NURS2016 - Acute Exacerbations of Chronic Conditions Spring Assessment Answer

Question 1:

Aphasia

Aphasia is described as a brain injury which is generally followed by a stroke in the brain. It causes difficulty in generating language and problems in understanding (Le & Lui,2023). The warbled and aphasia speech of Mrs. Fenech shows that the instances are linked with reduced flow of the blood in the left middle cerebral artery (MCA) area. The language processing regions like Broca’s area and Wernicke’s area get the blood flow from the MCA. The decreased perfusion in the language associated areas results in the closure of the left internal carotid artery (ICA). The neural circuits are disturbed due to which there is disturbance in the language. The difficulty in constructing and discovering words is due to Ischemia in the MCA which affects the neurons to communicate to each other (Navarro-Orozco & Sánchez-Manso, 2018).

Right Sided Facial Droop with Right Sided Weakness in Upper and Lower Limbs

The neurological impairment which is caused by the barriers in the ICA causes the right-sided facial droop and weakness in both the upper and lower. The ICA is important and responsible for the blood flow in the left hemisphere of the brain. This controls the motor function on the right side of the body (Tadi & Lui, 2022). The corticospinal tract in the brainstream crosses due to which injury in the left hemisphere affects the right side of the body. In order to initiate movement the frontal lobe of the brain sends signals to the corticospinal. The frontal lobe of the brain is also known as the motor cortex. The reduction in the blood supply in Mrs Fenech’s case is due to the ischemia in the motor cortex which resulted in the weakness of ICA obstructions. The sagging of the right side of the face is also due to the impairment in the motor cortex due to which the control on the facial nerves is also impaired (Tsatsakis et al., 2019).

Question 2: 

Reperfusion interventions

Reperfusion interventions are medical procedures and treatments that are aimed to restore blood flow to a tissue or organ that has been deprived of appropriate blood supply. The term "reperfusion" was used to describe this category of medical procedures and treatments. This condition can arise for a number of reasons, including obstructions in the blood arteries, thrombosis (the formation of blood clots), embolism (the obstruction of blood vessels by foreign material), or other vascular disorders. Particularly in situations of heart attacks, strokes, and other ischemic disorders, prompt restoration of blood flow is essential for preventing irreversible damage to tissue. This is the case because ischemia causes tissue death (Naito et al., 2020)

Thrombolysis with the blood thinner Alteplase is an essential treatment for the ischemic stroke that Mrs. Mary Fenech is suffering from. Alteplase is a tissue plasminogen activator (tPA), and its purpose is to break up the blood clot that is blocking the cerebral artery. According to Jilani and Siddiqui (2018), if Alteplase is administered as soon as possible—ideally, within the first few hours after the onset of symptoms—it can restore blood flow to the damaged portion of the brain and possibly lessen or reverse the damage that has been done to the neurological system. The National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Trial evaluated the effectiveness of Alteplase in individuals who had previously experienced an ischemic stroke. Alteplase is a thrombolytic medicine that is used to break blood clots and restore blood flow in certain medical disorders. It is also known as tissue plasminogen activator (tPA), another name for the treatment. It is a sort of reperfusion intervention that is frequently utilised in the treatment of acute ischemic stroke, pulmonary embolism, and acute myocardial infarction (Reed et al., 2018). Alteplase was demonstrated to have beneficial effects on neurological outcomes and enhance the likelihood of patients regaining their functional independence when administered within the first three hours after the start of symptoms. This was the case when it was administered within the first three hours after the onset of symptoms. This study underscores the role that Alteplase plays in generating reperfusion and improving patient outcomes (National Institute of Neurological Disorders and Stroke, n.d.).

ECR, which is also known as mechanical thrombectomy, is a process that involves the employment of specific devices in order to physically remove the clot that is causing the occlusion of the cerebral artery (Burnell et al., 2018). It is especially beneficial in cases of massive arterial occlusions, such as the one that occurred in Mrs. Fenech's case, in which the prompt restoration of blood flow is vital for maintaining brain tissue and minimising the severity of any handicap that may have occurred. In Mrs. Fenech's case, the early restoration of blood flow was successful in restoring blood flow. Numerous landmark clinical trials, such as MR CLEAN, ESCAPE, and EXTEND-IA, amongst others, have provided evidence that ECR is effective in improving clinical outcomes. This efficacy has been established. According to the findings of these research, ECR, when performed within the allotted time window, led to considerably superior functional outcomes and lower disability in patients who had suffered from major artery occlusions (Yu & Jiang, 2019). These findings were consistent across all of the investigations.

Question 3:

Top Five Clinically Important Nursing Interventions

Setting nurse interventions as a top priority is crucial for delivering quality care quickly. These are the top five clinically important nursing interventions, ranked in the order of importance for Mrs. Mary Fenech's case:

1- Initiate Stroke Pathway

2- Keep in Resuscitation Bay (Triage Category 2)

3- Connect to Continuous Cardiac Monitoring

4- Initiate Supplemental Oxygen if SpO2 < 93%

5- Prepare for Endovascular Clot Retrieval (ECR) to Restore Blood Flow

Question 4:

Maintain Nil by Mouth

It is imperative to maintain nil by mouth (NPO) in stroke patients who have impaired swallowing reflexes in order to prevent aspiration. Mrs. Fenech may have dysphagia, which puts her at danger of choking or aspirating food or liquids into her lungs (Emergency Care Institute, n.d.). Her slurred speech and weakness on the right side point to this possibility. Being in NPO state reduces this danger and gives time for a speech pathology consultation to evaluate her safe swallowing capacity (Reber et al., 2019).

Monitor for Haematemesis, Melaena, and Haematuria: Aspirin is Mrs. Fenech's anticoagulant prescription, so it's important to keep an eye out for signs of gastrointestinal bleeding (haematemesis, melaena) or urinary bleeding (haematuria). There's also a chance that bleeding from thrombolysis could occur. Early bleeding detection stops the condition from getting worse and enables timely action (Li et al., 2020).

Insertion of a Nasogastric Tube: By guaranteeing stomach decompression and preventing aspiration, nasogastric tube insertion lowers the risk of aspiration pneumonia, nausea, and vomiting. It also aids in maintaining electrolyte and fluid balance. In Mrs. In Fenech's case, a nasogastric tube guarantees safer nutrition and hydration due to her possible dysphagia and limited oral intake (Metheny et al., 2019).

Collaborating with the Family: It is imperative to collaborate with the family in order to obtain pertinent medical information, prescription specifics, and emotional support. In Mrs. Fenech's instance, including her family facilitates information sharing regarding her medical background, her prescription drugs, and possible stroke triggers. Together, we can enhance patient-centred treatment and facilitate decision-making (Varghese et al.,2020).

Healthcare Team Collaborations: Coordinating efforts among members of the healthcare team guarantees all-encompassing and integrated treatment. For Mrs. Fenech, this entails liaising with speech pathologists to assess swallowing, neurologists, interventional radiologists for endovascular clot retrieval, and other specialists as required. She receives excellent treatment and achieves the best results possible thanks to this interdisciplinary approach (Rosen et al., 2018).

References

Burnell, A. L., Ranta, A., Wu, T., Fink, J., McGuinness, B., Caldwell, J., & Barber, P. (2018). Endovascular clot retrieval for acute ischaemic stroke in New Zealand. https://researchspace.auckland.ac.nz/handle/2292/46251

Emergency Care Institute. (n.d.). Stroke. https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/stroke

Jilani, T. N., & Siddiqui, A. H. (2018). Tissue plasminogen activator. https://www.ncbi.nlm.nih.gov/books/NBK507917/

Le, H., & Lui, M. Y. (2023). Aphasia. StatPearls . StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559315/#:~:text=Aphasia%20is%20an%20impairment%20of

Li, Z., Wang, Z., Shen, B., Chen, C., Ding, X., & Song, H. (2020). Effects of aspirin on the gastrointestinal tract: Pros vs. cons. Oncology Letters, 20(3), 2567-2578. https://doi.org/10.3892/ol.2020.11817

Metheny, N. A., Krieger, M. M., Healey, F., & Meert, K. L. (2019). A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart & lung, 48(3), 226-235. https://doi.org/10.1016/j.hrtlng.2019.01.003

Musick, S., & Alberico, A. (2021). Neurologic Assessment of the Neurocritical Care Patient. Frontiers in neurology, 12, 588989. https://doi.org/10.3389/fneur.2021.588989

National Institute of Neurological Disorders and Stroke. (n.d.). Tissue Plasminogen Activator for Acute Ischemic Stroke (Alteplase, Activase®). https://www.ninds.nih.gov/about-ninds/impact/ninds-contributions-approved-therapies/tissue-plasmino

Navarro-Orozco, D., & Sánchez-Manso, J. C. (2018). Neuroanatomy, middle cerebral artery. https://www.ncbi.nlm.nih.gov/books/NBK526002/

Reber, E., Gomes, F., Dähn, I. A., Vasiloglou, M. F., & Stanga, Z. (2019). Management of Dehydration in Patients Suffering Swallowing Difficulties. Journal of clinical medicine, 8(11), 1923. https://doi.org/10.3390/jcm8111923

Reed, M., Kerndt, C. C., & Nicolas, D. (2018). Alteplase. https://europepmc.org/books/nbk499977

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. The American psychologist, 73(4), 433–450. https://doi.org/10.1037/amp0000298

Tadi, P., & Lui, F. (2022). Acute stroke. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535369/

Tsatsakis, A., Docea, A. O., Calina, D., Tsarouhas, K., Zamfira, L. M., Mitrut, R., Sharifi-Rad, J., Kovatsi, L., Siokas, V., Dardiotis, E., Drakoulis, N., Lazopoulos, G., Tsitsimpikou, C., Mitsias, P., & Neagu, M. (2019). A Mechanistic and Pathophysiological Approach for Stroke Associated with Drugs of Abuse. Journal of clinical medicine, 8(9), 1295. https://doi.org/10.3390/jcm8091295

Varghese, M., Kirpekar, V., & Loganathan, S. (2020). Family Interventions: Basic Principles and Techniques. Indian journal of psychiatry, 62(Suppl 2), S192–S200. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_770_19

Yu, W., & Jiang, W. J. (2019). A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Frontiers in neurology, 10, 502. https://doi.org/10.3389/fneur.2019.00502

Naito, H., Nojima, T., Fujisaki, N., Tsukahara, K., Yamamoto, H., Yamada, T., Aokage, T., Yumoto, T., Osako, T., & Nakao, A. (2020). Therapeutic strategies for ischemia reperfusion injury in emergency medicine. Acute medicine & surgery , 7 (1), e501. https://doi.org/10.1002/ams2.501

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