STROKE TREATMENT 3500 words
This case study relates to a patient (hereafter referred to as Patient X) in my care who developed swallowing difficulties subsequent to his stroke treatment. The assignment seeks to reflect on the standard and mode of care he was provided with in this regard through the mechanism and dynamics of a reflective framework pertaining to patient care. The study and analysis will also touch on physical, etiological and heretic issues which surface during such care and treatment. Furthermore, reference will be made to evidence based practice issues in terms interprofessional practice in regard to the same.
This aim of reviewing this case study is the effective application of the parameters of post recovery care dispensed through a multidisciplinary care team, along with the consideration of the relevant matters of ethical consideration and clinical governance. This, of course, mandates the examination of the clinical decision making process to be followed in the matter at hand to assess how the nursing care needs of patients with a post stroke recovery condition may be addressed.
Definitional aspects of the Case Study:
Stroke: According to the World Health Organization, Stroke is a clinical syndrome consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin’ (Hatano, 1976). The use of the term “Stroke” here refers to mini-Stroke as opposed to TIA (transient ischaemic attacks).
Dysphagia: Dysphagia is the clinical term to describe the condition of swallowing difficulties developing after a stroke. The NHS describes it as “…. a medical term that is used to refer to difficulties with swallowing. Some people with dysphagia have problems swallowing certain foods or liquids, while others are completely unable to swallow.
Dysphagia usually arises as a complication of another health condition, such as a stroke, throat and mouth cancer or gastro-oesophageal reflux disease (GORD), which is a condition where stomach acid leaks back up into the oesophagus”. (NHS .2009)
ABCD2: A prognostic score to identify people at high risk of stroke (NICE, 2008)
FAST: Face Arm Speech Test (used to screen for a diagnosis of stroke) (NICE, 2008)
MUST: Malnutrition Universal Screening Tool (NICE, 2008)
ROSIER: Recognition of Stroke in the Emergency Room (used to confirm a diagnosis of stroke (NICE, 2008)
NSF: National Stroke Foundation (NICE, 2008)
Case study: Patient Scenario
Patient X, male and aged 50 was admitted in the Urgent Care ward after a stroke and was able to avoid significant damage due to proper management by the doctors and nurses on duty. Six hours into the recovery a senior nurse noticed that X was developing symptoms of dysphagia, which is actually the development of swallowing difficulties by the patient (NICE, 2008). This occurrence necessitated the carefully combined use of urgent and planned care (Harwood et al, 2005). Another difficulty was that the patient was of Asian descent and had recently undergone a second ceremony of marriage. It was known that due to severe opposition by his first wife’s family he was going through a tough time and this was one of the reasons leading to his stroke. The second wife was present outside the ward and to avoid more distress to the patient this fact and some other details were withheld from the family of the first wife, which was making numerous telephone calls and demanding to be in direct contact with the patient. This was mainly due to the pressure and stress the patient suffered shortly before his stroke in an argument with his first wife. It was also intimated to us that the second wife had been given a life threat by the relatives of the first wife and thereby it was necessary to conceal the factum of her presence outside the recovery room and keep the current location of the patient confidential. The patient also wished to keep his previous history of heart disease and cancer secret from his second wife at the moment.
Finally, there was a dispute as to the methodology being undertaken for the cure of swallowing difficulties for Patient X and after much discussion the advice of the senior resident registered nurse was followed. It was however felt that much time would have been saved and better care could have had been delivered if the junior doctor staff had not challenged the experience of the registered nurse and hastened to contact an independent OT and a speech therapist for an early opinion and assessment.
Stroke and Dysphagia (swallowing difficulties)
Today it is a developing good practice to screen all stroke patients for dysphagia or potentially serious swallowing problems before they are signed off from the recovery room and allowed access to solid or liquid food (Livingston, 2003). This is because it is estimated that in the United Kingdom two in three patients will develop such a condition particularly if they retain consciousness during the acute stage (Youngson, 1990).
The most unpredictable aspect of this disorder is that it can occur anywhere between an hour of recovery to a week from the recovery from stroke and the likely reason for this is brain edema and this mandates close and careful observation of the patient (Warlow, 2008). Dysphagia usually has clear symptoms such as a wet voice or overall breathing difficulties (Sullivan et al, 1999). In the case of Patient X, wet voice was suspected to be a symptom and attention was duly drawn to it.
Cultural and etiological issues have a significant role to play here as a persistently strenuous life style can lead to fatal results if the Stroke condition is not properly managed. The patient was already suffering from severe mental distress from his Asian family due to his second marriage directly before he suffered a stroke. Other issues during such care pertain to protecting the recovering stroke patient from stressful events and factors during the recovery period as this can aggravate the nature of dysphagia (Spieker et al, 2000). Moreover, there can be immense difficulties in curing an already dehydrated or malnourished patient or someone who has a history of smoking or alcoholism (NGGS, 2004). Research shows that undernourished patients are likely to take longer to recover from their stroke conditions and the fatality rate for such patients is higher than those in a better health condition prior to may be unable to take in enough food or drink, leading to under-nutrition and dehydration (NICE, 2008a). The nurse and the other relevant medical staff taking care of the patient at such a time should be well aware that such swallowing difficulties in care of the patient can lead to food and drink being misdirected to the patients lungs which is a frequent cause of post stroke pneumonia (NICE, 2008). Since patient management during this period can make or break the patient’s long term social and psychological recovery it becomes imperative to deal with the risk of any further complications during the recovery period particularly to avoid dysphagia becoming a cause of pneumonia later on life (Hibbard, 1999).
In terms of evidence based practice I would like to comment at the outset that in case of Patient X interprofessional disagreements between the doctors, speech therapist and nurses caused a significant failure of timely detection, communication and management of swallowing problems arising for Patient X. There was an overall eight-hour delay in the proper procedure, which should have been carried out at the outset shortly after the patient was moved into the recovery room. Such a procedure will generally involve the screening for risk of food or fluid getting into the lungs as well as a standard screening for the effects of stroke on a person’s food intake and overall nutrition (NICE, 2008). No such care plan was formulated until 12 hours had passed and this was aggravated due to disagreement between the medical staff.
An interdisciplinary approach is extremely important for sound patient care and after full assessment of dysphagia after stroke a proper plan needs to be formulated. In the case of patient X despite delay in decision-making he was immediately put on strong oral care and a plan was carefully chalked to manage diet modification and rehabilitation techniques are applied. It was recommended by the resident senior registered nurses that he should undergo fibre optic evaluation or fluoroscopic examination to avoid a case of aggravated dysphagia, which would allow the multidisciplinary team to access whether his pathological conditions would be compatible with the treatment being provided (Herbert, 1996). These tests were however not carried out in the end and later this caused a near attack of pneumonia for the patient who, although not malnourished, was severely dehydrated even at the time he was admitted for stroke treatment. Since the swallowing difficulties continued during the next 40 hours he was put on intermittent tube feeding after a unanimous decision of the inter professional team.
Another issue was of confidentiality. According to McKenzie (2002), the concept of confidentiality within nursing care is, “as applied to information obtained by health professionals has ethical, legal and clinical dimensions…. (With) three basic ethical principles relating to confidentiality: autonomy, duty of care and non-maleficience”(2002:1).
The NMC Code of Conduct (2004, para 5.1) expressly requires all nurses and student nurses to “treat information about patients and clients as confidential, and use it only for the purposes for which it was given” (NMC, para 5.1). Furthermore, the code goes on to warn the practitioner or trainee nurse: “you must guard against breaches of confidentiality by protecting information from improper disclosure at all times” (NMC, Para, 5.1). Rare exceptions to such prohibitions within the NMC Code against disclosures include informed consent and public interest (para 5.3 and 5.4, NMC Code, 2004).
A unanimous decision was taken to preserve confidentiality for the patient especially in terms of his location and the presence of his second wife outside the ward. The medical history of the patient was also not intimated to the second wife on his personal request. Despite the obligation under the NMC (2008) to keep the near and dear ones of the patient well informed this decision was taken in the light of ethical and quality of life issues, and it was also decided jointly by the healthcare team that the emotional well being of the patient mandated keeping him isolated from the hysterical first wife who was making threatening phone calls to the second wife and his mother every few minutes. This requirement of confidentiality is enshrined in the Nursing and Midwifery Council Code (hereafter referred to as NMC, 2008). The Code (NMC, 2008) explicitly lays down a duty on nurses and midwives to protect confidential information and clearly emphasises the duty of trainee and practitioner nurses to respect a patient’s right to privacy and confidentiality (The NMC Code, 2008). Additionally, there is a requirement of ensuring how and why subject information is to be shared by nurses unless with the honest belief that the patient may be at grave risk of harm otherwise (para 5.3 The NMC Code, 2004). The NMC code states that the information given to nurses in confidence has to be treated only for the purposes for which it was provided (The NMC Guidelines on Confidentiality, 2008). Based on the above guidelines, any requests for disclosing the patient’s location or the factum of the presence of his second wife were refused.
Issues in diagnosis and treatment
It was seen that the patient was having emotional difficulties prior to the stroke. Thus there was a need to assess a sound methodology for treatment and management of the swallowing difficulties as we saw the patient breaking into tears and hiccups many times which can be dangerous. Even though a feeding tube was used for 48 hours it was later decided that Patient X should be allowed the intake of some modified textures of food and drink. For this purpose I and the other members of the nursing team were careful to utilize a certain sitting posture for the feeding session to avoid the food going into X’s lungs , with the aim of mobilizing him at the earliest.
It was observed that the secret of any multidisciplinary team’s success in carefully bringing such a patient back to health lies not only in supplying them with adequate information and good face-to- face and general communication but also through an organized and systematic program of therapy. For these purposes, to test the neurological symptoms the doctors utilized on the advice of the registered nurse the validated tool called FAST (Face Arm Speech Test) which was to be used in the early stages when swallowing difficulties were suspected along with his current ABCD2 score which was noted to be 3.7 which is a risk digit (NICE, 2008). At this point efforts were also made to utilize the MUST and ROSIER tools which were important to test the likeliness of malnutrition, exclusion of hypoglycemia as well as to confirm the type and magnitude of the stroke occurring (NCGS, 2004).
Due to the seriousness of post stroke symptoms, particularly dysphagia, it has been recommended by NSF that managing stroke patients after recovery should be dealt with specialist stroke teams which expert stroke clinicians (DOH, 2001). It has also been recommended that stoke teams should include a pharmacist as well as a speech and language therapist, physiotherapist and occupational therapist (Ellul et al, 1994). Other members should ideally consist of a dietician and a psychologist. Finally, since the patient in question was Asian and did not speak fluent English, the presence of a trained bi or multi-lingual co-worker to reflect upon his lingual needs would have been much more effective in his recovery (Hatano, 1976).
Interprofessional implications on stroke care
The patient’s immediate carer on the spot – his second wife – had perhaps wisely wasted no time in contacting 999.There are better-informed patients out there due to the efforts of the F.A.S.T. awareness campaign, which was launched by the Secretary of State in February 2009. Despite the delay later on during treatment her quick action in getting 999 help saved Patient X from the risk of death and disability. Luckily the patient’s condition did not aggravate towards a TIA (Transient Ischaemic Attack) but was restricted to a ‘mini-stroke’.
It was also noted that Patient X had already been a heart patient a few years ago and had a serious medical history of leg cancer and thus would be more likely to be prone to fatal consequences arising from medical errors and drug reactions. He had shown a slight reaction to an overdose of aspirin during his recovery from stroke and this was duly recorded. On the patient’s request, this factum of his medical history was not discussed with his second wife, keeping in view the confidentiality requirements of the NMC code (2008) discussed elsewhere in this case study (Anderson, 2006).
In any case the concern for quality and safety, as well as the financial feasibility of urgent and unscheduled care for stroke patients, plus after stroke complications, have often been debated in government policy particularly in response to the concerns that the new PCT (Primacy Care Trust) system is often inefficient and confusing as compared to the previous 24 hour GP system (pre-2004 position)(Wanless, 2002). The Wanless Report (2002) was the first government initiative focusing upon meeting such needs in terms of the finances and skills required. This was followed by many more efforts on behalf of the government health authorities like the Darzi Review (2007,2008) towards a more patient centred and properly governed care system particularly in the field of Urgent and Unscheduled care. The Darzi Review in particular has recently supported the setting up of Stroke centred Polyclinics around the country, which would allow the location of the General Practitioner and other essential medical services in a single place although less complicated in terms of access than the PCTs or the large hospitals (Darzi, 2007,2008).
One of the most significant features of this case study was however the tendency of a disagreement occurring between members of the interprofessional team particularly pertaining to treatment routes between interning doctors and senior nurses. This is mainly due to a failure to communicate between medical teams because the highly specialized culture of the new age of the medical set up in the United Kingdom has given those concerned a subtle feeling that such a ‘melting pot’ is actually threatening the professional identities of all members, whether they are nurses, medics or doctors. This is often attributed to a lack of motivation, leadership and teamwork amongst the IPLU groups. Sarra, N (2005) and Nyatanga (2002) have labelled this as professional “ethnocentrism” affecting the medical culture and often defined as a serious problem affecting team performance as it is a “belief that one’s own professional group is superior and better than all the others” (Nyatanga (2002:1). This causes disagreements and delays and is as such detrimental to success and better patient care.
In conclusion, this case study has reviewed the case of Patient X suffering from Dysphagia (swallowing difficulties) after a mini stroke. It has been observed that nurses can effectively manage a mini stroke patient if they have been properly trained. The role of the nurse is critical here as it is often the nurse present on duty that is likely to notice the patient having difficulty swallowing, or dysphagia. This mandates adherence to proper procedures pertaining to outline screening and management procedures. The best way ahead is not only to mobilize the patient as soon as possible and address his nutritional needs (through MUST) but also to avail him the best available facilities from speech and language therapists to prevent further aggravated aspiration.
As seen above this can either be achieved through the effective use of the liquid swallow screening techniques which are a really important part of the role of the nurse supervising any such episode. Effective management during such an episode can have long lasting effects on the patient’s long-term nutritional and psychological state of health. This makes early Dysphagia screening during stroke recovery imperative for the nurses on duty (Herbert, 1996).
The most important aspect is teamwork and harmony with other members of the interprofessional team managing such a patient. This stems from the realization that everyone is there to achieve a common goal – i.e. the betterment of the patient – and this can be better achieved though promoting a healthier work culture whilst also adopting a practical approach to the promotion of an organisational culture of “clear boundaries”, whereas the ‘melting pot’ acknowledges and appreciates rather than snubs these professional cultures (Sarra, N (2005).
Last but not least, one of the issues touched upon here was confidentiality as stressed within the NMC (2008) framework. In my teamwork during this episode I am happy to note that, while balancing the needs of confidentiality with the patient’s best interests, we were as a team able to formulate a way forward, and to save further degradation in the patient’s emotional health through an uncalled for disclosure about his location and the presence of his second wife next to him with other members of immediate family.
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