Clinical Practice Guidelines For Stroke Management: A Nursing Perspective

Nursing Interventions for Rehabilitation

Case study on “Clinical Practice Guidelines”.

Clinical Practice Guidelines is a document that guides the decisions to be taken for the carrying out diagnosis and treatment I the health care area. Stroke is a condition that affects millions of people in a year. The clinical guidelines for stroke are improved so as to provide optimum qualitative care to the patients (Gadhia et al., 2010). The clinical guidelines provide how to make emergency decisions, how to prevent re-occurrence of stroke, rehabilitation procedure, and care after the patient becomes fine. In the below paragraphs the nursing version of the clinical practice guideline for stroke management 2010 would be appraised.

The nursing interventions are based on assessing patient’s condition, listening to the worries and discomforts, providing medications, and reporting to the health professionals in case of emergencies. In the case study, Mary is transferred to the rehabilitation unit with her baby after 12 weeks of the emergency condition. The clinical practice guidelines for rehabilitation focus on impairment, activity, and participation level (Brouwers et al., 2010). The strategy behind this is to study how much patient has recovered from the after effects of stroke basically aphasia. The guidelines says the nurse has to assess the amount of weakness or pain the patient is having, how easily is the patient doing the daily activities, how much is the patient’s mobility level and most importantly the nurse has to help the patient in their daily activities or fulfill their other needs.

In the case study, Mary is walking still with assistance. According to the clinical guidelines Mary has to be assisted in her activities of daily living (Jauch et al., 2013). The nurse along with the team should be provided Mary the occupational therapy and physiotherapy for at least 2 to 3 hours of therapy in a week. The CPG says the nurse along with the team has to go for a constraint-induced movement therapy for the upper limbs functioning. Mary can’t even eat her food that suggests she has to go for the constraint-induced movement therapy. The guidelines are to be followed effectively to help the patient achieve mobility; however intense therapies are still to be avoided for certain weeks to months.

For Mary, according to the clinical guidelines a multidisciplinary team consisting of physiotherapist and dietician would surely help. It is because to help the patient attain the normal life back and also a healthy body with help of right food. The nurse along with her team should provide all the treatments that bring Mary back to her normal life. The strategy to involve multi disciplinary team as per the clinical practice guideline brings about fruitful results in patients by improving the after affects of the stroke. In some cases, the patient losses his mental ability or becomes very anxious and fear full than the clinical practice guidelines suggest to bring upon a psychiatrist to help the patient reduce his/her fears and anxieties (Yan & Hui-Chan, 2009). The strategy helps to bring back the patient to the normal mental level. But in some cases, it is seen the patient and their families are reluctant to carry out any appointments with psychiatrist due to the perception that they are mentally all fine.

Assistance with Physical Activities

The next nursing intervention according to clinical practice guideline is of communication. In case of Mary, the nurse should assess her speech pattern. Any kind of slurred speech or difficulty in speech has to be noted and examined to provide effective therapy (Yen et al., 2008). The CPG says because in many cases the stroke patient verbal efficiency is impaired due to loss of blood supply to the brain. The verbal impairment depends on the severity of stroke. The therapy should aim to recover the verbal impairment within the recovery phase. A speech therapist is to be appointed for the patient in such cases. In case of Mary, she does not have so much of verbal problem. It should also be checked that the patient should not find difficult to swallow or chew his/her food. Any difficulty should be assessed appropriately (Boysen, 2012).

Patients of stroke face one more major difficulty that is weakness. In case of Mary, same thing can be seen her left arm and left leg were weak. Although she has gain little amount of strength but, still she is finding difficult to attain the daily activities. The clinical practice guidelines suggest strength training in such cases (Furie et al., 2011). The reason behind this is it provides effortless muscle contraction, electrical stimulation, progressive resistive exercise, muscle re-education, and mental exercise. The nurse intervention is here to motivate the patient to attain the strength training exercises. The nurse should teach her how to carry it out and what will be the benefits of it. The nurse can also initiate little amount of exercises like moving hand to make a circle, moving legs up and down (Cumming et al., 2011). These small amounts of exercises will help patient by increasing the confidence to go for other therapies and exercises.

Additional nursing intervention according to the clinical practice guidelines are the assessment and assistance in physical activities. Mary needs assistance to do all the physical activities. The clinical practice guidelines for stroke suggests that physical activities like sitting, standing, and standing up, and walking needs to be assisted (Wendel-Vos et al, 2014). The nurse should help Mary to carry out all these physical activities. For example the nurse should hold her while Mary is standing up and help her to walk by holding her sideways. For Mary conventional walking should be started. Additionally cueing of cadence, mechanical assisted gait, and virtual reality training is suggested as per the clinical practice guideline should be carried out for Mary under supervision of the nurse (Pound, Gompertz, & Ebrahim, 2008). The nurse should provide support and encouragement to the patient at all times when they are carrying out the physical activities. The physical activities assessment is must to be carried out. The nurse should provide all the measures that aids in strengthening the limb activities.

Strength Training

Mental support and satisfaction is the other most important need of the patient for recovery and rehabilitation.  The clinical practice guidelines suggests that the nurse should be at all times provide support to the patient, active listener to the needs and discomforts of the patient,  and should satisfy and educate her about the medical procedures. Mary is a new mother and she is young. Thus, Mary needs a lot mental support and encouragement. The nurse should encourage Mary by words like “everything is fine don’t worry”, “enjoy motherhood I am her to help you”. As she is a new mother the nurse should also help her to take care of her child, explain her things which she is finding difficult (Young & Forster, 2007). The nurse should also be patient and provide Mary the mental satisfaction. The mental satisfaction can be provided to her by explaining her whole medical procedure. This will not only motivate her but, will also help to carry out the therapies and medical treatment effectively.

Mary practice Maori heritage so there are some social and culture beliefs regarding the health care services.  In Maori heritage, it is seen people visit the general practitioners are far less as compared to others. In their heritage the children and adult go for medical health services but the adult visit to GP’s is far less. To access services, people must first be aware that the services are available and that they are needed. Evidence suggests that many Pacific peoples are often unaware of the government services available to them. This demonstrates ineffective communication by health information services and providers. The nurse that is taking care of Mary should educate her about all the services that are available for the stroke patients, the new mothers and the new born babies. The CPG guidelines suggest the recovery and rehabilitation knowledge should be given to all the stroke patients (Barnett, Smith, & Cumming, 2009). The strategy is to make aware the patient of recovery process and improve their health in a short time to lead a normal life again. The nurse should teach Mary and make her equipped with all the facilities available for her who are generally not known by the people of the Maori heritage due to health literacy or any other factors.

Another major drawback of Maori heritage relating to the health services is not going for preventive services especially in adults. Lack of cultural competence is the causes (Price et al., 2009). The Maori people don’t opt for preventive measures like vaccinations, preventive medicines. This may be due to health illiteracy or financial problems but, is seen in many people of this heritage. Mary is also from the same heritage so she should be made aware of all the preventive services like immunization for herself and for her baby too (Starfield, 2011). The nurse should make her aware about the screening programs and preventive measures that may associate to the diet to reduce the risk of re-occurrence of stroke. The clinical practice guidelines for stroke management suggest effective preventive measures are to be taken by the health staff and the patient and their family are to be made aware of all the preventive and health management measures related to health. This decision would surely improve health and reduce the re-occurrence of stroke. 

Mental Support and Satisfaction

Conclusion

Health is strongly influenced by a broad range of cultural, social, economic, and environmental factors. In general, people with fewer socio-economic resources tend to have poorer health outcomes due to a combination of reduced material resources, greater exposure to health risks and behaviors, greater psychosocial stress, and reduced access to health services. Mary is from a Maori heritage that is not so inclined towards healthy well-being. The clinical practice guidelines suggest preventive, educational, as well as medical care for Mary and her baby. The CPG guidelines are very effective for stroke management. They should be carried out in rehabilitation and recovery of the patient to bring optimum health benefit. The nurse should make the decisions and carry out the medical care as per the guidelines. The nurse can improve Mary’s quality of life if she follows the proper recovery and rehabilitation procedure. At the end, it can be seen the clinical practice guideline are apt to bring about the improvement in patient’s health and bringing about a healthy well-being. 

References

Barnett, P., Smith, J., & Cumming, J. (2009). The Roles and Functions of Primary Health Organisations., Wellington: Health Services Research Centre

Boysen, G. (2012). Stroke scores and scales. Cerebrovasc Dis 2012;2:239-47.

Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F., Feder, G., Zitzelsberger, L. (2010). AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ: Canadian Medical Association Journal = Journal De L’association Medicale Canadienne, 182(18).

Cumming, T.B., Thrift, A.G., Collier, J.M., et al. (2011). Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke;42:153-58.

Furie, K.L., Kasner, S.E., Adams, R.J., et al. (2011). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American heart association/ American stroke association. Stroke;42:227-76

Gadhia, J., Starkman, S., Ovbiagele, B, et al. (2010). Assessment and improvement of figures to visually convey benefit and risk of stroke thrombolysis. Stroke;41:300-06.

Jauch, E.C., Saver, J.L., Adams, H.P. et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. Starfield B. (2011). The hidden inequity in health care. International Journal for Equity in Health, 10: 15-10.1186/1475-9276-10-15

Pound, P., Gompertz, P., & Ebrahim, S. (2008). A patient-centred study of the consequences of stroke. Clin Rehabil, 12(4), 338–347.

Price, C.J., Blacker, D.J., Grimley, R.S., et al. (2009b). National survey of management of transient ischaemic attack in Australia: Take Immediate Action. Med J Aust, 191(1), 17–20.

Wendel-Vos, G.C.W., Schuit, A.J., Feskens, E.J.M., et al. (2014). Physical activity and stroke. A meta-analysis of observational data. Int J Epidemiol, 33(4), 787–798

Yan, T., Hui-Chan, C.W. (2009). Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: A randomized controlled trial. J Rehabil Med, 41(5), 312–316.

Yen, C.L., Wang, R.Y., Liao, K.K., et al. (2008). Gait training induced change in corticomotor excitability in patients with chronic stroke. Neurorehabilitation and Neural Repair, 22(1), 22–30

.Young, J. & Forster, A. (2007). Review of stroke rehabilit.