Admission to hospital

George Cooper is a 65-year-old gentleman who lives with his wife in a four-bedroom family home. He has three daughters and one son, all of whom are adults and have left the family home. Twenty years ago he had heart valve replacement surgery, from which he had a complete recovery and returned to fully active living. However, he needs to take warfarin as a result of this. A couple of years ago, he retired from full-time employment but is currently employed on a part-time basis as an assistant in a local garage. Recently he has been experiencing increased stress due to family health problems and, as a result, his alcohol intake has increased substantially. Suddenly, while out shopping with his wife, he started to have difficulties with his speech and became unconscious. An ambulance was called and he has been admitted with a suspected stroke to the emergency department where you are on placement.

1. What are the causes of stroke?

2. What are the immediate priorities and actions for the emergency department team on his admission?

3. What tests or procedures might be carried out at this point?

4. How might George’s wife be feeling at this time and how might you be able to offer support?

Here is some information to help you with the possible responses to the questions.

A stroke (cerebrovascular accident or CVA)

According to Hildick-Smith (2000), a stroke occurs when there is an interruption in the blood supply to part of the brain causing the affected brain cells to be damaged or die. Strokes fall into two broad categories: ischaemic and haemorrhagic. Ischaemic strokes occur when blood is prevented from reaching the brain due to something blocking the relevant artery. This is usually caused by a clot or fat globule blocking the blood vessel. A haemorrhagic stroke happens when there is a haemorrhage within the brain, that is a blood vessel bursts and bleeds into the brain.

There are a number of factors which tend to increase the risk of someone having a stroke. These include genetics, age, diet, alcohol intake, smoking, fitness level (Lawrence et al 2009). The impact of the stroke depends on the part of the brain that is affected. However, common problems post-stroke include weakness/paralysis, balance problems, swallowing difficulties, incontinence, difficulties with speech and language, pain, perception problems and depression.

(See http://www.stroke.org.uk for information to help you to answer some of the questions in this case study and http://www.nhs.uk/Conditions/Stroke/Pages/Jimstory.aspx for personal experience stories of a stroke (accessed May 2012).)

Care and management of a patient following a stroke

According to the Intercollegiate Stroke Working Party (2008), treatment and recovery following stroke have three main phases:

1. Acute phase care: considering mainly the first 48 hours following stroke, although this phase may last up to 1 week. This focuses on diagnosis and acute treatment as well as preventing complications.

2. Recovery phase care: rehabilitation – the length of this phase ranges from a few days to 6 months, although further recovery is possible after 6 months. This phase tends to end either when the individual has regained their former level of functioning or their level of ability has stabilised. The focus of this phase tends to be on impairments and addressing or coping with activity limitation.

3. Long-term management after recovery: the focus of this final phase is to establish the level of support that enables the individual and any family carers to cope as well as possible with any outstanding issues following the stroke and devise strategies that make full use of opportunities to engage in social activities that are meaningful and acceptable to the individual.

Alongside these three phases is the need for secondary prevention – having had a stroke, the risk of having one or further events increases significantly. As a result, pharmaceutical and educational action need to be taken throughout the phases of treatment and recovery to minimise this risk.

Acute phase care

Stroke is a medical emergency equal to a heart attack. Government guidelines encourage early recognition of stroke (using the FAST synonym – Facial weakness, Arm weakness, Speech problems, Time to call 999). Early treatment minimises the risk of long-term problems remaining. (See the information on this campaign and the video accompanying it at http://www.nhs.uk/Actfast/Pages/stroke.aspx (accessed May 2012).)

For George, an ambulance was called and he arrived promptly in the emergency department.

The emergency department

In the emergency department, there were a few vital decisions that needed to be taken promptly.

1. Does George require immediate brain imaging?

2. Does he require thrombylosis?

Brain imaging helps determine whether the stroke is haemorrhagic or ischaemic. All people who have suspected strokes should have prompt brain imaging to determine the type of stroke and, therefore, the type of medical treatment that should be given. However, there are certain indicators that suggest that this should occur immediately, certainly within the hour. According to the National Institute for Health and Clinical Excellence (NICE 2008), these indicators include where the person:

George is on anticoagulant therapy and was unconscious and therefore had an immediate computerised tomography scan. This suggested that he had a haemorrhagic stroke.

Thrombylosis is a process by which blood clots are broken down by pharmacological means. As George has had a haemorrhagic stroke, there was no need for thrombylosis. As a result, he was transferred to the specialist stroke unit for monitoring and treatment.

During this very acute phase of his stroke, George was monitored predominantly in the following areas (NICE 2008):

• Blood glucose (seeking a normal range of between 4 and 11 mmol/L).

• Blood pressure (monitoring for systolic level of over 200 mmHg).

• Oxygenation (if saturation remains above 95%, oxygen therapy is not necessary).

• Temperature.

• Nourishment and hydration.