Stroke Care Management and Pressure Ulcer Assessment Tool

Student Number 21127187 Module appraisal and Therapeutic C atomic f be 18 Management Module Code AN 602 Assignment gloss A Case field of force solidus Care Management and stuff Ulcer Assessment Tool Word Count 3296 Date Submitted eleventh January, 2012 This donnish work aims to present a clinical case study of a enduring who is diagnosed of cerebrovascular accident (CVA), also called cuff, grasp a occulter attending of debilitating post- crack complications using an sagaciousness guide and anguish for interventions to the care for diagnosis of impaired come up integrity.This taste aims to incorporate the workout of a atmospheric shove ulcer grading opinion shit to evince baseline assessment data and facilitate ongoing wound care management in relation to twitch ulcers (PrUs) as unitary of languish term problems encountered in the care of a fortuity long-suffering. A holistic assessment of the tolerant get out be postulate, come acrossing activitie s of chance(a) living to alter the blow to devise a plan involving the sanativeal team in line with identify care for diagnoses.Due to limitation on word count, the essay will counseling more on the present wellness berth in relation to areas pertinent to PrUs management during the rehabilitation work at. For the purpose of this academic work, the patient will be protected by the nursing and midwifery Council (NMC) Code of Conduct (2008) by give of a pseudonym, Mr. X. Mr. X, is an 87 year-old elderly obese patient, with long-term diagnosis of Hypertension (HPN) and Non-Insulin Dependent Diabetes Mellitus (DM), on maintenance medications, who was recently diagnosed of Cerebrovascular Accident (CVA).Mr. X was transferred to a nurse home aft(prenominal) the acute hospitalisation for long-term care. Brunner (2008) defines CVA, Ischemic fortuity, or Brain Attack as sudden loss of neurologic carrying out outleting from fall flow disruption in intellectual blood vessels. Stroke has twain main types, Ischaemic and Hemmorhaegic the former is ca utilise by an infarct of blood clot in foreland arteria and accounts for 80 % of all bias cases while the latter is ca personad by bleeding into the brain tissues accounting to 20 % of stroke occurrences (Feigin et al, 2003).Stroke is the third leading cause of d tireh and is a major(ip) cause of adult neurological disability which affects approximately 130,000 people a year in the UK ( content Audit Office, 2005). Mr. X was diagnosed of having left middle cerebral artery (MCA) infarct 7 months ago resulting to neurological deficits on the contralateral side of the body. The extent of deficits following stroke depends upon the affected cerebral artery and subsequent areas of brain tissue compromised of blood supply by the shamed vessel (Porth, 2007). Upon assessment, Mr.X has right side hemiplegia, contralateral sensory impairment, dysphasia, bowel and bladder incontinence, and an existing Category I PrUs on both wienerwursts. The hemiplegia is explained by Brunner (2008) that because motor neurons decussate, a disturbance of motor control on one side of the body may reflect vituperate to the motor neurons on the opposite side of the brain. Williams et al (2010) states that following a MCA infarct, there is adaption of the brains ability to do by and interpret sensory data which results in Mr. Xs sensory impairment.Porth (2007) defines aphasia as a world-wide term with varying degrees of inability to comprehend, integrate, and express address. Porth (2007) further states that a stroke on the MCA territory is the most common aphasia-producing stroke. It is indeed imperative to s target the pathology of affected areas of the brain to anticipate presence of motor, sensory, and speech deficits where the nurses and wide-cut therapeutic team can intervene. For the purpose of data gathering and assessment, Gordons structural Health Pattern (1987) is utilize as a framework of th is essay.The perplex presents 11 on tap(predicate) health patterns categorized frameatically for data ingathering and analysis, and is used as a guide in the development of a comprehensive nursing data base ( Gordon, 2000). The nurses can identify functional patterns as the clients strengths and dysfunctional patterns as the nursing diagnoses, which assist the nurse in developing the care plan (Gordon, 1994, 200). The assessment guide is particularly chosen because it gives the nurse a full opportunity to examine not that the physical eyeshot f human functioning besides involves physiological and psychological disturbances fixd by the patient. nursing diagnoses can then be derived from the wide- come in of assessment data collected. The Gordons assessment tool is thereby used a framework for ensuring that all aspects of an individuals patients life are considered. However, this essay will only focus on the following health patterns Cognitive Perceptual, Nutritional-Met abolic, Activity and Exercise where nursing problems were place and thereby require therapeutic care management.The Agency for Healthcare insurance and Research Guideline for Post-Stroke Rehabilitation (AHCPR, 2005) recommends that initial assessment of stroke patients should include a complete annals and physical assessment with emphasis on medical co-morbidities, level of consciousness, trim assessment and risk of PrUs, mobility, and bowel and bladder function. Moreover, the following areas of assessment contri neverthelesse to the development of PrUs impaired sensory cognition or cognition, decreased tissue perfusion, nutrition and hydration status, friction and shear forces, skin moisture, mobility, and continence status (Brunner, 2008 Porth 2007).The specific areas mentioned above will be of greater emphasis delinquent to its contribution to PrU management in post-stroke Mr. X. Based upon explanation taking, Mr. X has been living with Hypertension (HPN) and DM for 12 year s and has been insulin drug-addicted for 5 months now after the occurrence of stroke. Past medical history must be taken into essential consideration especially in inveterate peg downs to condition levels of compliance to medical interventions, perception towards illness, and impact on patients lives (Crumbie, 2006).Establishment of rapport and consequently gaining trust from the patient thereby modifys the nurse to create a good baseline history assessment and attain patients cooperation through the entire rehabilitation process. The nursing process first step is assessment which involves collecting data to ease identify actual and potential health problems and patient needs. In rescript to develop curb nursing diagnoses, accurate assessments should be made to batten down allocation of appropriate resources in the planning stage to achieve judge outcomes. Potter and Perry, 2008). It could be suggested that nurses in this stage of nursing process should mesh opportunities for holistic assessments and use critical thinking in determining focus areas to be included in the database. The cephalo-caudal principle of assessment is incorporated as a guide for presenting the health patterns, which sets the Cognitive Perceptual pattern as the first to be approached highlighting assessments on cognition, perception, sensory, ail, and language.Williams et al (2010) states that post-stroke damage to the brain can result to cognitive and sensory impairment which often includes a decrease in thinking, effective decision-making, memory, and perception. Mr. Xs assessment of this health pattern reveals talk difficulty between patient and healthcare team. If converse problems arise, nurses conduct referrals to the Speech and Language Therapy (SLT) who diagnoses presence of aphasia. However, the type of aphasia has not been constituted yet since Mr.X has been reportedly uncooperative to therapies. It could be suggested however, that basing on seek, the Frenchay Aphasia Screening canvass (Enderby et al, 1987) can be utilised by the SLT to administer a promptly language measure. An other(a) recommendation is the participation of nurses in an interview (Inpatient operational Communication Interview, McCooey et al, 2004) by the SLT to hunt how Mr. X broadcast at bedside to friend the SLT diagnose conference problems, if any.The limitation on data gathering and assessment process can be compromised at this stage because of problems on communication between the nurse and the patient. It could be suggested that a referral to a speech diagnostician can be made to evaluate the patients speech, language and ability to pick up by testing verbal expression, writing ability, reading, and judgement of verbal expression (Barker, 2002). A nursing diagnosis identified is impaired verbal communication tie in to effects of dysphasia.It may be suggested that nurses should go away patients with aphasia a constant way of communicating, through mak e gesture, tone of voice, seventh cranial nerve expressions and verify responses with family members when warranted ( Holland et al, 2003). It may also be necessary to talk slow, clear, in simple terms and render the patient ample time to understand the information given (Barker, 2002). Family members of aphasic stroke survivors may also experience difficulty in various images of care giving since the patient cannot communicate effectively (Christensen and Anderson, 1989 Draper and Brocklehurst, 2007).Therefore, it is also necessary to include the family, caregivers, and the nurses at bedside during therapies to maximise nursing care (intercollegiate Stroke working(a) Party, 2008). Mr. Xs perception of pain is assessed periodically at varying times of a day to check off pain relief. Mr. X cannot verbalise pain, but most of the time shows nervus facialis grimaces while pointing to right shoulder and hand where pain are felt. Brunner (2008) says that as many as 70 % of stroke pa tients suffer severe shoulder pain that prevents patients to perform balance and perform self-care activities.Mr. X upon physical assessment has painful shoulder, swelling and stiffness on right hand, defined by Brunner (2008) as shoulder-hand syndrome which causes a frozen shoulder and subcutaneous tissue atrophy, and is forever and a day painful. However, according to Edwards & Charlton (2002), it cannot be a cause of pain if managed correctly with appropriate limb support. In this regard, pain assessments should always be subjective and be backed up with objective data gathered. Nursing diagnosis identified is inveterate pain related to immobility secondary to disease process (Heath, 2008).Mr. X has been prescribed with pain relief, Piroxicam gel onto pain areas trey times a day and Tramadol tab daily. Piroxicam Gel is a non-steroidal anti-inflammatory drug that inhibits the enzyme prostaglandin thereby reducing pain and swelling whereas Tramadol is an Opiod painkiller (Britis h National Formulary, 2010). Moreover, Mr. X has been receiving Amitryptiline HCl to help in the management of post-stroke pain but it causes cognitive problems and sedation (Brunner, 2008) thereby requiring safety nursing measures.However, non-ph outgrowthacological nursing interventions should be employed first hand before medical interventions. Brunner (2008) suggests elevation of the hand and arm to prevent edema. National stroke guidelines recommend any patient whose range of motion at a joint is reduced should submit to passive stretching of all affected joints on a daily basis, and furthermore, taught to carers (Carter & Edwards, 2002) provided that pain relief is achieved at all times.Referrals to physical therapy or occupational therapy are suggested to evaluate physical debilitations relating to functional mobility to promote pre-morbid independence and after enhance quality of life (Barker, 2011). The second health pattern to be presented is Nutritional Metabolic. Strok e can present a wide range of deficits which can affect ability to eat and predispose a post-stroke patient from malnutrition (Williams et al. , 2010).It is supported by Shelton and Reding (2001) who integ rank associated weakness and sensory loss on arm and face more than the leg in patients who has had occlusion of the MCA. Barker (2002) states that well one third of stroke survivors have dysphagia and chewing difficulties which prompts nurses strategies to liaise design risk with SLT and nutritionist or dietitian. Special diet and caloric calculations may also be needful for Mr. X due to daily insulin management, not to mention daily blood glucose monitoring.Waterlow (1985) emphasizes that those with eating difficulties are likely to eat less, thereby slowly predisposing to poor nutritional intake, so efforts should be tell at creating good balanced diet, is well-presented, and if possible, assistive devices are provided such as adapted cutlery for ease in eating, plate guard s, non-slip pads and beakers for drinking. Monitoring of nutritional deterioration of post stroke patients is essential during rehabilitation leg thereby giving attention to nutritional intake, burthen, gastrointestinal function, and general health condition (NICE, 2005).Weekly weighing has been advocated and utilization of nutritional screening tools that are validated and certain are recommended by NICE (2005). Review of systems provides skin assessment in nutritional metabolic health pattern which revealed presence of impel ulcer on heels. The European instancy Ulcer consultative impanel (EPUAP) and National imperativeness Ulcer Advisory Panel (NPUAP) (2009, p7) defines, A pressure ulcer is localized injury to the skin and/or underlying tissue commonly over a bony prominence , as a result of pressure, or pressure in combination with shear.Waterlow (1996) emphasizes that excessive weight increases pressure on a bony area thinly cover by tissue such as the sacrum, heels, a nd trochanters. Pressure ulcers (PrUs) on the heel is a very common site of PrUs, ranking second from the sacrum (Bennett & Lee,1985 hunting watch et al, 1985 Wong & Stotts, 2003) and is often painful (Black, 2005). Krueger (2006) in her study, stated that 25% of heel PrUs are related to diabetic neuropathy and peripheral arterial occlusive disease.PrU categorisation systems describe how severe the tissue damage is through progressive numbers or categories (Dealey, 2009). Given that all professionals utilize same system, logic dictates that all PrUs will be objectively assessed, however, Ousey (2005) debates that many grading systems available are or else subjective in nature giving professionals varying assessment interpretations. evaluate systems assists healthcare professionals identify the severity of PrUs and serve as a baseline for care plans. However, careful clinical judgement by the nurse s essential in ensuring that the classification systems are used only as a guide, professional skills in assessment are needed to ascertain objective assessment data. In conclusion, grading systems serve as precious tools to determine pressure sore severity in clinical practice, audit, and research ( Beeckman, 2007). Moreover, consistency in the use of classification system will enable the professionals to define progress of healing, allow evaluation of goals of treatment, and revise plans as deemed necessary.Based on the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) (2009) Pressure Ulcer Classification System, Mr. X has a Category I PrU and is defined as an area of inbuilt skin with non-blanchable redness of a localized area, usually on a bony prominence, which may present as painful, warm, and edematous. The NPUAP and EPUAP classification system was knowing to provide commonality in the definition and grading / categorization / represent of pressure ulcer, which is applicable in international settings.It h as foursome categories, Category I to IV, each defining level of skin injury and adding physiologic descriptions, which is recommended by NICE (2005). Terms such as unclassified or unstageable and deep tissue injury (DTI) which are classified as category IV is discussed separately in the new guideline (NPUAP and EPUAP, 2009). Ousley (2005) stated that Surrey system of classifying PrUs is the simplest tool available, presenting same four levels in plain terms, however, warns professionals of its relative subjectivity due to its simplicity.The EPUAP (2007) grading system is almost similar to NPUAP (2007), describing four grades, each is describe in detail. However, according to a study done by Beeckman (2007), the EPUAP system of classification has a low inter-rater dependability because of complex details in the definition, leading to a low commonality of professionals identifying the categories of PrUs, jeopardising audit of prevalence rates and affectivity of wound management.Th e Torrance grading system involves five stages, each stage expound simply and is easy to use, however it was not widely utilised because of its number of categories (Ousey, 2005), which may impose confusion against four categories, rather than achieving consensus. Healey (1995) in her study, revealed that Surrey, Torrance, and Stirling systems do not have a high level of reliability. Similarly, the Stirling Pressure unspeakable Severity scale (SPSSS) tool is argued by Healey (1995) to have the lowest reliability rate because of its most complex subscales under each category.There are four stages starting from 0 where there is no evidence of pressure ulcer, then each category has subsections, describing the level of skin injury, wound bed, and presence of contagion parameters (Ousley, 2005). However, Waterlow (1996) in her work on pressure sore bar realized the use of SPSSS as the standard classification system to be utilize because she argues that specialists and researchers ne ed to define pressure ulcers in greater depth whereas the other systems relative simplicity is regarded as weakness in lieu of its use on clinical audit.In this regard, the NPUAP and EPUAP guideline is considered useful because it provides evidence-based assessment as it is prove to be an effective and reliable tool in all(prenominal) healthcare setting. This will enable the healthcare team to improve the care required for pressure ulcer due to a common baseline assessment of the ulcer, thereby requiring a specified care management depending on its stage. Nurses can then devise a care plan based on ulcer grading, identify appropriate treatment, allocate care resources, implement the plan, and do continual evaluation of the care plan with its goal directed at wound healing.However, to achieve this level of patient assessment and care, every nurse should possess the necessary knowledge and skills which can be achieved through continue education and trainings in pressure risk assess ment and PrUs management, an interdisciplinary collaborationism ( NICE, 2005). Nursing diagnosis identified is Impaired skin integrity related to immobility and decreased sensory perception secondary to disease process (Heath, 2009). Nursing management employed were re berth Mr.X every 2 hours avoiding positioning on pressure area (EPUAP and NPUAP, 2009) and taking weight off the mattress by placing a pillow or a folded blanket under entire length of the leg and not under the Achilles tendon to protect the knee as well (Waterlow, 1996 NPUAP and EPUAP, 2009, Langermo et al, 2008). There are marketed devices for heel protection but needs constant care giver assessment since these devices are undercoat to not keep the heels off the bed better than pillows do (Tymec et al, 1997).Relieving the pressure off the heels is often all that is needed to recover the tissues in category I Heel PrUs (Langemo et al, 2008) and if offloaded continuously hastens recovery time (Black, 2005). Periods of frustration and stamp are sporadically experienced by 40 % of stroke patients passim the recovery process or as a new phase in the trajectory of a chronic illness and is often underdiagnosed (Barker, 2002).Ideally, a psychiatrist or a clinical psychologist diagnoses depression, but according to Intercollegiate stroke Working Party (2008) a healthcare professional with noetic health training can diagnose using a clinical interview. It can also be suggested to use brief screening tools to identify patients at risk of depression such as the Hospital solicitude and Depression Scale (Zigmond & Snaith, 1983) or the Geriatric Depression Scale GDS ( Yesavage et al, 1982) which are validated tools to assess mood in stroke populations (Williams et al, 2010). Amitryptiline HCl, a tricyclic antidepressant drug antidepressant (BNF, 2010) is prescribed for Mr.X, and is taken daily. Duncan (2005) sets the prevention of stroke recurrence as the highest priorities in stroke rehabilitation an d is therefore the responsibility of the nurse to understand stroke risk factors and apply contemporary evidence based lifestyle miscellanys after proper training (Lawrence et al, 2011). Barker (2002) reports that stroke survivors have 30% probability of recurring stroke within a year and 50% can suffer fatal strokes in 5 years. It could then be suggested that a Stroke Risk Screening Tool (Barker, 2002) be utilised to decrease risk of death and evaluate risk factors of Mr.X such as HPN which is managed at present with antihypertensives, DM managed with Insulin injections, Hypercholesterolemia managed with Antilipidemics, advancing age, obesity, and diet. Therefore, an important aspect of nursing care is health education whereby nurses promote lifestyle change and supportive behavioral approach towards long-term health modification. In conclusion, nurses role in the care of post-stroke patient is multi-faceted, one that requires interprofessional linkage and deep thought of contem porary evidence based interventions to address issues.DH (2007) further suggests that post stroke patients and their carers should receive support from varying range of services made available locally. Most importantly, though nursing interventions are standardized as guidelines, it could be suggested that it may not be all applicable in every patient interaction and care should be individualized as needed (Landers & McCarthy, 2007). Therefore, it is of prime importance for nurses to understand that healthcare decisions are based from patients individual choices derived from rational decision-making and the objective and rofessional advice of every member of the therapeutic team. Reference List Agency for Health Care Policy and Research. (1992) Pressure ulcers in adults prediction and prevention. Clinical practice guideline no. 3. 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