Report For Nursing Of Glasgow Coma Scale Over Time

Pathophysiology

Discuss about the Report for Nursing of Glasgow Coma Scale Over Time.

The essay is about the health condition of Mrs. Rhonda Bott, a 68-year-old lady admitted to the emergency department of the hospital. Her son Paul reported that her mother complained of headache, was unable to lift the right arm and had difficulty in speaking. She was subjected to several physical examination and CT scan. The results of CT scan indicated ischemic stroke and disregarded the presence of hemorrhagic stroke. The purpose of this essay is to discuss the pathophysiology of the patient’s condition and plan a treatment regimen for Mrs. Bott on a stroke pathway. It will mainly give a rationale for initial nursing care and treatment procedure patients.

Mrs. Bott’s condition indicated chances of either ischemic stroke or hemorrhagic stroke. To confirm the diagnosis, CT scan was done, which finally suggested she has an ischemic stroke. In relation to this diagnosis, it is necessary to know the pathophysiology associated with hemorrhagic and ischemic stroke. Stroke is primarily a heart or blood vessel disease. It primary pathology includes hypertension, atherosclerosis, heart disease, dyslipidemia, and hyperlipidemia (Liebeskind 2013). It symptoms include trouble in speaking, headache, numbness in face or arm, dizziness, watch which was also seen in Mrs. Bott. An ischemic stroke occurs when the blood clotting takes place in the artery linked to the brain and hemorrhagic stroke occurs when blood vessels rupture and bleeds into the surrounding parts of the brain (Hägg et al. 2014). Hemorrhagic stroke comprises 20% of stroke cases, and ischemic stroke comprises 80% of all strokes. A hemorrhagic stroke may occur within the intracerebral region called intracerebral hemorrhage or in the subarachnoid area called an arteriovenous stroke (Robinson et al. 2013). On the other hand, ischemic stroke occurs rapidly as the brain does not store energy substrate glucose and it is incapable of anaerobic metabolism. This condition deprives neuron of necessary substrates (Berkhemer et al. 2015). An intracerebral hemorrhage causes injury to brain tissue by disrupting all the connecting pathways and leading to localized pressure damage In both ischemic stroke and hemorrhagic stroke, destructive biochemical substances are released which plays a major role in tissue destruction.

It is necessary for patients to be aware the precipitating factors of ischemic and hemorrhagic stroke. The disease can be regulated by preventable and non-preventable risk factors. The non-preventable risk factors of stroke are age, gender, race and ethnicity, while the modifiable risk factor includes incidence of high blood pressure, diabetes mellitus, and coronary heart disease among patients family member. The interplay of the risk factor is essential for an understanding of stroke and planning effective stroke prevention programs patients. The disease can be managed by changes in diet, smoking and managing medical conditions like a cerebral aneurysm, obesity, atherosclerosis, hypertension, etc (Zhang et al. 2013).

Risk Factors

Mrs. Bott has been admitted to hospital after complaints of a headache, inability to lift arms and difficulty in speaking. To plan out initial nursing care for Mrs. Bott in the first 48 hours a careful examination of her physical condition is necessary. Her BP of 200/110 mg Hg indicates risk of heart attack and hypertension. Glasglow coma scale is useful in determining the level of consciousness in a patient following a brain injury. Mrs. Bott’s coma scale is eight which is an indication of severe brain injury (Barker et al. 2014). Severe brain injury has chances of long-term impairments in cognitive, physical and behavioral skills in the patient. She was also observed with right-sided facial droop, and so she could respond verbally. Mrs. Bott ECG report also indicated atrial fibrillation meaning a condition which disrupts heart beat in the individual. Her family history also revealed cases of anterior myocardial infarction due to which her father died at the age of 57 years. For managing the patient’s condition within 48 hours, the nurse would follow protocol leading to rapid intervention by IV administration of the clot-busting drug (Vargas, J., Spiotta, A.M., Turner, R., Chaudry, I. and Turk, A.S., 2015). The nurse should treat her with fibrinolytic recombinant tissue plasminogen activator (rtPA) drugs 4 hours post stroke. It helps in a dissolving blood clot, and this treatment has to be initiated as soon as possible to avoid permanent damage (Kernan et al. 2014). Secondly, maintaining airway, breathing and circulation in the patient will also be a priority for the nurse. After analysis of airway and respiratory signs, the nurse can provide intubation to Mrs. Bott. A nurse will continuously access patient’s vital signs, cardiac rhythm, oxygen saturation rate and neurological deficits for the first 24 hours. To decrease the risk of aspiration and improve venous return in patients, the nurse can change the position of head of the bed to 30 degrees. It will provide better circulation to the patient. As the patient is hypertensive, she will also be given hypertensive medication (Trialists’Collaboration, 2013).

Mrs. Bott’s Glasgow coma scale indicated severe brain injury and so thrombolytic is severe for her as it helps restore cerebral blood flow in patients with acute ischemic stroke. It may improve her neurological defects. Thrombolysis or thrombolytic therapy is a treatment procedure to dissolve blood clots formed in the arteries leading to the heart and brain. It involves intravenously injecting clot-dissolving drug by IV line or catheter to deliver it to the site of blockage. A few examples of thrombolytic agents includes Eminase, TNKase, Streptase, etc (Kang et al.,  2012).  This medication is approved for immediate treatment of patients with heart attacks and ischemic strokes. A blood clot creates a chance of heart attack when part of heart muscle gets damaged due to lack of oxygen being delivered by the blood. Thrombolytics helps stroke patients by dissolving blood clots quickly and helps in restoring blood flow to the heart. It prevents damage to heart muscle and reduces the risk of heart attack. However as the blood flow is not completely normal, additional therapy like angioplasty is also done on individual patients (Strbian et al. 2012).

Nursing Care

The doctor has decided to prescribe aspirin, frusemide and atorvastatin medication for Mrs. Bott following her stroke. According to American Heart Association and American Stroke Association guideline on secondary prevention of stroke, antiaggregant like aspirin is an effective drug to treat stroke patients (Emedicine.medscape.com 2016). Aspirin is given to relieve pain and inflammation. It is also prescribed to prevent strokes or heart attack. Its benefit is that it avoids blood cells from clumping together, and hence it helps in preventing conditions that lead to heart attack (Halvorsen et al. 2014). The risk of taking aspirin is that it increases the chance of bleeding in the stomach, small intestine, and brain. Taking a high dose of aspirin for longer time damages the layer of the stomach and small intestine and thus leads to bleeding. The gastric mucosal lesion is common in a patient taking a high dose of aspirin (Friberg et al. 2012). However, the benefit of low-dose aspirin therapy far outweighs the risk involved for some patients.

As Mrs. Bott is a hypertensive patient, medication is necessary to reduce her blood pressure and prevent the risk of heart attack. This is the reason for the doctor prescribing furosemide drugs to patients. Although furosemide is used to treat edema in patient with congestive heart failure and kidney disorder, it is also used to treat high blood pressure. Mrs. Boot has no signs of edema, so she has been prescribed this medication mainly to reduce high blood pressure. Lowering high blood pressure in Mrs. Bott will help to prevent future strokes. It is a loop diuretic pill that helps the body to get rid of extra water and salt by increased urination. However, there are a few side-effects of the drugs such as dizziness, light-headedness, headache and blurred vision. It has a risk of severe dehydration and so serious side-effects like a muscle cramp, fainting, dry mouth, thirst, etc. should be carefully checked in patients (Dunne et al. 2013).

Mrs. Bott medication drugs accurately follow A, B, C, D, E pneumonic for heart stroke prevention. A stand for antiaggregant drugs (example-aspirin), B stands for blood pressure lowering medication (Furosemide) and C stands for cholesterol lowering medication which is Atorvastatin drugs (Kernan 2014). Atorvastatin drugs is an HMG CoA reductase inhibitor which reduces bad cholesterol (low-density lipoprotein) and increases good cholesterol (high-density lipoprotein). It will lower the risk of stroke in Mrs. Bott. Common observed side-effects of the drug include Diarhhea, nasopharyngitis and uncommon side effects are a muscle spasm, limb pain, insomnia, wheeziness, liver pain, etc. Therefore doctors should reconsider the dose if the side-effects are severe and it does not subside (Rabar et al. 2014).

Treatment Procedures

Mrs. Bott’s ECG report indicated atrial fibrillation. It significance lies in the facts that atrial fibrillation is the major cause of ischemic stroke. Atrial fibrillation (AF) is the rapid and irregular heart rhythm. It has no symptoms and in occasional cases heart palpitation, shortness of breath and chest pain may occur. The finding of AF in ECG report is significance in the patient because this condition is associated with increased risk of heart failure and stroke. Hypertension is also a risk factor for AF (Sanna et al. 2014).

The possible pharmacological intervention of stroke will follow the standard guidelines for preventing stroke. It will comprise medication like anti-aggregates, blood pressure-lowering medication, cholesterol-lowering medication, carotid revascularization, management in diet and exercise (Kidwell et al. 2013). The purpose of three drugs like aspirin, furosemide and atorvastatin has been already mentioned above. To treat atrial fibrillation in Mrs. Bott, antiaggregant (aspirin and clopidogrel) and anticoagulants like (warfarin and rivaroxaban will be beneficial for the patient. These drugs are also approved by FDA to be an effective drug for stroke prevention. Other possible pharmacological intervention that would be appropriate for Mrs. Bott includes recanalization strategies like intravenous IV rtPA administration to establish revascularization (Ciccone et al. 2013). Current medical practice follows four strategies for treatment of ischemic stroke such as prevention of secondary complication, reperfusion strategy for arterial recanalization, neuroprotective strategies aimed at metabolic targets and inhibition of inflammatory response (Kernan 2014). Neuroprotective drug helps in reducing ischemia related damage of neuronal tissue. However, the majority of patients are not eligible for rtPA because of limited time frame and moderate success rate.

From the whole analysis of case study, it can be concluded that Mrs. Bott had high blood pressure, arterial fibrillation and ischemic stroke symptoms. The essay gave detail about the pathophysiology associated with hemorrhagic stroke and ischemic stroke. For a better understanding of the condition, detail about risk factors of both types of stroke has been provided. The stroke pathway plan for Mrs. Bott gave detail about initial nursing care for the patient within the first 48 hours. It also explained the significance of thrombolysis in patients. The pharmacological intervention for such patient provides information for current best practice guideline for secondary stroke prevention. Therefore the essay covered all aspects of ischemic stroke and its relevant treatment procedure.

Reference

Barker, M.D., Whyte, J., Pretz, C.R., Sherer, M., Temkin, N., Hammond, F.M., Saad, Z. and Novack, T., 2014. Application and clinical utility of the Glasgow coma scale over time: A study employing the NIDRR traumatic brain injury model systems database. The Journal of head trauma rehabilitation, 29(5), pp.400-406.

Medications

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Ciccone, A., Valvassori, L., Nichelatti, M., Sgoifo, A., Ponzio, M., Sterzi, R. and Boccardi, E., 2013. Endovascular treatment for acute ischemic stroke.New England Journal of Medicine, 368(10), pp.904-913.

Dunne, S., Shannon, B., Dunne, C. and Cullen, W., 2013. A review of the differences and similarities between generic drugs and their originator counterparts, including economic benefits associated with usage of generic medicines, using Ireland as a case study. BMC Pharmacology and Toxicology, 14(1), p.1.

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Halvorsen, S., Andreotti, F., Jurriën, M., Cattaneo, M., Coccheri, S., Marchioli, R., Morais, J., Verheugt, F.W. and De Caterina, R., 2014. Aspirin therapy in primary cardiovascular disease prevention: a position paper of the European Society of Cardiology working group on thrombosis. Journal of the American College of Cardiology, 64(3), pp.319-327.

Kang, D.W., Kwon, J.Y., Kwon, S.U. and Kim, J.S., 2012. Wakeâ€Âup or unclearâ€Âonset strokes: are they waking up to the world of thrombolysis therapy?. International Journal of Stroke, 7(4), pp.311-320.

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Kidwell, C.S., Jahan, R., Gornbein, J., Alger, J.R., Nenov, V., Ajani, Z., Feng, L., Meyer, B.C., Olson, S., Schwamm, L.H. and Yoo, A.J., 2013. A trial of imaging selection and endovascular treatment for ischemic stroke.New England Journal of Medicine, 368(10), pp.914-923.

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