For the purpose of this portfolio the author has observed, partaken in, researched and evaluated the nursing interventions and care received by a patient admitted to hospital following a cerebral infarction. The patient, whom I will refer to
Introduction
'Cerebrovascular diseases are the third most common cause of death in western countries' (Stevens and Lowe 2000 pg 436). The most frequent neurological manifestation of cerebrovascular disease is a sudden onset of dysfunction due to insufficient cerebral blood supply. This has been termed as a Cerebrovascular Accident (CVA) or stroke. For the purpose of this portfolio the author has observed, partaken in, researched and evaluated the nursing interventions and care received by a patient admitted to hospital following a cerebral infarction. The patient, whom I will refer to under the pseudonym of John, is an eighty four year old man who lived alone with some family support. 'Older people are at higher risk of a stroke and from the age of fifty-five onwards, the chances of having a stroke more than double every ten years' (MacWalter and Fraser 2003 pg 8). This is a biological trait that cannot be altered but is an important risk factor taken into consideration when a stroke is suspected. John's health status prior to admission showed a medical history of hypertension and high cholesterol levels. These medical conditions are the main possible causes of a Cerebrovascular accident alongside his contributing lifestyle factors and social history, such as smoking. 'Constricting the blood supply and promoting clotting are two ways in which smoking can make it more likely that a stroke will occur' (MacWalter and Fraser 2003 pg 9). A Cerebrovascular Accident is diagnosed from a patient's medical history and current clinical findings as a result of extensive tests and investigations.
Pathophysiological Processes
The clinical definition of a Cerebrovascular Accident is defined by Stevens and Lowe (2000 pg 437) as 'a sudden onset of a non-traumatic focal neurological deficit that causes death or lasts for over twenty-four hours'. This results in insufficient blood supply to the brain therefore affecting cells by the disruption in the supply of oxygen. The causes of strokes are divided into two main groups; Ischaemic, caused by cerebral infarction and haemorrhagic, caused by intracerebral and subarachnoid haemorrhage. 'It is characterised by a variable degree of neurological deficit produced either as a consequence of cerebral ischaemia caused by a thrombosis, embolism and/or atherosclerosis, or as a result of cerebral haemorrhage' (Montague, Watson and Herbert 2005 pg 117). An Ischaemic stroke is the most common type and occurs when there is a blockage in an artery in the brain. The word ischaemia relates to an interruption to blood flow, this interruption can be in the form of either a thrombosis (blood clot) an embolus, carried into the artery by the circulatory flow from a clot elsewhere, or as a result of a disease process in which the arteries are thickened or narrowed. John was diagnosed with suffering an Ischaemic stroke with the causal factors being atheroma affecting the right anterior cerebral vessels.
Clinical features of an Ischaemic stroke usually develop abruptly and depending on the site, cause and extent of brain damage, may include symptoms such as loss of consciousness, hemiparasis or hemiplegia of one side of the body, asymmetry of facial features, problems with balance and co-ordination, language and visual difficulties, dysphagia and incontinence (British Medical Association 2002). Sensation, movement or function controlled by the damaged area of the brain is impaired, however each patient's symptoms differ depending upon the type of stroke suffered. Symptoms depend on the lobes of the brain that have been affected. The anatomy of the brain includes the cerebral cortex which is divided into two hemispheres, left and right, and as the cranial nerves descend they cross over. The left lobes of the cortex control the movements and senses on the right side of the body e.g. voluntary movement, personality and mood, speech, bladder control, attention to stimuli and concentration etc. Similarly the right lobes of the cortex control movements and senses on the left side of the body e.g. feeling texture and shapes, dressing, special imaging, interpreting vision, facial recognition, orientation etc (Martini 2002). When admitted John presented with a sudden onset of left-sided weakness affecting his arm and leg and reducing co-ordination. This was then followed by visual disturbances in the form of blurred and double vision, a severe headache, confusion, slightly slurred speech, dysphagia, urinary incontinence and a period of unconsciousness. Stroke symptoms are initially exaggerated by the swelling and distortion of the injured neural tissue (Martini 2002).
Underlying the development of the Ischaemic stroke was the development of atherosclerosis and the contributing factors of hypertension and hyperlipidaemia. Atherosclerosis is the process that refers to the hardening and obstruction of arteries. 'It is due to deposits of lipids and other substances, in the form of atheromatous plaque in the intima of the medium and large arteries' (Montague, Watson and Herbert 2005 pg 431). Atheroma is the term given to the cholesterol-based plaque, as this collects it blocks off part of the lumen restricting blood flow. In addition to this atheroma predisposes thrombosis, where platelets adhere to the surface of the atheroma initiating the formation of a blood clot. This is what occurred in the case of John as thrombosis occluded the blood supply to the right anterior cerebral lobe resulting in Ischaemic tissue. Largely the level of cholesterol in the blood stream determines the risk of developing atherosclerosis, which can be dependent upon dietary and genetic factors (Campbell 2003). Elevated lipid levels, or hyperlipidaemia, may be a result of metabolic disease e.g. diabetes or possibly high fat diets, especially saturated fats and high dietary cholesterol and plays a role in the progression of atherosclerosis. 'There is no definitive causal relationship between saturated fat intake in the diet and the serum cholesterol levels but there is evidence that unsaturated fatty acids lower blood cholesterol whereas saturated fats tend to raise it (Montague, Watson and Herbert 2005 pg 432). Cholesterol is one of the lipids circulated in the blood flow and is an important constituent of cells and is involved in the formation of hormones and bile salts. Cholesterol transported by circulatory flow in the form of low-density lipoproteins (LDL's) is a risk factor for conditions such as atherosclerosis whilst cholesterol in the form of high-density lipoproteins (HDL'S) protects against arterial diseases. The optimum values agreed upon by medical professionals is a total cholesterol level less than 5.2 mmol/L, HDL cholesterol 0.8-1.8 mmol/L (male) 0.8-2.3mmol/L (female) and LDL cholesterol between 1.3 and 4.9 mmol/L (MacWalter and Fraser 2003). When admitted John's total cholesterol level was 7.9 mmol/L, which linked to a raised blood pressure of 180 mmHg systolic over 92 mmHg diastolic. Most authorities now agree that a resting systolic value above 140 mmHg and a diastolic persistently exceeding 90 mmHg indicates hypertension. Persistent hypertension is a common disease and approximately 50% of people in England aged 65-74 are hypertensive and this percentage increases for people even older (Marieb 2001). An average of three or more blood pressure readings are taken at rest, several days apart and if that average exceeds the upper limits of what is considered normal for that patient then hypertension is diagnosed. 'In the past there was more attention paid to the diastolic pressure value but there is increasing evidence that the height of the systolic blood pressure is a better predictor of both heart attacks and strokes' (Beevers et al. 2001; Montague, Watson and Herbert 2005 pg 486). Increased arterial pressure has an adverse effect as it places physical stress on the walls of blood vessels throughout the body. This can then promote the development of atherosclerosis, which in turn puts the individual at a greater risk of suffering a stroke.
'Cerebrovascular diseases are the third most common cause of death in western countries' (Stevens and Lowe 2000 pg 436). The most frequent neurological manifestation of cerebrovascular disease is a sudden onset of dysfunction due to insufficient cerebral blood supply. This has been termed as a Cerebrovascular Accident (CVA) or stroke. For the purpose of this portfolio the author has observed, partaken in, researched and evaluated the nursing interventions and care received by a patient admitted to hospital following a cerebral infarction. The patient, whom I will refer to under the pseudonym of John, is an eighty four year old man who lived alone with some family support. 'Older people are at higher risk of a stroke and from the age of fifty-five onwards, the chances of having a stroke more than double every ten years' (MacWalter and Fraser 2003 pg 8). This is a biological trait that cannot be altered but is an important risk factor taken into consideration when a stroke is suspected. John's health status prior to admission showed a medical history of hypertension and high cholesterol levels. These medical conditions are the main possible causes of a Cerebrovascular accident alongside his contributing lifestyle factors and social history, such as smoking. 'Constricting the blood supply and promoting clotting are two ways in which smoking can make it more likely that a stroke will occur' (MacWalter and Fraser 2003 pg 9). A Cerebrovascular Accident is diagnosed from a patient's medical history and current clinical findings as a result of extensive tests and investigations.
Pathophysiological Processes
The clinical definition of a Cerebrovascular Accident is defined by Stevens and Lowe (2000 pg 437) as 'a sudden onset of a non-traumatic focal neurological deficit that causes death or lasts for over twenty-four hours'. This results in insufficient blood supply to the brain therefore affecting cells by the disruption in the supply of oxygen. The causes of strokes are divided into two main groups; Ischaemic, caused by cerebral infarction and haemorrhagic, caused by intracerebral and subarachnoid haemorrhage. 'It is characterised by a variable degree of neurological deficit produced either as a consequence of cerebral ischaemia caused by a thrombosis, embolism and/or atherosclerosis, or as a result of cerebral haemorrhage' (Montague, Watson and Herbert 2005 pg 117). An Ischaemic stroke is the most common type and occurs when there is a blockage in an artery in the brain. The word ischaemia relates to an interruption to blood flow, this interruption can be in the form of either a thrombosis (blood clot) an embolus, carried into the artery by the circulatory flow from a clot elsewhere, or as a result of a disease process in which the arteries are thickened or narrowed. John was diagnosed with suffering an Ischaemic stroke with the causal factors being atheroma affecting the right anterior cerebral vessels.
Clinical features of an Ischaemic stroke usually develop abruptly and depending on the site, cause and extent of brain damage, may include symptoms such as loss of consciousness, hemiparasis or hemiplegia of one side of the body, asymmetry of facial features, problems with balance and co-ordination, language and visual difficulties, dysphagia and incontinence (British Medical Association 2002). Sensation, movement or function controlled by the damaged area of the brain is impaired, however each patient's symptoms differ depending upon the type of stroke suffered. Symptoms depend on the lobes of the brain that have been affected. The anatomy of the brain includes the cerebral cortex which is divided into two hemispheres, left and right, and as the cranial nerves descend they cross over. The left lobes of the cortex control the movements and senses on the right side of the body e.g. voluntary movement, personality and mood, speech, bladder control, attention to stimuli and concentration etc. Similarly the right lobes of the cortex control movements and senses on the left side of the body e.g. feeling texture and shapes, dressing, special imaging, interpreting vision, facial recognition, orientation etc (Martini 2002). When admitted John presented with a sudden onset of left-sided weakness affecting his arm and leg and reducing co-ordination. This was then followed by visual disturbances in the form of blurred and double vision, a severe headache, confusion, slightly slurred speech, dysphagia, urinary incontinence and a period of unconsciousness. Stroke symptoms are initially exaggerated by the swelling and distortion of the injured neural tissue (Martini 2002).
Underlying the development of the Ischaemic stroke was the development of atherosclerosis and the contributing factors of hypertension and hyperlipidaemia. Atherosclerosis is the process that refers to the hardening and obstruction of arteries. 'It is due to deposits of lipids and other substances, in the form of atheromatous plaque in the intima of the medium and large arteries' (Montague, Watson and Herbert 2005 pg 431). Atheroma is the term given to the cholesterol-based plaque, as this collects it blocks off part of the lumen restricting blood flow. In addition to this atheroma predisposes thrombosis, where platelets adhere to the surface of the atheroma initiating the formation of a blood clot. This is what occurred in the case of John as thrombosis occluded the blood supply to the right anterior cerebral lobe resulting in Ischaemic tissue. Largely the level of cholesterol in the blood stream determines the risk of developing atherosclerosis, which can be dependent upon dietary and genetic factors (Campbell 2003). Elevated lipid levels, or hyperlipidaemia, may be a result of metabolic disease e.g. diabetes or possibly high fat diets, especially saturated fats and high dietary cholesterol and plays a role in the progression of atherosclerosis. 'There is no definitive causal relationship between saturated fat intake in the diet and the serum cholesterol levels but there is evidence that unsaturated fatty acids lower blood cholesterol whereas saturated fats tend to raise it (Montague, Watson and Herbert 2005 pg 432). Cholesterol is one of the lipids circulated in the blood flow and is an important constituent of cells and is involved in the formation of hormones and bile salts. Cholesterol transported by circulatory flow in the form of low-density lipoproteins (LDL's) is a risk factor for conditions such as atherosclerosis whilst cholesterol in the form of high-density lipoproteins (HDL'S) protects against arterial diseases. The optimum values agreed upon by medical professionals is a total cholesterol level less than 5.2 mmol/L, HDL cholesterol 0.8-1.8 mmol/L (male) 0.8-2.3mmol/L (female) and LDL cholesterol between 1.3 and 4.9 mmol/L (MacWalter and Fraser 2003). When admitted John's total cholesterol level was 7.9 mmol/L, which linked to a raised blood pressure of 180 mmHg systolic over 92 mmHg diastolic. Most authorities now agree that a resting systolic value above 140 mmHg and a diastolic persistently exceeding 90 mmHg indicates hypertension. Persistent hypertension is a common disease and approximately 50% of people in England aged 65-74 are hypertensive and this percentage increases for people even older (Marieb 2001). An average of three or more blood pressure readings are taken at rest, several days apart and if that average exceeds the upper limits of what is considered normal for that patient then hypertension is diagnosed. 'In the past there was more attention paid to the diastolic pressure value but there is increasing evidence that the height of the systolic blood pressure is a better predictor of both heart attacks and strokes' (Beevers et al. 2001; Montague, Watson and Herbert 2005 pg 486). Increased arterial pressure has an adverse effect as it places physical stress on the walls of blood vessels throughout the body. This can then promote the development of atherosclerosis, which in turn puts the individual at a greater risk of suffering a stroke.
