrease in adenosine triphosphate (ATP) production. To combat this, mitochondria switch to anaerobic respiration, which produces large amounts of lactic acid, causes changes in cellular pH levels, anaerobic respiration is less efficient, and neurons are not capable of producing sufficient ATP to fuel the depolarisation processes (Farrell & Dempsey, 2014b, p. 1649; Craft, Gordon, & Tiziani, 2011). With the loss of ATP production, the active transport across the cell membrane ceases, leading to the destruction of the cell membrane, releasing more calcium and glutamate, vasoconstriction and generation of free radicals. As the cascade continues, intracellular pressures increase, causing oedema (Craft, et al., 2011, p. 192). This oedema reaches it maximum after about 72 hour, and slowly subsides over the following two weeks.

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There are four types of haemorrhagic stroke, namely – intracerebral, intracranial cerebral aneurysm, arteriovenous malformations, and subarachnoid haemorrhage, all with varying pathophysiology (Farrell & Dempsey, 2014b, p. 1661). The most common type is the intracerebral haemorrhage, which is mostly found in patients with hypertension and cerebral atheroschlerosis. Certain types of arterial pathology, brain tumour, and the use of medications may also cause intracerebral haemorrhage (Farrell & Dempsey, 2014b). Bleeding related to the condition is most commonly arterial and normally occurs in the putamen and adjacent internal capsule, cerebral lobes, basal ganglia, thalamus, cerebellum and brain stem (Farrell & Dempsey, 2014b).
Intracranial aneurism is dilation of the walls of a cerebral artery developing because of weakness in the arterial wall (Farrell & Dempsey, 2014b). Presumed causes of aneurysms are weakness in arterial walls, congenital abnormalities, hypertensive vascular disease, head trauma, infection, or advancing age. Aneurysms can occur in any area of the brain but commonly occur at the circle of Willis arteries. Arteries affected by aneurysms are the internal carotid artery, anterior cerebral artery, anterior communicating artery, posterior communicating artery, posterior cerebral artery and middle cerebral artery (Farrell & Dempsey, 2014b).
Arteriovenous malformations are caused by abnormalities in embryonic development or are the result of trauma. It is the formation of a mass of arteries and veins without a capillary bed, whose absence, leads to dilation of arteries and veins with eventual rupture. This type of haemorrhage is common in younger people (Farrell & Dempsey, 2014b).
Subarachnoid haemorrhage may occur because of arteriovenous malformation, intracranial aneurysm, trauma or hypertension. Most common causes are leaking aneurysms in the area of the circle of Willis or a congenital arteriovenous malformation of the brain (Farrell & Dempsey, 2014b).
Both ischaemic and haemorrhagic stroke have modifiable and non-modifiable precipitating factors. Modifiable factors are those that can be changed and include:

History of cardiovascular disease




Atrial Fibrillation



Physical inactivity

(Al-Asadi & Habib, 2014; Jarvis, 2012)
Non-modifiable factors are those that cannot be changed or altered, and in concert with modifiable risk factors, can indicate populations at higher risk. The factors are:



Low birth weight


Genetic disorders


(Al-Asadi & Habib, 2014; Jarvis, 2012)
Question 2
The nursing care required for the patient within the first 24 hours would initially include a neurological assessment, especially if thrombolytic therapy has been administered (Hinkle & McKenna Guanci, 2007). Nurses need to use the Glasgow coma scale (GCS), check vital signs pupil reaction and limb assessment. If the GCS falls during or after treatment, patients need to have an urgent CT scan to exclude haemorrhagic stroke. These observations need to be recorded every 15 minutes for the first 2 hours after thrombolytic therapy, then every hour for the next 24 to 48 hours (Hinkle & McKenna Guanci, 2007). Oxygen therapy will only need to be administered if the patient becomes hypoxic, which occurs if the oxygen saturation (SaO2) levels fall below 95% saturation. Blood sugar levels need to be monitored, as it is common for post stroke patients to become hyperglycaemic. Patients also need to be in an electric bed with the cot sides up and the head at a 30-degree angle, which reduces the risks of choking and falls (Catangui & Slark, 2012). Suction should be available at the bedside in case of angioedma. Electrocardiograms need to be performed regularly to detect any abnormal changes in heart rhythm. The patient is already in atrial fibrillation but this may alter if thrombolytic therapy is administered, as such, this requires assessment on an hourly basis. The nurse should also take the time to provide information to family members regarding the patient’s treatment (Felicilda-Reynaldo, 2013). The patient and family need to be informed why thrombolytic therapy is needed, what the desired outcomes are and if there are any adverse effects. When this treatment is needed, it is often in an emergency and can be frightening for family members to see their loved one in pain or distress (Felicilda-Reynaldo, 2013).
Question 3
Thrombolysis is the division of a blood clot or thrombus by the infusion of a fibrinolytic agent (drugs that are capable of breaking down fibrin, the main constituent of blood clots) into the blood (Tiziani, 2013). Thrombolytic agents act by activating plasminogen to form a proteolytic enzyme, plasmin, which attaches to fibrin, and consequently, breaks down the clot (Tiziani, 2013; Catangui & Slark, 2012); this process is called clot resolution. Thrombolytic agents vary in there action, for example, Alteplase and Reteplase, are recombinant tissue plasminogen activator (r-tPA) drugs that have fibrin specific actions, adhering to fibrin bound plasminogen, Tenecteplase, a genetically engineered tissue plasminogen activator (tPA) shares similar traits (Tiziani, 2013; Catangui & Slark, 2012). In contrast, Streptokinase is a non-specific plasminogen activator, which attaches itself to both fibrin bound plasminogen and unbound plasminogen (Tiziani, 2013).
The use of thrombolytic agents on stroke patients is time-critical. Catangui & Slark (2012), supported by Hinkle & McKenna Guanci (2007) and Farrell & Dempsey (2014b), describe a set of contraindications for the use of thrombolysis in stroke patients, these include age, blood pressure greater that 185mmHg/110mmHg, GCS score less than 8, time from onset of symptoms less than 4½ hours, or previous stroke or myocardial infarction. This is not an exhaustive list, but is relevant to the case study patient. From these indicators it can be shown that the patient falls into a category that contraindicates the use of thrombolysis in the treatment of her condition, i.e. her blood pressure is 200mm/Hg/110mm/Hg, and that it has been at least 6 hours since onset of conditions.
Question 4
Aspirin is both a non-steroidal anti-inflammatory (NSAID) and anti-platelet drug (Tiziani, 2013, p. 4 & 511). In its NSAID function, the drug acts to inhibit prostaglandin production, which is a mediator of inflammatory response and thermoregulation (McKenna & Lim, 2012). The anti-platelet properties of the drug inhibit the production of thromboxane A2, which is a vasoconstrictor that normally increases platelet aggregation (McKenna & Lim, 2012). Contraindications for this drug are for people with allergies to Salicylates, haemorrhage, and gastrointestinal bleeding (Tiziani, 2013; McKenna & Lim, 2012). Administration is by oral pathway. In the context of this case study, because the patient is not eligible for thrombolysis, aspirin would be beneficial in lowering the risk of further stroke by reducing the chance of further thrombosis forming through its anti-platelet properties. The risks in this context are exacerbation of her hypertension and possible bleeding; however, in this circumstance the prescription of aspirin is appropriate.
Carvedilol is a lipophilic vasodilating non-cardioselective β-blocker (Leonetti & Egan, 2012). This drug is used to treat hypertension by blocking norepinephrine binding to α1-adrenergic receptors in addition to both β1-adrenergic and β2-adrenergic receptors (Leonetti & Egan, 2012). Contraindications for this drug include bradycardia, heart block, diabetes, and bronchospasms (McKenna & Lim, 2012). Administration is by oral pathway. In the context of the case study, the administration of carvedilol is desirable because of her hypertension. It is further suggested that carvedilol contributes to a reduction in cardiac arrhythmias such as atrial fibrillation (Watson & Lip, 2006). The risk associated with this drug include hepatic failure, oedema, and deterioration if the patient is in heart failure (McKenna & Lim, 2012; Tiziani, 2013)
Atorvostatin is a hydroxymethylglutaryl co-enzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolaemia or hyperlipidaemia (McKenna & Lim, 2012). The drug acts to inhibit production of cholesterol by blocking HMG-CoA reductase from completing the synthesis of cholesterol (Tiziani, 2013). Administration is by oral pathway. In the context of this case study, Atorvostatin is not indicated for administration without further investigation into potential underlying causes, such as, heart disease or hypercholesterolaemia.
Question 5
In the context of this case study, atrial fibrillation could indicate heart disease, but further investigation would be necessary to determine this. Factors such as age, hypertension, ischaemic stroke, family history of myocardial infarction, and erratic pulse are evident and are all indicators towards heart disease (Bordignon, Corti & Bilato, 2012). McKenna & Lim (2012, p. 676) also associate coronary artery disease, myocardial inflammation, valvular disease, cardiomegaly, and rheumatic heart disease with atrial fibrillation.
Pharmacologically, the drugs considered for intervention include heparin, warfarin, and carvedilol (Watson & Lip, 2006). Both Heparin and Warfarin are anticoagulant drugs. Heparin is a fast acting, intra-venous or subcutaneously administered anticoagulant used in the acute setting, with changeover to orally administered warfarin, whose anticoagulant effect is evident after 36-72 hour, for longer-term use (Tiziani, 2013; McKenna & Lim, 2012). In context of the case study, aspirin use would be discontinued if heparin and warfarin were administered, as these drugs are recorded as having an adverse reaction (Tiziani, 2013; McKenna & Lim, 2012). These drug types have contraindications for active and potential bleeding, so issues such as haemorrhoid bleeding may exclude these drugs from administration (Tiziani, 2013).
As previously stated, Carvedilol is a nonselective β-blocker (Leonetti & Egan, 2012). This drug is administered orally and are safe in combination with heparin or warfarin (Tiziani, 2013). Contraindications for this drug include bradycardia, heart block, diabetes, and bronchospasms (McKenna & Lim, 2012). This drug had both antihypertensive properties and has been shown to reduce cardiac arrhythmias such as atrial fibrillation (Watson & Lip, 2006). The risk associated with this drug include hepatic failure, oedema, and deterioration if the patient is in heart failure (McKenna & Lim, 2012; Tiziani, 2013).
This paper has discuss and identified the pathophysiology of stroke, discussed the nursing care of the stroke patient, and identified and discussed pharmacological interventions available to treat the patient.
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Occupational Therapy After A Stroke Health And Social Care Essay

This meta analysis of the referenced studies aim to evaluate efficacy of occupational therapy: whether it focused specifically on personal activities of daily living improves recovery for patients following stroke and to know does .Occupational therapy aims to help people reach their maximum level of function and independence in all aspects of daily living.
Reviewing 07 studies with 1178 participants, people who had a stroke were more independent in personal activities of daily living like feeding, dressing, bathing, toileting and moving about and more likely to maintain these abilities if they received treatment from an occupational therapist after stroke.
Abstract (around 200-250 words)
Aims A systematic review of studies testing the effectiveness of occupational therapy in post stroke patient, focused specifically on personal activities of daily living improves recovery for patients following stroke.
Data sources We searched EBSCOMEDLINE, EMBASE, CINAHL and the Cochrane Library (2000- 2010). AMED:
Selection criteria Selection criteria included studies that used randomized controlled trials of an occupational therapy intervention compared to usual care or no care, where stroke patients practiced personal activities of daily living, or performance in activities of daily living was the focus of the occupational therapy intervention.
Review methods A meta-analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies’ sample sizes.
Findings.Main Result
We identified 64 potentially eligible trials and included nine studies (1258 participants). Occupational therapy interventions reduced the odds of a poor outcome (Peto odds ratio 0.67 (95% confidence interval (CI) 0.51 to 0.87; P = 0.003). and increased personal activity of daily living scores (standardised mean difference 0.18 (95% CI 0.04 to 0.32; P = 0.01). For every 11 (95% CI 7 to 30) patients receiving an occupational therapy intervention to facilitate personal activities of daily living, one patient was spared a poor outcome.
Patients who receive occupational therapy interventions are less likely to deteriorate and are more likely to be independent in their ability to perform personal activities of daily living. However, the exact nature of the occupational therapy intervention to achieve maximum benefit needs to be defined.
Chapter 1: Introduction:
The overall aim of this meta analysis was to evaluate the effectiveness of OT in post stroke patient. Extensive literature search was done by locating published stroke rehabilitation management intervention studies that measured personal activities of daily living outcomes among stroke patient. Data were extracted from study reports which included interventions designed to improve post stroke activities of patient.

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From WHO’s report of global burden of stroke it was found that Worldwide 15 millions people suffer a stroke annually. 5milloin of these die and another 5 million are left permanently disabled, causing burden on family and community. High blood pressure and tobacco use are considered as a major risk factor for stroke (WHO, 2010). The World Health Organisation (WHO) defines Stroke as “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” (WHO, 1978).
The causes of stroke can be classified as:
Ischaemic cause: blood supply to brain stopped due to formation of blood clot. It causes 70% of all cases.
Haemorrhagic: brain damage caused due to bursting of blood vessel which supply blood to brain
There is also a related condition known as a transient ischaemic attack (TIA), which affect 35 people per 100,000 of population each year and is associated with a very high risk of stroke in the first month of event upto one year (Coull, et al., 2004 ). In transient ischemic attack the blood supply to the brain is temporarily interrupted due to inadequate cerebral or ocular blood supply which is due to low blood flow, thrombosis or embolism. Symptoms last for less than 24hours causing a sort of ‘mini-stroke’ (Hankey and Warlow, 1994).
The risk of death due to stroke depends on its type like TIA has the best outcome whereas blockage of an artery is more dangerous, with rupture of blood vessels. It has found that even if country is having advance technology and facilities 60% people die or become dependent causing high cost of treatment (WHO, 2010).
Those of Afro-Caribbean origin are at increased risk of having a stroke, and the number of people affected by the condition is higher among this ethnic group than any other. This is because people of Afro-Caribbean origin have a genetic predisposition (a natural tendency) to developing diabetes and heart disease, which are two conditions that can cause strokes.
Ischaemic strokes occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty cholesterol-containing deposits known as plaques. This narrowing of the arteries is known as atherosclerosis.
As the age advances, our arteries become narrower, but certain risk factors can dangerously accelerate the process. Risk factors include:
high blood pressure (hypertension),
high cholesterol levels (often caused by a high-fat diet), and
a family history of heart disease or diabetes.
Diabetes is also a risk factor, particularly if it is poorly controlled, because the excess glucose in the blood can damage the arteries.
Haemorrhagic strokes occur when a blood vessel in the brain bursts. The main cause of this is high blood pressure (hypertension), which can weaken the arteries in the brain and make them prone to split or rupture.
The risk factors for high blood pressure include:
being overweight,
drinking excessive amounts of alcohol,
a lack of exercise, and
stress, which may cause a temporary rise in blood pressure.
A person’s ethnic group can also be a risk factor for high blood pressure. Half of all people of black-African or Caribbean origin who are over 40 years of age are likely to have high blood pressure. Research has suggested this is because people of African origin have an increased sensitivity to the effects of salt, which can cause their blood pressure to rise. A haemorrhagic stroke can also sometimes occur as a result of a traumatic head injury (NHS Choices, 2008).
Every year, an estimated 150,000 people in the UK have a stroke. That is one person every five minutes (Office of National Statistics, 2001).The brain damage caused by strokes means that they are the largest cause of adult disability in the UK.
People who are over 65 years of age are most at risk from having strokes, although 25% of strokes occur in people who are under 65 years of age. It is also possible for children to have strokes (NHS Choices, 2008).
Around 1000 people under 30 have a stroke each year. Stroke can result in many different disabilities ranging from motor control and urinary incontinence to depression and memory loss. Disablement has been conceptualized by the world health organization in terms organ dysfunction (impairments), disability (difficulty with task), and handicap (social disadvantage) (Post stroke rehabilitation, 1995).
The analysis of cost of illness of stroke by Saka et al (2009) has found that stroke has greater impact on economy of UK, as treatment of and productivity loss arising due to stroke cost £8.9 billion a year. In which treatment cost is nearly 5% of total UK NHS costs. Direct care including diagnosis, inpatient care and outpatient care accounts for approximately 50% of the total, informal care costs 27% and the indirect costs that is cost resulting from premature death due to stroke is 24%. This study concluded that chronic phase of stroke is most costly and therefore suggested better understanding of long-term care in terms of its effectiveness and cost-effectiveness is necessary.
Due to stroke one side of the body may be paralyzed or the muscles on the affected side may weaken. After stroke treatment is comprise of care and rehabilitation (Post stroke rehabilitation, 1995). During the period of acute inpatient care, patient will receive rehabilitation and care input from a variety of qualified and unqualified nursing and allied health staff. It is therefore important that all staff should be familiar with the consequences of stroke, and able to effectively manage problems relating to stroke appropriately within their roles. The consequences of stroke are manifold; as well as the more visible physical problems; stroke survivors will likely have a number of emotional, cognitive, and communication problems (Ross et al, 2009) Research shows that patients benefit from treatment in stroke units in the acute and rehabilitation phases (Indredavik, 2008).
Rehabilitation is the process of overcoming or learning to cope with the damage the stroke has caused. It is about getting back to normal life and achieving the best level of independence by: relearning skills and abilities; learning new skills; adapting to some of the limitations caused by a stroke; and finding social, emotional and practical support at home and in the community. The benefits of stroke rehabilitation packages are well documented (SUTC, 2000) but little is known about the efficacy of the various components of such interventions.
Rehabilitation requires multidisciplinary approach involving therapist (physical therapist, speech therapist, and occupational therapist), doctors, psychologist and social workers. Occupational therapist teaches the patient daily living skills and how to use living aids such as walkers or bathroom grab bars (stroke rehabilitation, 2010).
After stroke life become difficult due to disability caused by it. stroke have high morbidity rates which means that patient with stroke suffer from both mental and physical disability following stroke. It is the leading cause of lower quality of life in adults. Rehabilitation offers a chance to restore quality of life after stroke. Brain damaged caused due to stroke cannot be healed but rehabilitation helps a patient in maintaining existing abilities and provide strategy for handling disabilities cause by stroke. Stroke treatment depends on time duration after stroke, risk factor that may affect treatment. Depending on these factors stroke treatment include blood thinner medication which can dissolve a blood clot, or brain surgery for rupture blood vessel. Rehabilitation after stroke begins after acute treatment. It helps in relearning the skills lost due to stroke and compensating for disability caused by stroke. It stroke includes memory rehabilitation, language rehabilitation and emotional rehabilitation, motor and sensory control rehabilitation (Healthtree, 2010).
Functional impairment following acute illnesses -such as stroke – frequently have severe physical consequences for adult and older patients (Desrosiers, 2003). Occupational therapy is an essential component for the rehabilitation of disabled patients, having a wide range of interventions available to assist persons towards independence (cup, 2003).
The goal of occupational therapy is to restore functional independence when possible and to facilitate psychosocial adjustment to residual disability (Landi, 2006).
The philosophy of occupational therapy is founded on the concept of occupation as a key element of health and well-being. Practice in social care services embraces the social model of disability and is based on holistic and person-centered care, emphasizing the promotion of self-reliance and resourcefulness (College of Occupational Therapists, 2008).
The Occupational therapy is commonly used in the post stroke patients by an occupational therapist with the specific aim of facilitating personal activities of daily living to improve the outcomes for patients following stroke. Different trials have been conducted in different countries to prove the effectiveness of occupational therapy but there is lack of evidence suggesting that occupational therapy interventions can reduce the likelihood of such deterioration and improve patients’ ability to perform personal activities of daily living. Therefore the aim of this Meta analysis is to evaluate the efficacy of occupational therapy on stroke rehabilitation.
The main aim of occupational therapy (OT) is to maintain, restore or create a match beneficial to the individual between the abilities of the person, the demands of his or her occupations and the demands of the environment (Creek, 2003) Activity and participation limitations in stroke typically diminish health and wellbeing As a result, improvement of functional abilities, improvement of participation in society and an increased quality of life are important outcomes of OT treatment (Steultjens, 2005).
Historically, several treatment approaches have been introduced and adopted by physical and occupational therapists. The stroke rehabilitation methods adopted by therapists vary widely depending on their background knowledge, clinical experience, clinical skills, and personal preferences [6-9]. The availability of a plethora of treatment methods shows that stroke rehabilitation practices are continually evolving. Previous studies conducted
in the United Kingdom used surveys to determine common treatment practices in stroke rehabilitation among physical therapists [10-11].
The result of the study by Landi et al. (2006) shows that patients with stroke who received the combined program of physical and occupational therapy had a greater level of independence in activities of daily living over a period of 8 weeks than patients who did not.
It has been found from the Cochrane review of benefits of stroke rehabilitation that it reduces approximately 22% in death or dependency and these benefits are more prominent under and over 75 years of age, in both sexes. Length of hospital stay is also reduced due to early rehabilitation (Scottish intercollegiate guidelines network, 2002). Stroke is a complex condition where knowledge base is continuously increasing. There is constant advance in understanding of the condition, assessment and intervention techniques. Occupational therapists are a vital component in the rehabilitation of patient with this condition (Edmans, 2000).
Occupational therapist work with individuals who have conditions that are physically, mentally, developmentally, or emotionally disabling. They help them develop, recover, maintain daily living and work skills. The goal of occupational therapist is to help their client have independent, satisfying and productive lives (Weeks and Zona, 2000).
Chapter 2: The Literature Search
Selection criteria – brief description of the main elements of the question under consideration. This is subdivided into:
Types of studies – eg: RCT’s
Types of participants – the population of interest. This section may include details of diagnostic criteria, if desired or appropriate.
Types of interventions – the main intervention under consideration and any comparison treatments.
Types of outcome measures – any outcome measures/endpoints (for example, reduction in symptoms) that are considered important by the reviewer, defined in advance; not only outcome measures actually used in trials.
Definition of Occupational therapy
World federation of occupational therapist (2004) define Occupational therapy as a profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation.
The search strategy for systematic reviews of the efficacy of OT has identifies randomised trial comparing occupational therapy with other intervention or no intervention. It has been done by searching EBSCO host research database from 2000-2010. The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010).
Fifty-three studies were identified and abstracted. Four studies reported total
hemorrhagic stroke as the outcome, which includes intracerebral and subarachnoid hemorrhage.4,7,10,11 None of the studies reported information on subdural hemorrhagic strokes. We have used the term hemorrhagic stroke throughout the article. Two reports consisted of the same case patients but different controls and were treated as 2 separate studies. 23,24 From the 53 studies, 18 were further excluded for various reasons. Two studies were excluded because combined risk estimates were reported for men and women but levels of alcohol consumption were not the same for men as for women.49,50 We excluded 5 studies that examined only the effect of binge drinking or acute alcohol consumption (within 24 hours before stroke)51-55 because our study assessed habitual alcohol consumption and relative risk of stroke. Five studies that lacked sufficient data for calculation of relative risk estimates were excluded.56-60 The remaining 6 excluded reports did not use abstainers as the reference group.61-66 We included 19 cohort studies and 16 case control studies in our final analysis
Types of studies
This study included randomized controlled trials of stroke patients receiving an occupational therapy intervention provided by an occupational therapist. All of the selected studies intend to improve personal activities of daily living compared to usual care or no care in post stroke patient.
If large randomized trials are impractical, we have to draw the most reliable conclusions from smaller trials. Unfortunately, the conventional approach, the narrative review is unreliable. Conventional review usually fails to define the review question, to ensure that all relevant trials are explicitly based on the evidence. Systematic reviews set out to improve upon narrative reviews by applying scientific methods to the review of the research evidence (Langhorne, et al., 2008).
Types of participants:
This study included the trial if the participant of the study met the clinical definition of stroke as defined by WHO “a clinical syndrome of resumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more then 24 hours or leading to death” . All of the included studies have given clear inclusion criteria. They include participant on the basis of clinical diagnosis, except Sackley et al (2006) included residents with moderate to severe stroke-related disability by using Barthel Activity of Daily Living Index score (BI score 4 to 15 inclusive). Participants with other acute illness are excluded from the studies.
Types of intervention:
In this study trials are include if they have following features:
• Occupational therapy intervention which specially focused on activities of daily living and tried to improve their personal activities of daily living.
• The trials are included in which control group receives normal care or no intervention.
• Interventions are provided under the supervision of qualified occupational therapist.
The study by Sackley et al (2006) has developed an intervention by using existing evidence with the help of a group of expert occupational therapists delivered on individual level. The period of intervention was three month which include occupational therapy and carer education, wheras
Researcher included studies that used randomized or controlled clinical designs, of an occupational therapy intervention, compared to usual care or no care. In which stroke patient’s performance in terms of activities of daily living was the focus of the occupational therapy intervention
Data sources
Selected database is EBSCO host web research database this collection of databases provide access to key journals, many having links to full text journal articles.
It contains various databases as follow:
British Nursing Index
CINHAL plus with full text
MEDLINE with full text
SocINDEX with full text
The other sources are Google Scholar and The Occupational Therapy Research Index and Dissertation Abstracts register, scanned reference lists of relevant articles, relevant journals. (1999-2010) (See Appendix 1).
Key words or term used in literature search
KW: Stroke in Title
Rehabilitation in Abstract
Randomised controlled trail in Abstract
Selection criteria
Time frame: 2000-2010
Randomized controlled trial
Language or national context: English language only
Main focus of paper: Stroke rehabilitation
Peer reviewed journal only
National and international studies.
Types of outcome measure
The out come measure are that reflected the change in personal activities of daily living in stroke patient after receiving occupational therapy
Primary outcome
(1) Performance in personal activities of daily living (pADL including:
feeding, dressing, bathing, toileting, simple mobility and
transfers) at the end of scheduled follow up.
(2) Death or a poor outcome. Death or a poor outcome is defined
as the combined outcome of being dead or:
• having deteriorated, characterised by experiencing a
deterioration in ability to perform personal activities of daily
living (that is, experiencing a drop in pADL score); or
• being dependent, characterised by lying above or below a
pre-defined cut-off point on a given pADL scale; or
• requiring institutional care at the end of scheduled follow
Secondary outcomes of interest
(1) Death at the end of scheduled follow up
(2) Number of patients dead or physically dependent at the end
of scheduled follow up
(3) Number of patients dead or requiring institutional care at the
end of scheduled follow up
(4) Performance in extended activities of daily living (community
and domestic activities) at the end of scheduled follow up
(5) Patient mood at the end of scheduled follow up
(6) Patient subjective health status or quality of life at the end of
scheduled follow up
(7) Carer mood at the end of scheduled follow up
(8) Carer subjective health status or quality of life at the end of
scheduled follow up
(9) Patient and carer satisfaction with services
We aimed to record outcomes that reflected resource use (that is the
number of admissions to hospital, number of days in hospital, aids
and appliances provided, number of staff required per caseload).
Search methods for identification of studies
See: ‘Specialized register’ section in Cochrane Stroke Group
Occupational therapy
Secondary outcome
Papers excluded from the review were works that focused predominantly upon:
Stroke rehabilitation studies before 2000.
Which are not published studies
Which are other than English language
Research Design
A meta-analysis, by using quantitative methods such as a random effects model, of 7 randomized controlled trial identified literature search.
Analysis of Data
Researcher will analyse binary outcomes with a fixed-effect model, as odds ratios (OR) with 95% confidence intervals (CI). For continuous outcomes, a random-effects model will be used to take account of statistical heterogeneity. As there is some heterogeneity between the trials in terms of their design, duration of follow up and selection criteria for patients.
Researcher will performed an intention to treat analysis to reduce potential biases in terms of follow-up, publication, and reporting bias associated with extracting data from published reports. Publication bias will be assessed with a rank correlation test and a funnel plot.
Systematic reviews show that occupational therapy increases functional ability and/or social participation in elderly people and in patients with stroke or rheumatoid arthritis. For patients with progressive neurological diseases, cerebral palsy or mental illnesses the efficacy of occupational therapy is still unclear because high-quality studies are lacking.
Chapter 3 – Methodology
Justification of methodological approach – qualitative or quantitative
Methods of the review – description of how studies eligible for inclusion in the review were selected, how their quality was assessed, how data were extracted from the studies (evaluated), how data were analysed, whether any subgroups were studied or whether any sensitivity analyses were carried out,
A major challenge with stroke rehabilitation is that the intervention itself is likely to be very complex and non uniform. Any intervention developed by therapist or multidisciplinary team will involve many components which may interact in different ways. It is likely that these interventions may a mixture of both effective and ineffective elements so it is important that we are aware of variability between the different trials and we explore this variability when analyzing the result (Langhorne, et al., 2008).
Chapter 4 – The Studies
Description of studies – how many studies were found, what were their inclusion criteria, how big were they, etc.?
Methodological quality of included studies – were there any reasons to doubt the conclusions of any studies because of concerns about the study quality?
4.1 Characteristics of included studies:
Characteristics of included studies
Cindy 2004
Pretest and posttest randomized control trial
-53 participants
-Age: 55 years or older.
-Mean age: 72.1
-With primary diagnosis of stroke
-Living at home
Intervention group received additional home-based intervention in the use of devices
immediately after discharge, but the control group did not.
Subjects were assessed by
1.Functional Independence Measure and
2. The Quebec User Evaluation of Satisfaction with Assistive Technology.
Single blind randomised controlled trial.
-138 participants
-Mean age: 71
-with clinical diagnosis of stroke
-were admitted to
Glasgow royal infirmary NHS trust were
Intervention group received 6wk domiciliary programme and control group received included inpatient multidisciplinary
Subjects were assessed by
1.Nottingham extended activities of daily living scale
2. Barthel activities of daily living index.
Landi, 2004
-50 Participants
-Mean age: 78.3
– With primary diagnosis of ischemic stroke
Intervention group received received 8 weeks of a combined rehabilitation program based on occupational therapy and physiotherapy
received no input from the occupational therapists
Subjects were assessed by
– ADL scale
Randomised controlled trial.
-168 participants
-Mean age: 74
– clinical
diagnosis of stroke in previous 36 months
Intervention group received leaflets with assessment
and up to seven intervention sessions by an occupational
therapist. Control group received leaflets describing local transport services for
disabled people
-Postal questionnaires
– Nottingham extended
activities of daily living scale, Nottingham leisure questionnaire,
and general health questionnaire.
Multicentre randomized controlled trial.
-466 Participants
-Mean age: 72
.Randomization was done in three groups.
two treatment
groups received occupational therapy interventions at home for up to six months after recruitment.
The General Health Questionnaire (12 item), the
Nottingham Extended ADL Scale and the Nottingham Leisure Questionnaire
Randomised controlled trial with concealed
allocation and blinded assessment.
-168 Participants
-Mean age:74
-patients with a clinical diagnosis of stroke in the
previous 36 months
Control group received one session consisting of advice, encouragement, and the provision of leaflets describing local mobility services. intervention group received
the leaflets plus occupational therapy assessment and
up to seven intervention sessions for up to 3 months.
Primary outcome was self-report, Secondary outcomes were 1-self-report of the number of journeys outdoors in the past month, 2-Nottingham extended activities of daily living scale, 3-Nottingham leisure questionnaire. 4-general health questionnaire.
cluster randomized controlled trial
-118 Participant
-Residents with moderate to severe
stroke-related disability
– Residents with acute illness and those admitted for end-of-life care.
Occupational therapy was provided to intervention group but included carer education.
control group received usual care
1-Barthel Activity of Daily Living Index (BI) scores
2-Rivermead Mobility Index.
Characteristics of intervention included in study
Sample size
Randomization detail
Cindy 2004
Landi, 2004
Chapter 5 Findings / Results
What do the data show? The synthesis of results – thematic analysis or statistical analysis. Accompanied by a graph to show a meta-analysis, if this was carried out.
Chapter 6 – Discussion
Interpretation and assessment of results.
Chapter 7 – Conclusion
Subdivided into Implications for practice and Im

Post Stroke Depression Health And Social Care Essay

Stroke is considered to be one of the most devastating vascular events (Beekman et al 1998) which can cause death. The patients who survive are developing physical impairment. This impairment can make the patients disable or dependent. As a result of loss of functional activity and normal life style, the stroke survivors may also develop psychosocial disorders. The most common disorders among stroke survivors are depression, anxiety, impatience, impulsivity, insensitivity toward others, poor social perception, memory disabilities, apathy, irritability, and eating disturbance (Barker-Collo 2007, Barskova et al 2006, Bour et al 2009). In my research, I will focus more on the prevalence of post stroke depression in the Arab world. I will also investigate the QOL among the Arabic stroke survivors and the factors that influence their mental health and their QOL.

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Stroke, which also called cerebrovascular accident (CVA), is a neurological disorder that results from blood vessels disease (Carr et al, 242). It is caused by a sudden block of blood from flowing to brain leading to irreversible tissue damage result from thrombotic, embolic, or hemorrhagic events (Robinson et al 2010). There are two types of stroke: occlusive and hemorrhage. Occlusive stroke results from closure of a blood vessel while the hemorrhage is due to bleeding from a vessel. It is considered to be a third killer in the world after coronary heart disease and cancer and it is the most cause of disability among people who living in their own homes (Carr et al, 243). In the united state, Europe, and Australia, approximately 400 person per 100,000 populations over age 45 have a stroke (Bruce et al 2005). About 20% of stroke patients die within the first month of onset (Carr et al, 244). However, the reminding 80% of stroke patients can survive with medical management and rehabilitation. The medical management depends on the type of lesion (Carr et al, 245). Surgery is recommended for patients with subarachnoid hemorrhage, well-defined carotid disease, and good surgical risks (Carr et al, 246??). To reduce the muscle spasm, pain, and posture that interfere with patient’s functions, the patients are injected with botulinum toxin into the muscles (Bruce et al. 2005). After the patients are stable medically, they commence active rehabilitation to prevent secondary physical, emotional, and intellectual deterioration (Carr et al 247). The rehabilitation team of stroke survivors usually consists of the followings: physician, nurse, physical therapy, occupational therapy, speech therapy, social worker, and psychologist.
Psychosocial issue:
The clinical picture of the stroke patient is complex and varied between physical and psychological disorder. To insure the patient acceptance to different levels of care, it is important for all health care providers to communicate with information about patient’s moods, general symptoms, and worries and concerns about their own health as well as their neurological handicaps, treatments, and co-morbidity (Skaner et al, 2007). The psychiatric complications of stroke include a higher frequency of depressed mood, anxiety, memory disabilities, apathy, irritability, impatience, impulsivity, poor social perception and insensitivity toward others, and eating disturbance(Bour et al 2009 , Barskova et al 2006). Fatigue and sadness are the most common symptoms and 39% of patients always felt tired that is associated with feeling of depression(Skaner et al 2007).
Depression is affective disorder characterized by intense feelings of sadness, hopelessness, despair and the inability to experience pleasure in usual activities(Rang et al 2007).It is more common with left anterior hemisphere injury (Robinson et al 2010). It is considered to be significant risk factors for increase death within 7 years from date of onset (Robinson et al 2010). Every year there is 5000,000 new strokes in United State. Approximate 150,000 of them develop depression in the first year of post stroke (Elis et al 2010). The depressed patients complain from loss of interest, impaired ADL, psychomotor impairment, and gastro-intestinal complaints (Bour et al 2009).
Management of Depression:
The treatment of these symptoms can be established by pharmacotherapy and
Non-pharmacotherapy. The pharmacotherapy may include the followings: imipramine, phenelzine, and fluoxetine which have some side effects on patients. It can cause nausea, anxiety, insomnia, weight loss tremor, drowsiness, and orthostatic hypotension (Rang et al 2007). The non-pharmacotherapy can include aerobic exercises and stretching (Foley et al 2008).
Assessment tools:
Despite of previous symptoms, the diagnosis of depression in stroke patients is difficult because of overlap of somatic and neurocognitive symptoms directly related to the cerebral damage of stroke and the symptoms of a depressive episode (coster et al 2005). However, the examiner can observe some behavior or use some instrument to judge if the patient is depressed or not (Robinsion et al 2010). The behaviors include: difficulty falling asleep, waking up early in the morning, not eating, losing weight, frequent tearfulness, social withdrawal, or acts as self-harm(Robinsion et al 2010). Whereas, the instruments include Montgomery Asberg depression rating scale (Farner et al 2009), Mooddepression questionnaire, and Beck’s depression scale (Cohen 2007).
Montgomery Asberg Depression Scale is an assessment tool that measure psychological symptoms of depression as symptoms that can affect physical function. Snaith et al defined four degree of depression severity and recognize the patient as a depressed if the score more than 6 in this scale (Sagen et al 2009). Because it is valid and reliable, it can be used in assess treatment outcome and can also used in research (Zimmerman et al 2004).
Another scale is Beck’s depression scale which was designed by Beck, Rush, Shaw, and Emery (Cohen 2007). The scale, which is a questionnaire, consists of 21groups of statements. The patient selects the most statement that best describes hisher feeling past 2 weeks (Questionnaire form). The patient is considered as a minimal depressed if the scale range between 0-13, mild depressed if range between 14-19, moderate depressed if range between 20-28, and sever depressed if range between 29-63(Barker-Collo 2007). It is valid and reliable measurement and (Beck et al 2002) it translated to Arabic to use in assessment and research (Abdel-Khalek et al 1998).
Manchester Short Assessment of Quality of life (MANSA), which is the LQLP modified and brief version, is another assessment tool (Priebe et al 1999). It is used to measure quality of life of people with mental illness and physical disability (Eklund et al 2006). It is administered as a structured interview and consists of three sections (Priebe et al 1999). First section is about personal details: date of birth, gender, ethnic origin, and diagnosis. Section 2 contains details that can be varying over time: education, employment status, monthly income, state benefits, and living situation (Priebe et al 1999). The last section covers 16 quality of life domains which are work, finances, social relations, leisure, living situation, safety, family relations, sexual relations, and health. Fourteen domains have one item and the reminders two have two domains. These domains are health which assessed as physical health and psychological health and living situation: satisfaction with housing and living with someone or alone. Satisfaction scale are rated on 7-point rating scales started with couldn’t be worse and ended with couldn’t be better. This tool is reliable and valid and has good internal consistency (Eklund et al 2006).
One further measure instrument is Patient Competency Rating Scale (PCRS) which is self rating tool. This instrument is used to assess emotional competencies such as: empathy, social initiative, and communication of one’s own emotional states through 30 items. Its items are divided in four domains which are activities of daily living, emotional, interpersonal, and cognition. It is designed to measure patient’s mental and physical status after traumatic brain injury. Later on, it is used with stroke patients also. It is valid and reliable tool that can be used with stroke (Barskova et al 2006).
Literature Review
Stroke is the third cause of death in the world (Carr et al, 243). It is lead to disability and restricts activity of daily living. As a result of these physical problems, the patients can develop many psychological issues. Depression is considered to be one of these problems. Many studies show that 19.3% among hospitalized patients can develop post stroke depression and 23.3% among outpatients (Robinson 2003) .Here I mention some of studies that were done on post stroke depression.
Townsend and his colleges (2010) did a study to evaluate the relationship between the acceptance of disabilities and depression following stroke. Ninety eight patients who were diagnosed with a stroke before one month and had no cognitive impairment or aphasia participated in this study. Twenty two of them had had a prior stroke. However, only 81 of participants were followed up nine months post stroke. The researchers used a prospective cohort mixed design with them. All participants participated in structured interview which yielded quantitative data one month after stroke. It included diagnostic type interview for depression and self report scale to measure disability and personal beliefs about accepting disability. Depression symptoms were assessed using the Structured Clinical Interview of the Diagnostic and Statistical Manual of the American Psychiatric Association. In addition, they used National Institute for Health Stroke Severity Scale to measure stroke severity, Barthel Index to measured personal activities of daily living, reverse scored Nottingham Extended Activities of Daily Living Scale to measure disability in extended activities of daily living, and adapted version of eight-item Acceptance of Illness Questionnaire to measure non-acceptance of disability.
This structured interview was repeated after nine months of onset. In addition, there was semi-structure interview done in the first month of onset and only sixty participants participated in this interview. It included open-ended questions about patients concerns and it was used to extract thoughts and feeling about their condition. The researchers found that for every three stroke patient one of them complained from depression. In their sample, 29 of 89 (33%) patient developed depression one month after stroke, while 24 of 81 (30%) developed depression after nine months. They also found that there is no relationship between disability and depression or no physiological relationship. The non acceptance of disability, or psychological issue, has been the cause of post stroke depression. The depressed participant described themselves as useless and inadequate.
Skaner and his collages (2007) aimed to investigate the self rated health after stroke and the prevalence of symptoms of depression and general symptoms three and twelve months of onset. Their study included 145 patients (69 were men and 76 were women) with a first -ever stroke and their mean age was 73.3 years. The participants were classified according to Katz ADL Index into seven groups, A-G, to assess the patient’s functional level. The ‘A’ refer to patients that had no need of help, and patients in ‘G’ are dependant and the help is necessary for them. They received questionnaires from the researchers to assess their self -rated health, symptoms of depression, and general symptoms. Self-rating of health was assessed by Goteborg Quality of life Instrument (GQLI). The same instrument was used to assess the prevalence of general symptoms which covered six different symptoms: mental, gastro-intestinal/urinary, musculoskeletal, metabolic, cardio-pulmonary and head/miscellaneous. The prevalence of depression symptoms were evaluated by Montgomery Depression Rating Scale which includes nine items: mood, feeling of unease, sleep, appetite, ability to concentrate, initiative, emotional involvement, pessimism, and zest for life.
In this study the researchers compared the patient’s situation three and twelve months after stroke and they found that more than half of patients suffered from symptoms of depression with no significant change frequency between 3 and 12 months. The most common general symptoms after 3 months were reported by patients were fatigue 69%, sadness 58%, pain in legs 52%, dizziness 48%, and irritability 46%. While the most common symptoms after 12 months were fatigue 58%, impaired hearing 49%, pain the joints 49%, sadness 46%, and pain in the legs 45%.
Barker-Collo (2007) examined the prevalence of depression and anxiety after stroke. He also investigated the relationship between depression and anxiety with age, gender, hemisphere of lesion, functional independence, and cognitive functioning. He included 73 patients who were diagnoses of stroke three months before. Of the participants, 40 were males and 33 were females with a mean age of 51.7 years. Their CT scans showed that 31 of them had left hemisphere damage and 33 were right hemisphere damage. The researcher used many measurement tools to get the results. He used Beck Depression Inventory-II (BDI-II) to measure depression. BDI-II is contain 21 four-choice statements and its total score ranges from 0 to 63. Participants selected the better choice that descripts their emotional and vegetative symptoms in the past two weeks. According to this scale, result between 0-13 is considered to be minimal depression, 14-19 is mild, 20-28 is moderate, and 29-63 is severe.
The researcher also used Beck Anxiety Inventory to examine the anxiety symptoms and California Verbal Learning Test-II to measure recall memory. Visual Paired Associates test was used to examine visual learning and memory, and Digit and spatial spans test was used to test memory working. Additionally, Functional Index Measure which includes 13 motor and 5 cognitive items was also used to assess outcomes of rehabilitation. The motor items include self care, sphincter control, mobility, locomotion, and social cognition. While the five cognitive items cover independence in comprehension of communication, expressive communication, social interactions, problem solving, and memory. Furthermore, the researcher included Integrated Visual Auditory Continuous Performance Test and Victoria Stroop. The mood assessments and neuropsychological took about 120 min to be completed according to standardized procedures.
The researcher found from his measurements that the prevalence of depression and anxiety three months post stroke was 22.8 and 21.1% respectively with one in five patients have either moderate or severe depression or anxiety. According to the site of injury, he found the patients with left hemisphere injury were more likely to get depression or anxiety. Because of the left hemisphere is the part which is responsible about language skills, the lesion in it can cause communication deficits which then can lead patients to feel depressed. Suffering of post stroke depression or anxiety can affect the physical therapy sessions. Depressed patient may lack the motivation to complete the session while the anxious patient can suffer from fearful of falling to attempt to walk without device.
Appelros and Viitanen (2004) also measured the prevalence of post stroke depression in a Swedish Population during 1999-2000. They included 377 patients, 129 were females and 124 were males, with first ever cases of brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, and stroke of undetermined pathological type and with mean age 74.5 years old. One hundred and nine patients complain of right hemisphere damage while 138 patients were left hemisphere damage. The researchers used Swedish version of the Geriatric Depression Scale (GDS) which include 20 items, and cutoff is >5. The items cover anxiety, panic, insomnia, hypochondria, and pain. Patients in all cases answered the questions which were read aloud for them. Further evaluation was subjected to patients who crossed cutoff on the GDS. One year follow up, Modified Rankin Scale was used to assess dependency. Cognitive impairment was measured by using Mini Mental State Examination which define the cognitive impairment at a score of Purpose of Study
The purpose of this study is to investigate the prevalence of depression among Arabic stroke survivors. The QOL of the Arabic stroke survivors will also be further investigated. The researcher will use Barthel Index to measure level of function of the participants. Additionally, the researcher will investigate the factors influencing the mental health and the QOL of the Arabic stroke survivors in terms of: onset date of injury, site lesion, type of brain injury (infarct, intracerebral hemorrhage, or subarachnoid hemorrhage), functional level, gender, educational level, employment, and productivity level.
In this study, 200 Arabic patients with first-ever stroke will be included. Inclusion criteria: stroke at least 6 months or above, right and left hemisphere types of stroke, both male and female participants will be recruited from all government hospitals in Kuwait. However, patients with aphasia, cognitive impairments, dementia, and current psychotic episode, and non Arabic patients will be excluded from the study. Patients who will participate in this study will receive a written informed consent.
Data Collection Procedure
After obtaining approval from the Committee for the Protection of Human Subjects in Research at Kuwait University Health Sciences Center, the researchers will initiate the proposed project. This study will be run by two researchers and one research assistance. The research will select all the names of Arabic participants with stroke from the registry from the 5 general hospitals in Kuwait. The hospital include: AL-Adan, AL- Jahra, PMR, and AL-Amiri hospital. Then, the research assistant will randomly select names. Each participant will be asked to voluntarily participate in this study. Upon approval, each participant will sign a consent form indicating his/her willingness to participate in this study.
The Beck Depression Inventory (BDI), which was translated to Arabic form, will be used to measure depression among the 200 stroke patients in Kuwait Hospitals. BDI-II contains 21 four-choice statements and its total score ranges from 0 to 63. The participants will select the most accurately statement which describe their feelings in relation to emotional, behavior, and vegetative symptoms over the past two week. According to this scale, result between 0-13 is considered to be minimal depression, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. The participants will have one hour to complete the test (Cohen 2007).
Another tool that which will be used is the Arabic version of MANSA. This tool is used to measure the quality of life of people with mental illness and physical disability (Eklund et al 2006).
To assess functional ability and ADL of stroke survivors, the researchers will use the Barthel Index. It has 10 items of ADL which can collect via direct conversation, questionnaire, or phone interview. These items are feeding, bathing, grooming, dressing, bowel and bladder control, toileting, ambulation, transfers, and stairs climbing. The final score is ranged between 0, fully dependant, and 20, independent. It is valid and reliable to be used as outcome measurement for clinical and research purpose (Yang J et al 2008).
Data Analysis: All data will be analyzed by using SPSS (19) for analysis.

Stroke The Causes And Effects Health And Social Care Essay

In this assignment I discuss Paul who is a 65 year old male and has suffered a stroke. My aim is to explain what a stroke is, the causes and effects, and give you my understanding of how I as a Health Care Worker can help identify, meet and care for the client’s needs following a stroke. For this assignment I will bring together the knowledge I have gained as a health care assistant student to date along with some research also.

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I have carried out my research using the internet, Irish heart foundation, stroke centre organisation, My focus as a health care assistant is to explain what care my client should receive after his stroke, identify the assistance needed and give recommendations to meet his rehabilitation, to help him keep abilities and gain back lost abilities and also take care of his needs such as physical, emotional, social and intellectual needs.
“A stroke is caused by an interruption of the blood supply to part of the brain, the term stroke comes from the fact that it usually happens without any warning, ‘striking the person from out of the blue” ( A stroke can happen to anyone, some people are at higher risk for different reasons such as age and family history. Other risk factors include high blood pressure, smoking, being overweight, diabetes, and high cholesterol. “2 people per 1000 in the world have a stroke, people affected are mostly over the age of 60, and stroke is the 3rd leading cause of death over the age of 65yrs”. ( Paul is 65 years old and lives alone he was very active and in good health up until he suffered a stroke. Paul suffered an ischaemic stroke (a cerebral thrombosis) a cerebral thrombosis is the most common type of stroke. When Paul arrived at the hospital he was met by the stroke physician. He spent 2 days in intensive care and 4 days on the high dependency ward and is now is on a recovery ward. I the health care assistant along with the rehabilitation team in the hospital doctor, nurse, consultant, and physiotherapist etc will help assist in my client’s recovery.
Stroke Effects
“A stroke causes damage to the brain, the effects depend on the part of the brain that is affected, but every stroke is different”. ( For some people the effects are mild and don’t last long, other strokes can have severe or continued disability. “The right side of the brain controls the left side of the body and vice versa”. ( Any weakness or paralysis in the right arm can result from a stroke from the left side of the brain. The left side of the brain in the majority of people controls language, reading, talking, writing and understanding. On the right side perceptual skills (understanding what you see, hear, touch) and spatail skills (speed, position, and distance) are controlled.
Paralysis happens because of damage to the area of the brain that sends messages to the limbs and balance can be affected also. Swallowing problems affect half of the people who have had a stroke, so food and liquids are harder to swallow. Communicating can affect the person’s ability to use and understand language this is known as aphasia, two main communication problems are difficulty understanding the spoken word and trouble to express words. Vision can be lost on one side, if the person has weakness on the left side of the body it can be difficult to see on that side. “Emotional changes ups and downs can be caused either by distress that comes from having a stroke, or changes that have happened in the brain”. ( Changes in the brain cause mood swings, depression, anger, sadness and loss of confidence, so the patient may find it hard to control emotions and can laugh or cry for no reason.
Needs Met
Physical ~ some people find it difficult to keep up with leisure activities due to low mood, no motivation, a disability or low self-esteem following a stroke. While still in my care, i will help my client by keeping his abilities he has, and gain back the abilities he has lost with stroke, I will help my patient with any exercise he needs and help him become more independent. I will along with the physiotherapist will help my client get into good sitting and lying positions as this helps to prevent skin breakdown, support the weak side affected to help reduce changes in muscle tone due to inactivity, and at all times encourage my client to reach his personal goals.
Hygiene ~ the care of a client’s personal hygiene is very important for their health and wellbeing. I will ensure that the client’s hygiene needs are met and will help my client with his daily hygiene by washing him at his bedside until he is able to get into the shower, also helping him with dressing, shaving and brushing his teeth.
Nutrition ~ is very important in maintaining the client’s health, and good nutrition is vital as it helps maintain body weight and keeps the cells working properly. My client Paul is left handed and is very weak on the right side so I will assist with his meals until he gains enough strength to feed himself. He has dysphagia (difficulty in swallowing), so I have pureed his food to make it easier for him to swallow. There are specialised utensils that will help my client when he gains the ability to feed himself.
Emotional ~ following a stroke the person is left with a sense of loss and may feel anger, fear, worry, uncertainty and rejection. I will provide Paul with psychological comfort re assuring him that he is in safe and secure surroundings, and will show him patience, understanding, empathy and encouragement supporting him always in his recovery.
Aftercare & Care at Home
“Stroke rehabilitation is the process by which a stroke survivor works with a team of health care providers with the aim of regaining as much of the function lost after a stroke as possible”. ( My client will join in a comprehensive rehabilitation programme in hospital and when he leaves, this will increase his chances of recovery and help him regain a large part of his functions lost as a result of stroke. Some of the professional team involved in this will be: Physical medicine & rehabilitation physicians, “physiatrists take both the physical impairments and medical conditions of their patients into account and work with other health practitioners to devise treatment plans”. ( Physical therapy will help my client restore function, improve mobility, relive pain and help limit permanent disabilities and also help with maintaining overall fitness and health. Occupational therapy will help Paul with any mental, physical or emotional problems by developing his ability to perform tasks in his daily living surroundings, and help him recover or keep daily living and work skills. Speech therapy is a very important part of life after a stroke as aphasia disturbs the process of language and understanding due to brain damage from a stroke my client can receive this to help him gain back this ability. My client has family are able to help, and will play a vital part in the care and wellbeing that Paul will need when he goes home. They can help him by supporting and encouraging him through the different stages of his recovery. The public health nurse is part of a community care team and will provide helpful advice on managing difficulties that can happen while caring for a person in their home. She will also assess my client’s needs, so that she can supply him with appropriate support services, speech therapy, physiotherapist, social worker, and home help etc. Paul can also get advice on practical aids such as walking frames, suitable beds and any other mobility aids my client may need.
A stroke can be a devastating and distressing experience to happen to the individual and their families, stealing the person effected of their independence, confidence, abilities and health. Stroke recovery is usually a slow process and can often take months while the brain is healing. Recovery all depends on the person and long term effects can range from mild to severe. There is a wide range of specialists that care for a stroke patient from the medical, nursing, and therapy professionals. The multi-disciplinary team give care to the person in a range of settings, ICU, general ward, and home after care. Some people are affected mildly and may not take long to recover, but in others it can leave the person with severe disabilities, paralysis, communication problems, and loss of vision, physical and emotional changes. All of the people involved aim to help the person regain the highest level of function, although after a stroke the person may depend totally on others as they can be very ill. The care and needs will change as their conditions may get worse or better,

Psychosocial Impact Of Stroke Health And Social Care Essay

The literature review was based on extensive survey of books, journals and international nursing studies. A review of literature relevant to the study was undertaken which helped the investigator to develop insight into the problem and gain information on what has been done in the past. An extensive review of literature was done by the investigator to lay a broad foundation for the study and a conceptual framework framed based on Peplau’s Interpersonal Theory to proceed with the study under the following headings.
For the purpose of logical sequence the chapter was divided into the following sections.
2.1 Part-I : Studies related to psychosocial impact of stroke.
2.1Part-II : Studies related to effectiveness of psychosocial interventions on psychosocial health of stroke clients.
Caso V, et al., (2012) conducted a cohort study among women aged between 54 and 79 without an history of stroke for a period of six years to identify the depressive symptoms using the mental health index score. Findings revealed that during this 6 year follow up, 1033 incidence of stroke were documented. They concluded the study by telling that having a history of depression was associated with an increased risk for total stroke.

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Choi-Kwon S, et al., (2012) conducted a study on prevalence of post stroke depression (PSD) and post stroke emotional incontinence (PSEI) among 508 acute ischemic stroke clients by using Beck’s depression inventory and Kim’s criteria. Findings revealed that PSD and PSEI were present in 13.6% and 9.4% of patients, respectively, at admission and in 17.6% and 11.74, respectively at 3 months after stroke. Low social support (p=0.042) was related to PESI 3 months after stroke.
Campbell Burton et al., (2011) in the meta-analysis study reported that approximately 20% of the stroke clients experienced anxiety and depressive symptoms at some point following stroke incident.
Clau JP, Thopmpson DR., (2011) conducted a quantitative study to assess the perceived self-esteem level among 50 stroke survivors. Findings reported that self-esteem is seen to enhance people’s ability to cope with disease. Low self esteem may inhibit stroke clients participation in rehabilitation and thus result in poor health and social isolation.
Gallagher P (2011) conducted a grounded theory study to examine the emotional process of stroke recovery among 9 stroke survivors. Data was collected from formal unstructured interview and one group interview. The findings revealed that physical and emotional recovery is inseparable, becoming normal was influenced by personal strength, family support, faith and comparing self to peers.
Gurr B, Muelenz C (2011) in a descriptive follow-up study on psychological problems after stroke among 35 stroke survivors reported that early detection and review of post stroke psychological problems may optimize recovery from stroke. The study highlights the importance of mood assessment for all the stroke patients. The researcher suggest that patients with psychological distress must have an access to psychological interventions.
Buijck BI et al., (2010) conducted a longitudinal multicenter study to assess the prevalence of neuropsychiatric symptoms (NPS) among 145 stroke clients using Neuropsychiatric inventory -Nursing home version. The findings revealed that the most common NPS were depression(34%), eating changes (18%), night time disturbances(19%), anxiety(15%) irritability(12%), disinhibition (12%). The findings of the study suggest that NPS should be optimally treated to enhance the outcome of rehabilitation.
Hackett ML, et al., (2009) conducted a cohort study on psychosocial outcomes in stroke among seventy stroke survivors less than 65 years of age. They stated in their study that each year approximately 12,000 Australians of working age survive with stroke. They have the responsibility for generating the income and providing family care. The suggestions of the study were effective rehabilitative medical and social interventions must be provided for them to promote and maintain healthy ageing and mental health condition.
Sharma, et al., (2009) conducted an explorative study to explore the relationship of self esteem level, self esteem stability and admission functional status on discharge depressive symptoms in acute stroke rehabilitation among 120 stroke patients by using state self-esteem scale during inpatient and completed a measure of depressive symptoms at discharge. Functional status was rated using functional independence measure. Results suggested that patients with lower self rated self esteem and poorer functional status indicated higher levels of depressive symptoms.
Carin-levy G, et al., (2008) conducted a descriptive study among 40 stroke survivors, experience of taking part in exercise and relaxation classes were explored which contributed to improved self perceived quality of life, improved psychosocial functioning and improved motivation to take part in recovery process.
Asplaud K et al., (2007) conducted a prospective study to describe the various aspects of psychosocial function after stroke and the development of change over time on 50 stroke survivors. Findings revealed that patients with two years post stroke had more psychiatric problems. The study was concluded by stating that major depression early after stroke, functional impairment and an impaired social network interact to reduce life satisfaction for the long-term survivors.
Edward C. Jacob (2007) in the descriptive study on assessing the quality of life among stroke survivors stated in the study that stroke is been feared because of the short and the long term disability involved. Approximately around 4.4million stroke client are not able to get back to their lives productively. Quality of life scale and Barthel index score was used to collect the data. The findings revealed that in an stroke episode 30% of them require assistance in their activities of the daily living, one third of the survivors suffer from post stroke depression.
Lightbody CE et al., (2007) conducted a cross-sectional study among 28 post stroke clients to identify depression by using Geriatric mental state examination and Montogmery-Asberg depression rating scale. The findings suggested that 25% of the clients were depressed and Montogmery-Asberg depression rating scale is quicker to administer, it may prove more useful to nurses clinically.
Raju RS et al., (2007) conducted a prospective hospital based study in CMC Punjab among 1 month post stroke clients. Data regarding psychosocial problems and quality of life was analyzed by using WHO quality of life BREF scale. The conclusion of the study is that presence of anxiety, depression, and functional dependence were associated with impaired quality of life.
Jun EM, Roh YH., (2012) conducted a quasi experimental study to assess the effect of music movement therapy on physical and psychological outcomes among stroke patients. A convenience sampling method was used to randomize experimental and control group. The intervention music movement therapy was given for 60 minutes three times per week for 8 weeks. Findings revealed that the experimental group had significantly increased mood state in psychological function compared with control group. The study concluded by emphasizing early intervention for stroke clients during their hospitalization.
Morris J, Oliver Kroll., (2012) conducted a descriptive study among stroke clients to assess the importance of psychological and social factors in influencing the uptake and maintenance of physical activity. After a structured review of the empirical literature, the study concludes that self efficacy and social support appear relevant to physical activity behavior after stroke and should be included in theoretically based physical interventions.
Yang NC, Yeh SH., (2012) reported in the case report that patients with stroke related disabilities are at risk of depression and social isolation. While good at dealing with physical illness, nurses are often poor at attending to patients mental and spiritual needs. The author had used a model of spiritual care and in-depth evaluation to identify several underlying psychological issues of stroke clients. These included feelings of hopelessness and loss of control and motivation. The authors established trust through active listening. A multidimentional spiritual care approach was applied to help the patient shift from hopelessness to hopefulness. This enhanced motivation of the patients to participate in rehabilitation.
Cynthiya L. Flick (2011) developed a self-directed learning module to assess the stroke outcome and psychosocial consequences. She discussed on the predictive factors for mortality and functional recovery. The importance was laid on the rehabilitation programs-reintegration and socialization after stroke and management of psychosocial effects of stroke on patients and families.
Green TL, King KM (2011) conducted a descriptive correlational study to examine the relationships between mild stroke functional and psychosocial outcomes among the 38 elderly mild stroke clients. Functional outcome was measured using Modified Rankin scale, patient’s quality of life using stroke impact scale, mood using the Beck depression inventory. Findings revealed that at three months post discharge, patient’s functional status scores had significantly improved with corresponding increase in quality of life scores. The study concluded that the nurses must consider the psychological and social implications of the recovery process of stroke clients following discharge.
Kim DS, et al., (2011) conducted an experimental study to assess the effects of music therapy on mood in stroke patients. Samples selected were 20 post stroke patients divided in to experimental and control group. The experimental group participated in the music therapy program for three weeks. Psychological status was evaluated with the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) before and after music therapy. Findings suggested that BAI and BDI scores showed a greater decrease in the music group than the control group. The study concluded by stating that music therapy has a positive effect on mood in post stroke patients and may be beneficial for mood improvement with stroke.
MacIssac (2011) conducted a mixed method study to explore the supportive care needs after stroke, a need assessment survey was developed and administered to 10 patients with stroke to identify the specific needs of the population and the applicability of the tool was further evaluated through a focus group of nurses working in stroke care. The results suggested that the survey aided the nurses in early identification of the supportive care needs for the patients.
Hua CY et al., (2010) conducted a descriptive study to identify the mediating roles of social support on post stroke depression and quality of life among 102 clients with ischemic stroke. The clients were assessed using social support inventory, Barthel index, quality of life index stroke version and face to face survey interviews. The results suggested that half of the clients suffered depression and social support partially mediated the prediction of post stroke depression by functional ability.
Forsblom A, et al., (2009) conducted a study on therapeutic role of music listening in stroke rehabilitation. Data was collected by two parallel interview schedule of stroke patients (n=20) and professional nurses (n=5) to gain more insight into the therapeutic role of music listening in stroke rehabilitation. Results suggested that music listening can be used to relax, improve mood, and provide both mental and physical activation during the early stages of recovery from stroke.
Salter, Folley N, Teasell., (2009) in a systemic review of literature states that psychological consequences of stroke are important determinants of health related quality of life. As many as one-third of stroke clients will experience post stroke depression, however perceived social support may be protective in terms of both onset and duration of depressed mood. Improvement of available social support could be an important strategy in reducing or preventing psychiatric distress and warding of post stroke depression.
Vickeryi CD, Sepehri., (2009) conducted a quasi-experimental study on self- esteem in an acute stroke rehabilitation sample: a control group comparison. Stroke survivors (n=80) were matched on age and education to a group of neurologically intact community dwelling control participants. Data was collected using visual analogue self esteem scale, Rosenberg self esteem scale, geriatric depression scale. Findings revealed that stroke survivors rated significantly lower mean levels of self esteem on the visual analogue self esteem scale (37 versus41) and the Rosenberg rated higher mean levels of depressive mood on the geriatric depression scale (9versus 6). Significantly higher correlations between self esteem and mood ratings were noted in the stroke group that in control group. The study suggest that lower self esteem ratings do not appear to be a byproduct of depressive mood. Clinicians may facilitate the emotional adjustment of the survivor by considering this facet of psychological impact and intervening to address self esteem.
Lamb M., (2008) in a systemic review of literature revealed that the onset and early period following a stroke is a confusing and terrifying experience. The period of recovery involves considerable psychological and physical work for elderly individuals to reconstruct their lives. For those with a spiritual tradition, connectedness to others and spiritual connection is important during recovery.
Mant J Winner S., (2008) conducted a descriptive study on family support for stroke. Twenty stroke clients family was visited and data was collected regarding functional dependence and used stroke impact scale, care giver burden was assessed. Findings revealed that family support is essential for stroke clients to have a regular follow-up and to alleviate the psycho social problems of stroke clients.
Robinson Smith G., (2008) conducted a study on prayer after stroke-its relationship to quality of life among eight stroke patients who used prayer after stroke as a coping strategy to improve self efficacy and quality of life. A qualitative approach using the interview method was employed to expand on spiritual practices expressed through prayer as a way of coping after stroke. Findings revealed that stroke may encourage patients to re-examine spiritual aspects of life and the challenges associated with stroke can promote spiritual growth and development. potential strategies are suggested to nurses to identify patients spiritual needs.
Vohora, R., Ogi, L., (2008) conducted a pre-experimental study to address the emotional needs of stroke survivors in a stroke rehabilitation ward at Moseley Hall Hospital, U.K. A group intervention was developed for 31patients in stroke ward. The interventions were group discussion where they share their experiences, thoughts and feelings and had group activity. The group met five times over two and a half weeks. Each session was designed to last for around an hour. To analyze the result of the intervention Patients were asked to indicate the degree to which they liked each session, 26 responses were given regarding the perceived most helpful aspects of the group, with only 5 responses were for the least helpful. The study was concluded by reporting that it is crucial to address patients emotional needs following a stroke and attention should be paid to psychological intervention. Patients reported, finding the opportunity to share experiences with others in similar situations as the most helpful aspect of the stroke group.
Bandagi R, Fox PG., (2007) in a descriptive study on coping with stroke: psychological and social dimensions on U.S patients reported that stroke patients experience physical and emotional symptoms which affect their daily functioning. Coping strategies included maintaining a positive attitude and asserting independence as much as possible in acute stroke experience. The findings revealed that Hopefulness was often inspired by interaction with family and spiritual beliefs. The study suggested that Nurses can understand the patient’s perceptions of stroke experience and increase their ability to provide interventions to promote their coping strategies.
Micheal KM, Allen JK., (2007) conducted a quantitative study to identify the relationship of social support on fatigue after stroke among stroke survivors. The severity of fatigue in a sample of 53 community dwelling subjects was assessed by using fatigue severity scale. The findings suggested that 46% of the sample had severe fatigue and patients with elevated fatigue severity score had lower social support (p 

Patients With Post Stroke Dysphagia Health And Social Care Essay

This chapter deals with discussion, summary and conclusions drawn. It clarifies the limitations of the study, the implications and recommendations given for different areas in Nursing practice, Education, administration and research.
The present study was designed to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. The researcher carried out the study among 30 patients and adopted pre-experimental research design with single group pre test post test design. The researcher used non probability purposive sampling technique to select the 30 subjects. The researcher conducted this study to assess the effectiveness of Shaker Exercise and Hyoid Lift Maneuver on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.
The demographic variables included in the study were Age, Sex, Education and Habits.
The mean Age of the subjects was 60. Half of the subjects were in the Age group 50-70 years. Almost equal numbers of subjects were in the 30-50 and above 70 years Age groups and it was about 23 and 27 percent respectively.
Regarding the Sex, nearly equal numbers of subjects were in the male and female Sex group and it showed 53 and 47 percent respectively.
On the basis of their Educational Status, 67 percent of the subjects were studied up to secondary Education. About 33.33 percent of the subjects completed any one of the graduate degree course.
In accordance with their Personal Habits, 53.33 percent had no bad Habits like Smoking and Alcoholism. Ten percent of subjects had the habit of Tobacco use. Seven percent of subjects were consuming Alcohol. Thirty percent of the subjects had the habit of both Tobacco and Alcohol consumption.
The clinical variables include Type of Stroke and Co-morbid Illness.
In consistent with the Type of Stroke, 10 percent of the subjects had Stroke due to the problem in anterior circulation, 40 percent of the subjects had Stroke due to problem in middle circulation and 50 percent of the subjects had Stroke due to problem in the posterior circulation. With reference to the Co-morbid Illness, 13.33 percent of the subjects had No Co-morbid Illness. About 10 and 40 percent of the subjects had the complaints of Diabetes Mellitus and Hypertension respectively. Remaining 36.67 percent of the subjects had both Hypertension and Diabetes Mellitus.
The major findings of the study were discussed according to the objectives:
The first objective was to assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.
In the pre test assessment of the Swallowing Performance using GUSS Score indicates 23.33% of the subjects had Mild Dysphagia, 40% of the subjects had Moderate Dysphagia and 36.67% of the subjects had Severe Dysphagia. The post-test assessment of Swallowing Performance explains that 16.67% of the subjects were improved to the No Dysphagia stage with good Swallowing and Feeding Performance. About 26.67% of the subjects had Mild Dysphagia and 23.33% of the subjects had Moderate Dysphagia. Remaining 33.33% of the subjects had severe Dysphagia with various improvements in the Swallowing Performance.

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The pre test and post test Feeding Performance Score using FOIS describes equal number of subjects in the Tube Dependent (36.67%) and Total Oral Intake category (63.33%). Despite the result revealed an equal number of subjects in the pre and post test assessment, the subjects had an improvement in the Feeding Performance during the post test assessment from no oral intake level to tube supplement with consistent oral intake level in the Tube Dependent category. Likewise, subjects showed an improvement from the intake of single consistency to the total intake with no restriction in the Total Oral Intake category.
The present study was supported by Trapl et al., who conducted study in 2002 and described that out of 30 patients, 30 to 50% had Severe Dysphagia and showed significantly higher risk of aspiration with liquids compared with semisolid textures (p=0.001). Therefore they confirmed the subsequent sequence of GUSS.
The second objective was to determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.
With reference to the Swallowing Performance based on the GUSS Score, the mean pre-test SwallowingS among subjects was 12.50 and the mean post-test Swallowing Score was 13.87 based on the GUSS tool. Paired ‘t’ test was used to compute the mean difference. The ‘t’ value for this mean difference between pre and post test Swallowing Score was 6.150. The ‘t’ value obtained at .001 level of significance and at 29 degrees of freedom. Hence there is a significant difference exist between the mean pre and post test Swallowing Scores. It further implies that the Swallowing Score in the post test was higher than the pre test Swallowing Score. This improvement was due to the Selected Nursing Interventions such as Swallowing Exercises and Positioning while Swallowing. So the Swallowing Exercises such as Shaker Exercise and Hyoid Lift Maneuver found to be effective in improving the Swallowing Performance in Stroke patients. The final result concluded that 22 subjects (73.3%) expressed improvement after the treatment. Remaining 8 subjects (26.7%) had no changes in their Swallowing Performance after the therapy.
The median of pre-test Feeding Score among subjects was 5 and the median of post-test Feeding Score was 6.5. Sign test was computed to find out the difference between the pre and post test median Scores of Feeding. The sign test Score showed the p value 0.000 which was significant at .001 level. It showed that, a significant difference present between the pre and post test Feeding Scores. It further implies that the Feeding Score in post test was higher than the pre test Feeding Score. This improvement in the Feeding Performance was due to the Selected Nursing Interventions. So the Swallowing Exercises were effective in improving the Feeding Performance in Stroke patients having Dysphagia. Median test was used to compare the effect between the pre test and post test group instead of mean as because the FOIS was a 7 point likert scale. As the variables did not follow the normality and the highest Score was 7, parametric test was not applicable. Hence non parametric sign test was adopted which is equivalent to paired ‘t’ test to find out the effectiveness.
The result of the present study was substantiated with a study conducted by Mepani et al., in 2005 on augmentation of deglutitive thyrohyoid muscle shortening by the Shaker Exercise. The study involved the effect of 6 weeks shaker exercise in 11 dysphagic patients; six patients were randomized to control group and 5 patients to the Shaker Exercise group. After the therapy the change in thyrohyoid distance among Shaker Exercise group was significantly greater compared to the control group (p=0.034), this subsequently improve the swallowing function of the patients.
Association of the Swallowing and Feeding Performance with selected Demographic and Clinical variables among patients with Post Stroke Dysphagia
The Fisher exact test was used to associate the selected Demographic and Clinical variables with the Swallowing and Feeding Performance of the patients with Post Stroke Dysphagia.
The calculated p values for the association between the Swallowing Performance of Post Stroke patients with the selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and Co-morbid Illness were not significant and hence there exist no association between them.
The calculated p values for the association between the Feeding Performance of Post Stroke patients with selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and history of Co-morbid Illness were not significant and hence there is no association between them.
The aim of the present study was to assess the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia, for which the following objectives were formulated;
To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.
To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.
To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables.
The study was based on Ernesteine Wiedenbach’s helping art of clinical nursing theory (1970). The research design applied for the study was pre experimental single group pre test-post test design. Study was conducted in KMCH. 30 samples were selected by non probability purposive sampling technique. The tool used for data collection consists of Demographic and Clinical variables, Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) to assess the Swallowing and Feeding Performance in Post Stroke Dysphagic patients. The data were collected for a period of 6 weeks. Descriptive and inferential statistics were used in statistical analysis, to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia. Fisher exact test was used to find out the association between the selected Demographic and Clinical variables with the Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.
Major findings of the study
On the basis of Gugging Swallowing Screening (GUSS), the investigator observed the degrees of improvement in Swallowing difficulty after the therapy among patients with Post Stroke Dysphagia. About 16.67% of the subjects had No Dysphagia, 26.67% had Mild Dysphagia, 23.33% had Moderate Dysphagia, and 33.33% had Severe Dysphagia.
In accordance with the Functional Oral Intake Scale (FOIS), 36.67% of the subjects were in Tube Dependent category and 63.33% were in Total Oral Intake category with sustained improvement in the Feeding Performance.
The mean pre test score of the Swallowing Performance using Gugging Swallowing Screening (GUSS) tool was 12.50. The mean post test Score of the Swallowing Performance using GUSS evaluation tool was 13.87.
There was a significant difference between the mean pre-test and post-test Swallowing Performance Score. The ‘t’ value obtained was 6.150 which is significant at 0.001 level and at 29 degrees of freedom.
The final result explained that, 22 subjects (73.3%) expressed Swallowing improvement after the treatment. Remaining eight subjects (26.7%) had no changes in their Swallowing Performance after the therapy.
Median test was used to compare the Feeding Performance Score of the pre and post test groups. The median pre test Feeding Performance of the patients with Post Stroke Dysphagia was 5 with a range of 1 to 6 and that of post median test was 6.5 with a range of 1 to 7.
The non parametric sign test was used to find out the effectiveness of the therapy on Feeding Performance. The obtained p value was 0.000 at 0.01 level of significance. This revealed a significant improvement in the Feeding Performance of Post Stroke Dysphagic patients.
The final result revealed that 24 respondents (80%) showed an improvement in their Feeding Performance after the therapy and was assessed by FOIS scoring. But remaining six respondents (20%) showed no changes in the Feeding Performance when assessed by FOIS.
There was no significant association exist between the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients with the selected Demographic and Clinical variables.
The study was tested and accepted the hypothesis that there is a significant difference in Swallowing and Feeding Performance before and after the implementation of Selected Nursing Interventions in Post Stroke patients with Dysphagia.
The result concluded that the study group had better outcome than the others. There was a significant improvement in the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients after the Exercise and Positioning therapy. The participants had reduced the risk of aspiration and aspiration related complications after the therapy. Hence, Selected Nursing Interventions such as Swallowing Exercises like Shaker exercise and Hyoid Lift Maneuver and positioning during Swallowing can be recommended for the patients with Post Stroke Dysphagia.
The present study has its own implications in nursing practice, nursing education, nursing administration and nursing research.
Nursing practice:
Dysphagia is one of the major complications among Post Stroke patients. This study implies the effectiveness of Selected Nursing Interventions in the improvement of Swallowing and Feeding Performance among the Post Stroke Dysphagic patients.
This study creates awareness among the nursing personnel about the importance of the various complications after the Stroke and its various evidence based management.
The present study shows that the exercise intervention for the Post Stroke Dysphagic patients can prevent the risk of aspiration and aspiration pneumonia.
The result shows that, Selected Nursing Intervention for the Post Stroke patients can reduce the risk of malnourishment.
Nurses can gain skill for providing Swallowing Exercises in the Post Stroke Dysphagic patients to improve their quality of life.
Nursing Education:
The nurse educator can create awareness among the health care professionals about the complicated effects of Stroke and its various evidence based management.
The nurse educator can arrange in-service Education programs to update their knowledge regarding the new techniques and modalities to manage the Post Stroke Dysphagia.
The nurse educator can teach the students about the present study findings and its implication in patients with Post Stroke Dysphagia. This will help to improve the knowledge of the students on Swallowing Exercises.
The nurse educator can motivate the nursing personnel and students to use this Swallowing Exercises and positioning in the improvement of Swallowing and Feeding Performance and in the reduction of aspiration risk in Post Stroke Dysphagic patients.
Nursing administration:
Nurse administrator should aware of the problem experienced by the clients after the Stroke.
Nurse administrator can provide continuing education or short term courses in the clinical area for preparing the nurses with competence in managing the after effects of Stroke especially Dysphagia.
Nurse administrator can plan and organize seminars, workshops and conferences about “Selected Nursing Interventions for the improvements of Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.
Nurse administrator can formulate protocol to incorporate the study findings in nursing intervention.
Nursing research:
This study provides a basis for further studies.
The findings of the study can be a foundation for conducting the study on large sample to strongly support the efficacy.
The implications of the study can be used as a motivation for nurses to conduct research in India, where the health care system is advancing.
This study helps to update the knowledge and proper utilization of resources in the field of nursing practice.
The study was limited to small sample size of 30 subjects.
The study was limited to a single setting.
The study was conducted using a single group.
A similar study can be conducted with large number of subjects to generalize the research findings.
A study can be conducted at different settings.
Similar study can be undertaken using different Swallowing and lingual exercises.
This study can be conducted with experimental and quasi experimental design.
A comparative study can be conducted between different types of Swallowing Exercises in Post Stroke Dysphagic patients.
A similar study can be done to assess the effectiveness of Swallowing Exercises among patients with Dysphagia who are receiving head and neck radiation for cancer.
The present study entitled “Effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. This study was undertaken during the year 2012-2013, in partial fulfillment of requirement for the degree of Master of Science in Nursing at KMCH College of Nursing, Coimbatore, which is affiliated to the Tamilnadu Dr. M.G.R. Medical University, Chennai.
Objectives: 1.To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia. 2. To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia. 3. To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables. Research Design: Pre experimental design with single group pre test-post test design. Setting: Neuro inpatient and outpatient department of Kovai Medical Center and Hospital, Coimbatore. Samples: All Post Stroke Dysphagic patients. Sample Size: The sample size was 30. Sampling Technique: Non probability purposive sampling. Conceptual framework: Ernestine Widenbach’s Helping Art of Clinical Nursing Theory (1970) was adopted. Intervention: Selected Nursing Interventions such as Swallowing Exercises and Positioning during the swallowing were incorporated. The clients were instructed to do the Shaker Exercise and Hyoid Lift Manoeuvre 3 to 6 times a day for a period of 6 weeks. The subjects were instructed to elevate or down the chin and tilt the head towards stronger side while Swallowing. Outcome Measures: Swallowing and Feeding Performance was assessed by Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) respectively. Results: The mean difference between pre and post test Swallowing Score was 6.150 and which was significant at 0.001 level. The p value obtained for Feeding Score was 0.000 at 0.001 level of significance. The result showed a significant improvement in the Swallowing and Feeding Performance. Conclusion: This study proved that the implementation of Selected Nursing Interventions rather than the other conventional treatment will improve Swallowing and Feeding Performance among Post Stroke patients with Dysphagia. Hence the Swallowing Exercises and Positioning can be recommended in clinical practice to improve the Swallowing and Feeding Performance in Post Stroke Dysphagic patients.

Epidemiological Data Of Stroke Health And Social Care Essay

This piece of assignment will discuss about a stroke patient that I have provided care for, it will describe the significance of epidemiological data of stroke, It will demonstrate knowledge and understanding on a nursing frame work that has been used to assess patient physical, psychological and social state it will also going to looking at the care that has been required to the patient based on the nursing assessment. I am going to use the Roper Logan Tierney model for assessing, planning, implementing and evaluating the patient need I am also going to be using Kaiser Model to manage and deliver a quality care for patient. In accordance with the Nursing and Midwifery Council Code of Conduct and Performance (NMC), (2008) to maintain confidentiality the patient’s name and hospital will be disclosed, he will be referred to as Mr P. Patient information must be treated as confidential and should only be used for the purpose intended for (NMC 2008).

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Mr P is a 72years old black Caribbean origin admitted to the ward from accident and emergency with ischemic stroke. On arrival in accident and emergency Mr P had been assessed by using Glasgow coma scale (GCS) to find out his level of consciousness Robert (2008) the scale comprises of three tests eye, verbal and motor responses Mr P was unable to response to verbal sounds makes no movement and only opens his eyes to painful stimuli, checking his blood pressure which was high and he also had a CT scan to examine the various structures of the brain to look for stroke, area of bleeding or blood clotting in the brain and what type of stroke if it is hemorrhagic or ischemic Sophie Cottrell and Alex Davies (2006) the result showed that there was a blood clot in his brain which is called ischemic stroke. Mr P has a past medical history of diabetes and high blood pressure; he was initially found unconscious by his wife in his home and was taken to accident and emergency by ambulance. Mr p was used to work for a company as an accountant before he become retired, he lives with his wife and youngest daughter and does some voluntary job at his local elderly day centre he smokes five to eight packet of cigarette per day he is very friendly and quite popular in his local pub.
The rational of choosing stroke patient is because it is a huge public health concern According to stroke association (2008) stroke is the third largest cause of death in the UK it also mention that at least 450,000 people are severely disabled as a result of stroke in England with high morbidity and disability that raised my interest to know more about stroke and its management. It is also a life changing long term condition and a number one reason why people admit to nursing homes, as an adult student nurse I will definitely face a stroke patient in my future placement and career therefore I am required to have knowledge and skills on how to deliver a quality of care to chronically ill patients.
Ischemic stroke occurs when an artery to the brain is blocked.  The brain depends on its arteries to bring fresh blood from the heart and lungs. The blood carries oxygen and nutrients to the brain, and takes away carbon dioxide and cellular waste. If an artery is blocked, the brain cells cannot make enough energy and will eventually stop working. If the artery remains blocked for more than a few minutes, the brain cells may die Kathryn et al (2006). The CT scan Mr P had in accident and emergency department also confirmed that the effect of the stroke is a left sides hemisphere stroke, the effect of a left hemisphere stroke include right-sided weakness or paralysis, sensory impairment, problems with speech and understanding language(aphasia), visual problems including the ability to do math or to organize, reason, and analyze items, behavioural changes such as depression, cautiousness and hesitancy, impaired ability to read, write and learn new information, and memory problems.
Stroke is the leading cause of disability; it is the third biggest killer in the UK and its one of the most expensive conditions to treat. Each year more than 110,000 people in England will suffer from a stroke which costs the NHS over £2.8 billion department of health (DOH) (2005). almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85 which Mr P are, the incidence of first ever stroke is expected to rise by 30% over the next decades from 1983-2023 due to ageing demographic, there are at least 300,000 people in England living with moderate to severe disabilities as a result of stroke. According to National Health Service (NHS) (2009) about 72-86%of strokes are ischemic. Each year in England over 130,000 people have a stroke, Mr p age is one of the factor that put him to have stroke, the estimated annual stroke incidence in England and Wales male aged 75+ is 26,269, people aged 75 years or older have nine-fold higher risk of suffering from a first ever stroke, and a 14- fold higher risk of suffering a recurrent stroke when compared to people to aged 45 to 64 years. Stroke causes over 60,000 deaths each year in the UK, in 2004 male who are aged 75 years or older the number of deaths caused by stroke was 16,596. Factors such as his ethnicity, hypertension and diabetics have contributed to Mr P stroke incidence. According to Graeme et al(2003) African-Caribbean people are twice as likely to have a stroke compared with Caucasian (white) people possibly because of a high prevalence of hypertension and diabetes which Mr p suffers from. According to NICE (2008) More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities. One of the risk factor which leads Mr p to have a stroke is his smoking according to Warlow et al (2001) cigarette smoking is associated with approximately double the risk of ischemic stroke in males and females. Warlow et al (2001) also mention that increasing age is associated with both increasing blood pressure and risk of stroke.
For the purpose of this assignment under the supervision of my mentor I used the Roper, Logan and Tierney model (1996) is widely used in nursing practice in UK. The advantage of using Roper, Logan and Tierney’s activities of living model of nursing it indicates 12 activities daily of living which are related to basic human needs, they are maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying,( roper et al.) by using this model I am able to produce a care plan for Mr p and able to carryout a nursing assessment on him. Royal college of nursing (2004) explains assessment is considered to be the first step in the process of individualised nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status.
Because of the word limits I am only going to looking at eating and drinking, mobilising and personal cleansing and dressing the reason I choose those is because they are essential for life if a person is not mobilising that means he is not able to do his personal care and eating and drinking which can affect him from socialising, give him depress and isolated from others.
About half of patients admitted to hospital following a stroke cannot swallow safely. Mortality in this group is high (rowan al.2005). Mr P swallowing function evaluated before he was given any food, fluid, or medication by mouth. If he cannot adequately swallow he is at risk of choking. Patients who cannot swallow on their own may require nutrition and fluids delivered intravenously or through a tube placed in the nose. According to NICE (2008) on admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral foods, fluid or medication. Immediately after admission bed side swallowing test was done by the trained nurse he has been given a small spoon of water and different thickening drinks to listen his chest if he is able to swallow it with out any problem however Mr P was coughing and straggle to swallow, so the nurses referred him to the speech and language therapists they are responsible for assessing and treating swallowing and communication difficulties the salt suggested that Mr P require his drinks to be thickened up with thickening powder to a syrup or yoghurt consistency so it goes down slower.
Swallowing problems affect over a third of people after stroke when a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and into the lungs called aspiration which can lead to chest infections and pneumonia.
Ischemic stroke affect Mr Ps ability to swallow, problems of swallowing were in the past thought to occur only where both hemisphere were involved over the years by stroke damage. In the early weeks after stroke about one-third of patients with single hemiplegia suffer from swallowing problem (Gordon et al., 1987).
The plan was to feed Mr P, reemphasize proper positioning and thinking about swallowing. Allow him to see and smell the food in order to stimulate salivation, and place the food on the most sensitive mouth areas. When spoon feeding, pass the utensil below his chin to encourage neck flexion, give him only small portions, using verbal coaching to emphasize chewing, holding the food, and swallowing hard. Pause between feeding allow him to rest, and make sure all of the food was swallowed.
He also referred to dietitian for further ongoing assessment, to allow monitoring, the risk of malnutrition, to ensure his identified needs are referred for specialist advise, In meal time to assist Mr. P to seat up on his bed in a good position, Keep the surrounding area clean and free of unpleasant smells, remove bedpans, urinals and other such objects from Mr P’s sight. It is important that the patient’s room and table offer a pleasant environment for eating. As Mr P is unable to use his right side of his body when he is feed, put the tray on his right hand side just to remind him he can use his right hand to eat this will encourage Mr P’s ability to use his weaken side of his body, to provide a special tray and cutlery to help him not to spelt the food, and monitor quantitatively all food and drink consumed as accurately as possible on the food chart. Food record charts can provide the essential information that forms the basis of a nutritional assessment and help to determine subsequent treatment plans. They are therefore a valuable resource for dietitians, nurses and ultimately the patient. (Nursing times 2002).
Swallowing difficulty cause psychological effect on Mr P such as considerable distress for him and family and contribute to him loss of self esteem and self worth, loose his appetite and discomfort, less enjoyment of eating; embarrassment in social situations involving eating. As well as making difficult for family members to understand or communicate with him. According to Ebrahim, (1985) and Collin et al (1987) more severe psychological effects such as anxiety, agitation or clinical depression, requires more specific intervention. A patient who is severely depressed will lack motivation to perform even the simplest task such as maintaining posture, attempting communication etc. Physically he loses weight and start developing malnutrition include weakness, bedsores and urinary tract infection. Emotionally he become distress and become very angry in mealtime especially when he spelt food.
Washing is important not only for the reason of hygiene, but also for self esteem, the hemiplegic hand particularly can smell offensive if not washed regularly Robert Fawcus (2008) Mr p was unable to wash himself and dress due to his left hemisphere stroke the right side of his body is become paralyse.
The plan was as he requires full assistance from another individual for personal care. Personal hygiene is an important aspect of his daily living routine. To keep him remain fresh through the day, every morning to assist him brush his teeth, shower and deodorize him, to keep his skin, nails hair clean and to provide him clean cloth.
A break in this routine will give him a feeling of being dirty and cause depression and frustration. Unfortunately, personal hygiene may become an issue for Mr P, due to stroke.
Maintaining personal hygiene enhances an individual’s physical and emotional wellbeing. Mr P becomes dependent because of his long term condition; he can experience a deep loss of independence and self-esteem. On the other hand helping him to smell fresh and look his best can be a great booster to Mr P.
After brain damage by stroke, normal muscle tone is missing. First and foremost normal movement depends on normal muscle tone and without normal muscle tone the patient will never again normal movement Margaret (1987) after assessed by the manual handling advisor to evaluate his ability of moving and to determine how much assistance he needs in terms of movement due to weakness of right side of his body he is at high risk of developing pressure sore so he has been put on waterlow risk assessment chart The primary aim of this tool is to assist nurses to assess risk of patient developing a pressure ulcer.
The plan was to be given good skin care and light powder areas were skin touch skin to avoid friction, with two assistant using sliding sheet to turn him frequently to change position provides exercise for muscles stimulates circulation, helps prevent ulcers and comfort him and he has been provided pressure relief mattress to avoid any pressure sore also to give him dignity while doing personal care when he need bedpan.
According to NICE (2008) early mobilisation may have beneficial effects on oxygenation and lead to a reduction in complications such as venous thrombo-embolism and hypostatic pneumonia. There could be benefits in terms of motor and sensory recovery, and patient motivation.
Mr p is referred to physiotherapist to be assessed to his mobility to help promote his health and wellbeing and to assist the rehabilitation process by developing and restoring body systems, he also being referred to occupational therapist (OT) to assess his physical, mental and social challenges and devises, treatments, programs such as rehabilitation to increase the ability to tackle his difficulties independently.
At the result of lying on bed all the time due to his mobility and unexpected disability made Mr P depressed. This also affected his social life as he cannot go out and socialise with friends like he used to without assistance. This might make him isolated and frustrated and have a feeling of worthlessness.
At the centre of the health and social care long term conditions model is the Kaiser Permanente Health Care Model. This model builds a personalised vertical care continuum for patients with long term conditions. It also identifies the percentage of patients who will require delivery of care at different levels of the continuum through a risk assessment system. The Model provides a structured and consistent approach to help local health and social care partner’s shape the way they deliver integrated long term care locally. It details the infrastructure available to support better care for those with long term conditions as well as a delivery system designed to match support with patient need (department of health.,2007) according to Kaiser model Mr P is on level two This involves providing people who have a complex single need or multiple conditions with responsive, specialist services using multi-disciplinary teams Because of his vulnerability, simple problems can make his condition deteriorate rapidly, putting them at high risk of unplanned hospital admissions or long term institutionalization.
According to National Service Framework (NSF) (2005) anyone with a long term neurological condition who would benefit from rehabilitation is to receive timely, high quality rehabilitation service in hospital or other specialist settings when they need them, also People with long-term neurological conditions living at home are to receive a full range of rehabilitation, advice and support to meet their continuing and changing needs. This is to increase their independence and help them to live as they wish.
On the discharge date of Mr. P the multi disciplinary teams got involve because of his contentious care needs the social worker to provide career and to keep supporting him and his wife financially and for social net working such as a day centre, physiotherapist working with Mr. p to identify the physical problem, developing and reviewing treatment programs, to educate and advise Mr. P and his family how to prevent and improve his condition. He has been referred to occupational therapy which is important for him improves daily living activities and social participation, and to a district nurse to make regular home visits for example to arrange equipment such as wheelchair commode or hoist to be provided through social services and to take blood pressure measurements.
Mr. P and his family understood what foods he can and cannot eat. He has been told to eat slowly, and chew food thoroughly liquids or pureed foods than solids in order to swallow easily.
He has been advised for safety measures around the home to compensate for difficulties in mobility that are inherent with this problem. For example, avoid clutter, leave wide walkways, and avoid throw rugs or other objects that might cause slipping or falling.
Family members have been given advice to encourage Mr P to participate in normal activities and to have extreme patience because he suffers from poor coordination. Take time to demonstrate ways of performing tasks more simply. He has been advice to continue taking antiplatelet medication due to blood clot according to national clinical guidelines for stroke (2008) all patient with ischemic stroke who are not on anticoagulation should be taking an antiplatelet agent such as aspirin .Antiplatelet medication reduces the ‘stickiness’ of platelets. This helps to prevent blood clots forming inside arteries. He has been given advice to stop smoking and to have a regular check up for his blood pressure, to eat a healthy diet and to keep his blood sugar as near normal as possible to avoid further stroke, teaching him to perform specific tasks using repetitive drills in response to certain stimuli. For example, he was told to press a buzzer each time he hear a specific number. A variant of this approach trains him to relearn real-life skills, such as driving, carrying on a conversation, or other daily skills.
In conclusion the Roper, Logan and Tierney model of nursing I found it very useful in terms of assessing patient, to provide proper holistic care from admission to discharge, it allow multidisciplinary team to get involve in order to deliver quality of care for patients. The Kaiser model also helps me to identify in what stage my patient is and give me an idea of what kind of care he/she require. Overall doing this assignment I learnt so much about stroke the cause, symptoms and its management and it allow me to know the patient, how he felt and react about his illness and how it affect him psychologically, socially or emotionally.

The Role Of Proprioceptive Neuromuscular Facilitation Stroke

Stroke is a “rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (Aho K Harmsen 1980). Stroke is a disease of developed nation and it’s the third leading cause of death and long term disability all over the world with an incidence rate of 10 million per year (Sudlow and Warlow 1996). Stroke occurs at any age but it is more common in elderly between 55 to 85 years of age (Boudewejn Kollen and Gert Kwakkel 2006).

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Stroke is classified into two types based on the pathology and cause, Ischemic stroke, occurs when the blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. The ischemia results when there is Thrombosis, Embolism, Systemic hypoperfusion and venous thrombosis. Hemorrhagic stroke occurs when there is accumulation of blood anywhere within the skull vault. These hemorrhage results when there is microaneurism, arterio venous malformation and inflammatory vasculitis (Capildeo and Habermann 1977).
Normal cerebral blood flow is approximately 50 to 60 ml/100g/ Minutes and varies in different parts of the brain. When there is ischemia, the cerebral auto-regulatory mechanism will compensate for the reduction in the cerebral blood flow by local vasodilatation and increase the extraction of oxygen and glucose from the blood. When the Cerebral Blood Flow is reduced to below 20 ml/100g/min, an electrical silence occurs and synaptic activity is greatly diminished in an attempt to preserve energy stored. Cerebral blood flow of less than 10ml/100g/min results in irreversible neuronal injury. These neuronal injuries occurs when there is formation of microscopic thrombi, these microscopic thrombi are triggered by ischemia induced activation of destructive vasoactive enzymes that are released by endothelium, platelets and neuronal cells. These result in the development of hypoxic ischemic neuronal injury which is primarily induced by overreaction of some neurotransmitters like glutamate and aspirate. Within an hour of hypoxic-ischemic insult there will be ischemiec penumbra where auto- regulation is ineffective. This stage of ischemia is called window of opportunity, where the neurological deficit created by ischemia can be partly or completely reversed. After this stage is a stage of neuronal death, in which the deficit is irreversible (Heros 1994).
Functional restrictions resulting from stroke are paralysis of upper limb & lower limb function, cognitive deficit, visual disturbances, disturbance of gait and mobility, spasticity of muscle, loss of co-ordination and speech problems. The loss of upper extremity control is common after stroke with 88% of survivors having some level of upper extremity dysfunction. Basic Activities of Daily Living (ADL) skills are compromised in acute stroke, with 67% to 88% of patients demonstrating partial or complete independence (Amit Kumar Mandall 2009). Muscle weakness, or the inability to generate normal levels of force, has clinically been recognized as one of the limiting factors in the motor rehabilitation of patients with stroke. Following stroke, some patients lose independent control over select muscle groups, resulting in coupled joint movements that are often inappropriate for the desired task. These coupled movements are known as synergies and, for the upper limb flexor synergy: shoulder flexion, adduction, internal rotation, elbow flexion, wrist flexion and finger flexion. Upper limb extensor synergy: shoulder, elbow, wrist and finger extension.
The rehabilitation of upper extremity is quite challenging. Many therapeutic approaches are currently available in the rehabilitation of upper extremity function. Most commonly used treatment approaches are ROODs approach, Sensory motor approach, PNF, Brunnstroms movement therapy, Bobaths technique and neuro developmental therapy. In this Proprioceptive Neuromuscular Facilitation (PNF) is widely used in the rehabilitation of upper extremity function in stroke patients. (Amit Kumar Mandall 2009).
PNF is a therapeutic intervention used in rehabilitation which was originally developed to facilitate performance in patients with movement deficits. PNF exercises are based on the stretch reflex which is caused by stimulation of the Golgi tendon and muscle spindles. This stimulation results in impulses being sent to the brain, which leads to the contraction and relaxation of muscles. When a body part is injured, there is a delay in the stimulation of the muscle spindles and Golgi tendons resulting in weakness of the muscle. PNF exercises help to re-educate the motor units which are lost due to the injury. A variety of methods fall under the rubric of PNF, including the exploitation of postural reflexes, the use of gravity to facilitate movement in weak muscles, the use of eccentric contractions to facilitate agonist muscle activity, hold relax, contract relax, rhythmic stabilization, rhythmic initiation and the use of diagonal movement patterns to facilitate the activation of bi-articular muscles (Etnyre & Abraham L D, 1987; Hardy & Jones, 1986 Osternig, Robertson, Troxel, & Hansen, 1987).
Tomasz Wolny, Edward Saulicz and RafaÅ‚ Gnat in 2009 conducted a randomized control study on the efficacy of proprioceptive neuro-muscular facilitation in rehabilitation for activities of daily living in late post-stroke patients. In this study sixty four stroke patients were recruited from the neurological rehabilitation centre Subjects for this study were recruited based on some inclusion criteria. The patients with loss of sphincter control, loss of mobility, locomotion and communication were included in this study and patients with grade 5 or 6 ‘Repty’ Functional lndex scale were included in this study. After the recruitment of patients, all the 64 patients were randomly divided into two groups, group A (control group) and group B (experimental group). Group A will receive conventional treatment like strengthening, gait training etc. Group B will receive PNF based exercise. A pre and post assessment of the functional status of the stroke patients was done using ‘Repty’ Functional lndex scale. The treatment will be continued for 21 days for both the groups in the neurological rehabilitation centre. . The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. ANOVA was used to compare the average changes among the two groups. The result of this study showed that PNF-based rehabilitation exercise of late post-stroke patients significantly improved in their ADL functional performance and in locomotion when compared to the control group treated with conventional therapy.
Kuniyoshi Shimura.A, Tatsuya Kasai. B in 2002 conducted a study on Effects of proprioceptive neuromuscular facilitation on the initiation of voluntary movement and motor evoked potentials in upper limb muscles activity. In this study author investigated the effect of PNF limb positions and neutral limb positions on the initiation of voluntary limb movement and motor evoked potentials in upper limb muscles. In this experimental study the patients were divided into two groups, in experimental group 1 they investigated the effectiveness of PNF by considering the effects of limb position changes on the initiation of voluntary movement in terms of electromyographic reaction times. In experimental group 2 they investigated the effectiveness of no (neutral limb position) movement by considering the effect of limb position changes on the initiation of voluntary movement with electromyographic reaction times. After signing the consent the experiment was conducted on the patients. Two upper arm positions used in this study, a neutral position (N) and a position facilitating activity of the upper extensor muscles (PNF). The effects of these positions are observed in the EMG. The subject could passively adopt the two upper arm positions using his right (affected) arm by means of especially made arm holders. For each arm position, six blocks of 10 trials were performed. All trials of the first
block and the first trial of each of the following blocks were excluded from the analysis to eliminate start-up effects. In addition, a few trials were discarded because of obvious mistakes in the recording. EMGs were recorded simultaneously from three muscles (Brachioradialis, triceps brachii and deltoid) using 3 cm diameter, bipolar, silver surface electrodes connected to an EMG-unit.
The result of this study showed that the EMG discharge order differed between the two positions. PNF position improves movement efficiency of the joint by inducing changes in the sequence in which the muscles are activated. Hence PNF has an effective role in the initiation of voluntary movement and motor evoked potential in upper limb muscle activity.
Pamela Duncan and Lorie Richards et al., in 1998 conducted a study on the effect of Home-Based Exercise Program for Individuals with Mild and Moderate Stroke. In this randomized controlled pilot study, 20 individuals with mild to moderate stroke who had completed acute rehabilitation program and those who were 30 to 90 days after onset of stroke were randomized to a 12-week (first 8-week will be therapist-supervised program and the next 4-week will be independent program) rehabilitation program. After signing the consent form, patients were selected based on some inclusion criteria like (1) 30 to 90 days after stroke; (2) minimal or moderately impaired sensorimotor function (3) ambulatory with supervision and/or assistive device; (4) living at home; and (5) living within 50 miles of the University. The exclusion criteria for this study are (1) a medical condition that interfered with outcome assessments or limited participation in sub maximal exercise program, (2) a Mini-Mental State score The participants for this study were selected and evaluated by a therapist based on the inclusion and exclusion criteria. If the subjects agreed to participate in this study, then the basic assessment is done after getting the informed consent. The severity of the stroke were assessed using Orpington Prognostic Scale (Sue-Min Lai and Pamela W. Duncan 1998) and Fugl-Meyer Motor Score (Pamela W Duncan 1982) that includes assessment of motor function of the arm, upper extremity proprioception, coordination, balance, and 10 cognitive questions. The functional assessments are performed using Barthel Index Activities of Daily Living (Fricke and Unsworth 1997) Lawton Instrumental Activities of Daily Living and Medical Outcomes Study-36 Health Status Measurement (Colleen and John 1992).
Functional assessments of balance and gait of the participants were assessed using 10-Meter Walk, 6-Minute Walk (Kosak and Smith 2005) and Berg Balance Scale (Berg, Wood-Dauphinee and Williams 1995). Upper extremity hand function was evaluated with the Jebsen Test of Hand Function.The Jebsen is a standardized assessment to measure the time taken to perform hand activities. These includes: writing a short sentence, turning over 3×5 cards, picking up small objects, stacking checkers, simulated eating, moving empty large cans, and moving weighted cans(Jebsen, Taylor, Trieschmann 1969).
After baseline assessment the subjects were randomly assigned into two groups, experimental group and control group. In experimental groups the PNF exercise were taught to the patients on day one as an home exercise and they were asked to continue the same exercise as an home program for eight weeks with three visits to the physical therapy department every week. The exercise includes assistive and resistive exercises using Proprioceptive Neuromuscular Facilitation Patterns and Theraband exercise to the major muscle groups of the upper and lower extremities. Subjects in the control group received usual care as prescribed by the physicians. The subjects of this group were assessed by the research assistant.
The demographic data of both the groups were statistically compared using Wilcoxon rank sum tests. The results of this study showed that there is no difference in the pre and post exercise treatment. There is no change in the upper extremity function and the functional health status in both the experimental group as well as in control group after the treatment interventions.
Ruth Dickstein, Shraga Hochman, Thomas Pillar, and Rachel Shaham in 1992 conducted a study on Stroke Rehabilitation with Three Exercise Therapy Approaches. One hundred and ninety-six hemiplegic patients were randomly selected for this study. All subjects were referred to the physical therapy department of a geriatric-rehabilitation hospital over a period of 18 months were admitted to the study. All patients had a recent cerebrovascular accident and came for a rehabilitation program after an average stay of 16 days in a general hospital. Sex distribution was equal with a mean age of 70.5 years. Thirteen physiotherapists were enrolled in the study for exercise administration and the subjects were assigned randomly to each therapist. The data were collected in a separate form, which has two parts; first part was used to collect the basic information like age, gender, side affected and location of the damaged artery. The second part was used to record the variable data. Each therapist treated their first five patients with conventional method, next five with PNF method and the last five with Bobath method. All patients were treated for five days a week for six weeks, and each treatment sessions were last for 30 to 45 minutes.
The outcomes of each patient are measured before the treatment and every week thereafter. The functional independence is measured with Barthal index. Muscle tone of the involved extremities
was checked by passive movements of the extremities with the patients in supine position. Muscle tone was graded using an ordinal scale composed of five points: a) flaccid, b) low, c) normal, d) high, and e) spastic. Ambulatory status of the patient was assessed and classified with a nominal four category scale: a) patient does not walk, b) patient walks with an assistive device and person’s help, c) patient walks with an assistive device, and d) patient walks independently. The treatment was continued for 6weeks in both the groups. The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. The Kruskal-Wallis one-way analysis of variance (ANOVA) was used to compare the average changes among the three groups.
The results of this study showed that there is no significant difference in the improvement of activities of daily living and in the walking ability. But there is significant difference in the improvement of muscle tone in PNF group and in Bobath group when compared to the conventional treatment group.
The poor quality of the trials reviewed severely limits the conclusions that can be drawn. However, it seems that currently there is no evidence, that interventions based on the Proprioceptive Neuro-muscular Facilitation (PNF) are more effective than other approaches. One Study done by Ruth Dickstein on PNF vs. Bobath concluded that PNF exercise given in conjunction with Bobath technique are more effective in improving wrist strength and upper limb function than giving PNF alone. But the outcomes used in these studies are ordinal rating scales, which may not be sensitive enough to differentiate the effect of the two techniques. The number of subjects recruited for these studies is very less. We cannot come to conclusion on the effect of PNF in upper limb function with these less number of studies.
Stroke patients may vary widely on factors such as physical impairments, speech impairments, severity of impairments, cognitive impairments, and also in the individual personality and learning styles. So, we cannot assume that this PNF technique is superior to all other techniques, because we cannot say this technique can be used in individuals with stroke and at every stage of recovery. For example one approach may be effective in initial stage of stroke, but the same approach may not be effective for chronic stroke patients. Factors such as depression, spatial awareness, cognition, comprehension and sensory loss could also have an impact on the response of a technique.
In most of the studies there is no exact clinical finding about the problem, size of lesion and the site of lesion. Characteristics of the lesion may explain the variability in responsiveness to the intervention. There is no ideal timing of the interventions, whether the technique should be given in the initial stage or late stage of stroke.
In this review on the effect of PNF in upper limb function in stroke, evidence on the current practice is lacking. Because of the lack of evidence on current practice it is very difficult to make a conclusion. Evidence of support and treatment used in these articles is not standard to use in today’s health care practice. It is suggested that further studies comparing the effect of PNF with other approaches using sensitive, reliable outcome measures and with homogenous sample size should be done. Therefore it is important that future studies clarify the analysis and interventions used within the PNF technique to enable accurate evaluation of the study. No studies on this review assessed the efficacy and the effectiveness adequately, so further studies should be done to get an effective and optimal approach in the rehabilitation of upper limb function in stroke patients.

PBL – Stroke Case Study

Written by: Yung Bing Yong
The brain is the primary organ of the centre nervous system that controls our body and houses our mind. It is metabolically active and dependent on a continuous supply of oxygenated blood. If the blood supply is interrupted, the brain could not function normally, resulting a rapid appearance of focal or global disturbance of cerebral functions and its consequent neurological symptoms. If deprived of oxygen for 20s, the brain falls into unconsciousness as the electrical activity cease due to energy depletion. This can become irreversible if it extends beyond 5 min when permanent damage has been made[1].
In this PBL scenario, a 67-year-old Caucasian woman who has a 15 pack-year smoking history arrived in A&E with ipsilateral weakness of both her right upper and lower limb, difficulty speaking and is known with atrial fibrillation and hypertension. Her current medication is warfarin and amlodipine. Clinical presentation and further investigation suggests that she had a stroke.
To further understand the cases in more details, four learning objectives below are proposed in attempt to cover the knowledge necessary to explain the scenario in this PBL:

Describe the blood supply of the brain.
Explore the epidemiology of strokes.
Explain the value of CT with and without contrast in this PBL scenario.
Consider the treatment and prognosis of the patient.

Term to be clarified:
(a) Warfarin: An anticoagulant to reduce the risk of blood clotting by inhibiting vitamin K epoxide reductase. It
decrease the levels of active vitamin K and thus lowered the efficiency of blood coagulation cascade.

Amlodipine: A calcium channel blocker. It works by blocking calcium influx into smooth muscles cells of the wall

of blood vessels. As a result, vasoconstriction is inhibited and thus reducing the blood pressure.

Aphasia[2]: Difficulty in using language. It is categorised into four main types:

Expressive aphasia – patients know what to say, but are having trouble saying what they mean.
Receptive aphasia – patients are having difficulty making sense of the words or diagrams.
Anomic aphasia – patients are facing problems recalling words, names or numbers. (“speaking in a

roundabout way”)

Global aphasia – patients cannot speak, understand speech, read, or write. It is the combination of

expressive and receptive aphasia.

Pack year: unit for measuring the smoking history of a person as to be used in risk factor estimation.

1 pack year= 20 cigarettes per day.
Formula: No. of pack year =

Equivocal plantar response: normal and consistent plantar reflex of both legs. Plantar reflex is a reflex elicited

when the sole of the foot is stimulated with a blunt instrument. The toes flex as a
result. This is to disregard the Babinski sign (the toes extend and fans out), which
indicating the presence of spinal cord injury.

Describe the blood supply of the brain.

The brain constitutes just about 2% of the body weight but demands 20% of the available oxygen and 15% of the cardiac output[3]. Blood is supplied to the brain via two sets of branches from the dorsal aorta, which forms the anterior and posterior circulations. The anterior circulation supplies the forebrain and the deep structures such as the basal ganglia, thalamus, and internal capsule entering through the carotid canal and foramen lacerum by making a stepwise turn; whereas the posterior circulation supplies the structures of the posterior fossa (posterior cortex, midbrain, cerebellum and brainstem) entering the skull cavity through the foramen magnum.
The anterior circulation carries 80% of the blood supply of the brain. Once entering the brain, the internal carotid artery (ICA) passes through the cavernous sinus and branches off as the middle cerebral artery (MCA) and anterior cerebral artery (ACA). The two anterior cerebral arteries are anastomosed by the anterior communicating artery. The remaining 20 % of the arterial supply of the brain derived from the posterior circulation comprises the vertebral, basilar and posterior cerebral arteries (PCAs).

The two circulations are united at the base of the midbrain around the optic chiasm by a network of arteries called the Circle of Willis (Fig. 2).
Looking at the anterior circulation of the Circle of Willis, which arises from the ICA, the ophthalmic artery can be observed. It supplies the orbit, the eye muscles and the retina, and eventually connects to the external carotid arteries.
The MCA is the largest and thus the most important branch of the ICA due to its clinical relevance as the common site of stroke. It receives 80% of the carotid blood flow and its proximal part gives off deep branches- lateral and medial striate arteries supply corpus striatum and the internal capsule regions of the brain. Occlusion of these deep arteries is the chief cause of classic stroke, and the most common location is the putamen and internal capsule.

The disability experienced by the stroke patient depends on the area of brain tissues damaged due to cerebrovascular accident in one particular or more blood supply of the brain. Figure 4 illustrated the functional areas supplied by individual cerebral vasculature.
Figure 5, on the other hand gives a few examples of possible symptoms caused by damage from strokes in different areas. In the interest of this PBL scenario, damage in Broca’s area lead to expressive aphasia; damage in Wernicke’s area provokes receptive aphasia; damage in both respective area will then prompt to global aphasia.

Having compared the homunculus of the somatosensory and motor cortex as shown above (Fig. 6) to the functional area supplied by cerebral arteries (Fig. 4), the legs to the hips is on the medial surface of the cerebral cortex that is supplied by the ACA. Therefore, even though, the MCA is occluded in this scenario, there is not complete paralysis in the legs.

Explore the epidemiology of strokes.

Stroke occurs approximately 152,000 times a year in the UK in which men are at a 25% higher risk of having a stroke and at a younger age compared to women.[4]
It is defined as the temporary or permanent loss of function of brain tissues caused by interruption of the vascular supply. It is subdivided into:

Haemorrhagic stroke: Aneurism of blood vessels in the brain that burst.
Ischemic stroke: Blood vessels in the brain are either clog by local atherosclerosis or thromboembolism.
Transient ischemic attack (TIA): Same pathophysiology as ischemic stroke, but occurrence last less than 24 hours. Therefore, it is always a retrospective diagnosis.

Risk factors of stroke can be classified into:

Modifiable risk factors

Non-modifiable risk factors


Age > 75



Being overweight/obese

Family history

Alcohol Use

Genetic predisposition

Direct or indirect causes:
Ischemic stroke– Atheroscelerosis, hypertension, atrial fibrillation, valve disorder, sickle cells, thrombocytosis Haemorrhagic stroke– Aneurysm, head trauma, arteriovenous malformation, chronic hypertension, drug

Explain the basic principle of CT with and without contrast in this PBL scenario.

Ideally, when stroke is suspected, a brain CT scan is arranged immediately to differentiate the type of stroke: Haemorrhagic or ischemic stroke, which determine the treatment option that are significantly different.
In practice, non-contrast CT is usually not sensitive in diagnosing ischaemic stroke or cerebral infarction in an emergency situation but is a quick method to identify acute haemorrhage in the brain, as a pool of blood will show up in white and disqualify the use of thrombolytic or clot-buster. As the time passes (first 24 hours) loss of grey-white differentiation would be shown on the CT that could suggest signs of infarction.[5][6] This is the why the patient in this case did not present any sign of stroke at 7:05am on the head CT.
To better diagnosing ischaemic stroke, recent advances in CT technology, be it the contrast CT called CT angiography provide additional data to visualise the cerebral vasculature shortly after an intravenous contrast bolus.
If an ischaemic stroke is diagnosed as in the case of this PBL, and it has been less than four and a half hours since symptoms started, Alteplase will be given intravenously, while haemorrhagic stroke can be managed with surgical repair.[7]

Consider the treatment and prognosis of the patient.

Treatment for ischaemic stroke
(1) Immediate Care

Thrombolytic (within golden 3-4.5 hours): Tissues plasminogen activator (tPA); Alteplase; Urokinase
Intravenous fibrinolytic therapy
Surgery: carotid endoterectomy/ angioplasty
Ultrasound-enhanced thrombolysis

(2) Rehabilitation
Life after stroke can be very difficult and challenging. Rehabilitation is necessary to improve quality of life and the eventual outcome, if not full function of the body.

Speech & language therapy helps people who have problems producing or understanding speech.
Physiotherapy helps with relearning movement and co-ordination of muscles.
Psychological care helps with common mental health problems such as depression.
Occupational therapy helps with assessing patients’ home and improving their abilities to carry out daily activities such as dressing and eating.

(3) Secondary Prevention 3 in 10 stroke survivors will suffer another stroke or TIA.[8] That is why secondary prevention is much importance. Seeing the fact that the patient as illustrated in this case has atrial fibrillation and is on warfarin but still encountered a stroke attack, a close monitor of warfarin INR should be done afterwards and possible increase in doses or change of medication. Healthy lifestyle that covers the diet and exercise should be recommended and implemented.
How well a patient does after acute ischaemic stroke depend on numerous factors, such as the area of brain tissues is damaged, the affected body function, and the time of appropriate treatment is received.
Generally, patient often improves in moving, talking and thinking in the weeks to months after a stroke and undergoes rehabilitation. However, they do suffer some sort of morbidity. Only roughly 30% of patients are neurologically normal or near normal. Fortunately, about 50% of patients are completely or almost completely independent in daily living.[9]
(1855 words)

Adams HP Jr, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25: 1901-1914.
Brierley JB. Experimental hypoxic brain damage. Journal of Clinical Pathology 1977s3-11: 181-187.
Bryan RN, et al. Diagnosis of acute cerebral infarction: Comparison of CT and MR imaging. AJNR Am J Neuroradiol 1991; 12: 611-620.
Clarke DD, Sokoloff L. Regulation of Cerebral Metabolic Rate. Basic Neurochemistry: Molecular, Cellular and Medical Aspects, 6th edition. Philadelphia: Lippincott-Raven; 1999.
Lee JM, Grabb MC, Zipfel GJ, Choi DW. Brain tissue responses to ischemia. J Clin Invest. 2000;106(6):723-731.
MedlinePlus. Aphasia. Available at: [Accessed 24th March 2015].
Michael-Titus A, Revest P, Shortland P. STROKE AND HEAD INJURY. The Nervous System, 2nd edition: Elsevier Limited; 2010. pp. 200-209.
NICE. Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122). Available at: http://www. [Accessed 11 April 2015].
Rull G. Thrombolytic Treatment of Acute Ischaemic Stroke. Available at [Accessed 11 April 2015].
Stoke Association. State of the Nation Stroke Statistics-January 2015. Available at: [Accessed 11 April 2015].
Townsend N, et al. Coronary heart disease statistics 2012 edition. British Heart Foundation: London
Xavier AR, et al. Neuroimaging of Stroke: A Review. South Med J. 2003;96(4). Available at: [Accessed 11 April 2015]

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Figure 4:
Figure 5:
Figure 6:

[1] Lee JM, Grabb MC, Zipfel GJ, Choi DW. Brain tissue responses to ischemia. J Clin Invest. 2000;106(6):723-731.
[2]MedlinePlus. Aphasia. Available at: [Accessed 24 March 2015].
[3] Clarke DD, Sokoloff L. Regulation of Cerebral Metabolic Rate. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition. Philadelphia: Lippincott-Raven; 1999.
[4] Townsend N, et al. Coronary heart disease statistics 2012 edition. British Heart Foundation: London
[5] Bryan RN, et al. Diagnosis of acute cerebral infarction: Comparison of CT and MR imaging. AJNR Am J Neuroradiol 1991; 12: 611-620.
[6] Adams HP Jr, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25: 1901-1914.
[7] NICE. Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122). Available at: http://www. [Accessed 11 April 2015].
[8] Stroke Association. State of the Nation Stroke Statistics-January 2015. Available at: [Accessed 11 April 2015].
[9] Rull G. Thrombolytic Treatment of Acute Ischaemic Stroke. Available at [Accessed 11 April 2015].

Impact of Stroke Case Study

Jithra is now 68 years of age. Her family consists of husband, daughter, nephew and nephew’s wife. She has been living with left side hemiplegia caused by stroke since she was 64. As this interview went, Jithra was holding her daughter’s hand and slowly elaborated her word by word experience in tears. Before an episode of stroke damaged the right side of her brain and put her in bed for the rest of her life, Jithra was living a life of a healthy person. She stated that poverty and debt were the most important factors that motivated her to wake up at 4:30 am on regular basis in order to prepare food and beverage for her respective customers who kindly supported her small restaurant. A strong belief that she did not have any health issue strengthened by the fact that an annual physical check-up was so expensive disguised Jithra from realising how essential it was to have her blood pressure and blood glucose level regularly monitored when she aged. As now that she spends her activities of daily living in bed, pressure sore has become the main concern for both Jithra and her family. Though Jithra does not complain of soreness, redness on skin does indicate that some areas need attention. This essay will provide an overview understanding of stroke and its negative effects posed on Jithra. Furthermore, this essay will emphasise on the intervention and prevention of pressure ulcer in depth.
Understand Stroke
According to World Health Organization (2014), stroke occurs when there is an interruption of the blood supply to a part of the brain. Stroke can be divided into two major types. The first type is called haemorrhagic stroke. This type of stroke accounts for approximately 13 percent of all strokes (Brown & Edward, 2012). It results from bleeding into the brain tissue. The bleeding caused by a rupture of blood vessels results in the leakage of blood into the brain impairing the delivery of oxygen and nutrients. Haemorrhagic stroke can be caused by a number of disorders affecting the blood vessels. Some of which are long-standing high blood pressure and cerebral aneurysms, a thin or weak spot on a blood vessel wall. The weak spots that cause aneurysms are usually present at birth. The development of aneurysms happens over a number of years and don’t usually cause detectable problems until they break (Stroke Foundation, 2014). Jithra’s daughter stated that Jithra complained of headache and nausea approximately 48 hours, especially during periods of activity, before an episode of stroke occurred. Headache particularly distinguishes haemorrhagic stroke from ischaemic stroke. Its other symptoms also include nausea, vomiting, decreased level of consciousness, neurological deficits and hypertension (Brown & Edward, 2012).

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The second type is called ischaemic stroke. It accounts for approximately 85 percent of all strokes. According to Brown and Edward (2012), this type of stroke occurs as the result of partial or complete obstruction, caused by a blood clot, of a blood vessel that supplies blood to the brain. This leads to an insufficient of oxygen supply and glucose needed for cellular metabolism. A clot may be formed by means of embolism or thrombosis. Both types of clotting formations can be differentiated by their characteristics. The term embolism in relation to stroke is characterised by a condition where an embolus is created in one part of the brain or the body, circulates in the bloodstream, and eventually blocks the flow of blood through a vessel in another part of the brain (Crosta, 2009). This is called embolic stroke. On the other hand, the term thrombosis is characterised by the formation of a clot resulted from fatty deposits or plaque blocking the passage of blood through the artery. This type of clot remains in one area of blood vessels without being carried throughout the bloodstream. This is called thrombotic stroke (Brown & Edward, 2012).
Stroke risk factors
There are multiple risk factors associating with stroke as according with (Brown & Edward, 2012). The risk factors can be classified into non-modifiable risk factors and modifiable risk factors. Non-modifiable risk factors include age, gender, race and heredity. Modifiable risk factors include diabetes mellitus, heart disease, atrial fibrillation, heavy alcohol consumption, hypercoagulability, hyperlipidaemia, hypertension, obesity, physical inactivity, sickle cell disease and smoking.
Jithra, at 68, was diagnosed with hypertension or high blood pressure and diabetes mellitus. Age, hypertension and diabetes mellitus have played a key role in contribution to stroke. ‘Stroke risk increases with age, doubling each decade after age 55 (Brown & Edward, 2012, p. 1622).’ The rate of atherosclerotic development is usually increased by the stress of a constantly elevated blood pressure. The term atherosclerosis is referred to as hardening of the arteries resulting from the formation of fatty deposits or plaques. The narrowing of the blood vessels is its consequence. The carotid artery in the neck is a common site where these plaques develop and tend to break away and lodge in the vessels of the brain (Sander, 2013). Likewise, diabetes mellitus increases tendency towards the dysfunction of the inner linings of the blood vessel walls leading to an increase in the tendency towards the development of plaques. In addition, high cholesterol and triglyceride levels are highly likely among people with diabetes mellitus (Brown & Edward, 2012, p. 863).
Impact of Stroke
According to Brown and Edward (2012), stroke is a leading cause of serious, long-term disability. Jithra has been living with left side paralysis since she was 64 as a consequence of stroke. Immobility and the weakness in Jithra’s right arm and leg are the key limitations. She relies greatly on her family members when repositioning in bed is attempted and a combination of self-care abilities and activities of daily living, such as eating or drinking, are performed. Dysarthria, a disturbance in the muscular control of speech, is also experienced. Impairment may involve pronunciation, articulation and phonation. This helps explaining why Jithra feels uncomfortable communicating with strangers. As the interview went, a sudden change in emotion was spotted. Persons who have had a stroke may have difficulty controlling their emotions. Emotional responses may be exaggerated or unpredictable (Brown & Edward, 2012, p. 1628).The daughter said that Jithra sometimes cried without any reason. The interchanging between laughing and crying took only minutes to do so. Besides pressure, shearing force, friction and excessive moisture contribute to pressure ulcer formation (Maklebust & Sieggreen, 2001). As mentioned above that Jithra is bed-bound and greatly relies on her family members when repositioning is attempted, manual handling is used in order to lift and move her around the bed. However, the incorrect techniques combined with non-supportive equipment, such as sliding sheet, have put the maintenance of Jithra’s skin integrity becomes much more difficult.
Pressure Ulcer
According to Sydney South West (2008, p. 4), pressure ulcers are defined as “any lesion caused by unrelieved pressure when soft tissue is compressed between a bony prominence and an external surface for a prolonged period.” Factors that influence the development of pressure ulcers include the intensity of the pressure; the length of time the pressure is exerted on the skin; and the ability of the tissue to tolerate the externally applied pressure. Intrinsic factors that put Jithra at risk in developing pressure ulcers consist of advanced age, malnutrition and diabetes mellitus. Extrinsic factors include pressure, shear and moisture Sydney South West (2008).
Although the skin remains intact, the appearance of persistent redness, particularly in sacrum, followed by itchy sensation indicates that stage one pressure ulcer has already developed. Stage one pressure ulcer can be intervened as referred to pressure ulcer intervention guidelines (Jones, 2013) by strictly maintaining the skin integrity. This can be done by relieving the externally applied pressure, protecting fragile skin and bony prominence, preventing friction and shearing and protecting skin from moisture.
In relieving the externally applied pressure, a regime of repositioning combined with the use of pressure relieving devices has already been utilised by Jithra’s daughter. However, it might not be enough in terms of the frequency. The frequency of repositioning depends on the ability of the tissue to tolerate the externally applied pressure. In this case, Jithra should move or be repositioned frequently enough in allowing reddened area of affected skin to recover from the effects of pressure. A turn clock may be a helpful reminder of correct body positions and appropriate turning times. Additionally, a 30-degree side lying position may well be utilised for Jithra as it diverts pressure from the sacrum. Maintaining a 30-degree side lying position can simply be done by using pillow or foam positioning wedges. However, lying on the side may increase pressure on extremities, especially knees and ankles. Placing pillows between the legs helps preventing opposing knees and ankles from exerting pressure on one another (Maklebust & Sieggreen, 2001).
In protecting fragile skin and bony prominence, an appropriate support surfaces shall be used and yet its cost has to be taken into consideration. Poverty and debt make it very difficult for Jithra to afford buying or renting them. ‘Charges can range from $24 to purchase a foam overlay to a daily rental fee of $125 for a highly technical therapy bed (Maklebust & Sieggreen, 2001, p. 75).’ Regardless of the variations in price, There is no scientific evidence that one support surface consistently works better than any others. Nevertheless, pressure points require protection whether at risk persons are in a bed or on a chair. Using pillows to bridge vulnerable areas, again simple, is an effective way to eliminate pressure. A regime of repositioning, together with the use of pillows has proved to be highly effective in protecting fragile skin and bony prominence.
In preventing Jithra from friction and shearing, a family education on how friction and shearing occur and correct usage of manual handling techniques and appropriate equipment shall be provided. Shear is greatest when a caregiver drags an at risk person along the surface of the sheets during repositioning or allows the person to slide from high-fowler’s position. In order to minimise shearing force, the head of the bed shall not be raised exceeding a 30 degree angle, unless the patient is eating. Furthermore, friction, a precursor of shear, is commonly caused by pulling a patient across the bed linen. Rubbing the protective layer of skin away increases the potential for deeper tissue damage.
Excessive moisture may be the result of sweating, wound drainage, soaking during bathing and faecal and urinary incontinence. Moist skin is five times as likely to become ulcerated as dry skin. The intervention guidelines suggested that protecting skin from moisture can be done by using continence management systems, using barrier skin cream to prevent skin maceration and keeping the site clean and dry. Living in a hot and humid country like Thailand may put Jithra at a higher risk of developing pressure ulcer due to sweating. Thailand normally has its temperature sitting at around 30 degree Celsius. Two fans, together with the application of baby powder are used in maintaining the dryness of Jithra’s skin.
According to Jones (2013), it is highly recommended that risk assessments must be done on Jithra by using the Waterlow scale. In doing so, her body mass index is required. The scale will give a score which helps identifying if Jithra is at risk, high risk or very high risk in developing pressure ulcers. Therefore, repositioning regime can be precisely arranged in order to ensure optimum pressure redistribution. Manual handling, together with the use of equipment such as hoists or slide sheets, effectively helps avoiding shear and friction. Education on the use of the mentioned equipment shall also be provided. A dietician shall be involved in discussing knowledge of healthy diet and considering the need for food fortification and nutritional supplements. Make sure that Jithra consumes adequate fibre and well hydrated as she is more prone to constipation due to immobility.
This can be concluded that the maintenance of skin integrity plays a key role in avoiding the development of pressure ulcers. Being rich or poor might not be the factors in treating and preventing pressure ulcers. This essay has shown how beneficial it is to have carers or family members who strictly put pressure ulcer intervention and prevention guidelines into practice to look after Jithra. The mattress that Jithra lays her body on might not be the best that the family can afford but frequently turning and maintaining dry skin have proved in lowering the risk of developing pressure ulcers. Only stage one pressure ulcer developed though, Jithra has been suffering from disability for 4 years.
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