Cerebrovascular

Accident

1. Goals for Health Promotion, Rehabilitation and Prevention of Further Disease Progression

1.a. Health Promotion

For the patient to have knowledge about modifiable risk factors for stroke

which include hypertension, exposure to cigarette smoke, diabetes, atrial

fibrillation (AF), dyslipidaemia, carotid artery stenosis, sickle cell disease,

postmenopausal hormone therapy, poor diet, physical inactivity, and obesity – especially

truncal obesity.

For him to follow these dietary advice:

eating at least five portions of fruit and vegetables per day.

eating at least two portions of fish per week, including a portion of oily fish.

eating a diet in which the total fat intake is 30% or less of total energy intake,

saturated fats are 10% or less of total energy intake, dietary cholesterol is less

than 300 mg/day, and saturated fats are replaced by monounsaturated and

polyunsaturated fats.

to limit their intake of oily fish to two portions a week.

For him to have these physical activity:

take 30 minutes of at least moderate-intensity exercise a day at least five days a

week.

exercise at their maximum safe capacity.

exercise that can be incorporated into everyday life, such as brisk walking, using

stairs and cycling.

exercise in bouts of 10 minutes or more throughout the day.

For him to be able to manage weight:

Offer people who are overweight or obese advice and support to work towards

achieving and maintaining a healthy weight.

For him to reduce alcohol consumption:

For men to limit their alcohol intake to 3-4 units a day.

For women to limit their alcohol intake to 2-3 units a day.

For everyone to avoid binge drinking.

For him to stop smoking:

If people want to stop:

Offer support and advice.

In addition, provide medication to help with smoking cessation when

indicated.

1.b. Rehabilitation

Improved independence in the performance of basic activities of daily living such as

grooming, dressing, hygiene and feeding, laundry and housekeeping tasks, meal

planning, grocery shopping and community mobility.

Improvement in endurance, range of motion, balance and functional ambulation.

Support and counselling for changes in mood and affect that often accompany stroke.

Desired functional outcomes include a return to the least restrictive setting possible. The

stroke rehab program includes family support and education. Training is provided about

stroke, medical care and adaptive techniques. Patients and caregivers receive assistance

with adapting to lifestyle changes, financial concerns and discharge planning.

1.c. Prevention of Further Disease Progression

Follow lifestyle changes which include smoking cessation, physical activity, diet, weight

control and avoiding excess alcohol.

For the patients to be reviewed and treated of risk factors for vascular disease for the rest

of their lives after a stroke with inclusion of annual follow-up.

To be able to maintain the patient’s blood pressure: Monitor regularly with BP checks

plus appropriate blood tests (eg, U&E and renal function on ACE inhibitor).At this time,

first-line agents for the treatment of hypertension in stroke include thiazide diuretics,

calcium-channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and

angiotensin receptor blockers (ARBs). Beta blockers are considered second-line agents,

given their inferiority in preventing events despite similar reductions in blood pressure.

To be able to receive antithrombotic treatment:

If there is a history of persistent or paroxysmal AF in a non-haemorrhagic stroke,

consider anticoagulation first-line:

Anticoagulation should be started in every patient with persistent or

paroxysmal AF (valvular or non-valvular) unless contra-indicated.

Anticoagulants should not be used for patients without persistent or

paroxysmal AF unless there is a major source of cardiac embolism.

Anticoagulation is indicated for other cardiovascular risk factors for

thromboembolism, eg prosthetic valves. Anticoagulants should not be

started until brain imaging has excluded haemorrhage, and usually not

until 14 days have passed from the onset of an ischaemic stroke.

Patients with ischemic stroke (not due to AF) should be on clopidogrel (only use

modified-release dipyridamole in combination with aspirin if clopidogrel is not

tolerated). Clopidogrel is also the preferred treatment option in patients with

peripheral arterial disease or multivascular disease.

For patients post-MI, an option including aspirin is preferred (use clopidogrel

only, if aspirin is not tolerated).

To be able to receive anti-lipid agents:

Treatment with a statin should be given to all patients with ischaemic stroke or

TIA unless contra-indicated.

2. Health Teachings for Discharge Summary

2.a. Because of possible injury to the brain from the stroke, these manifestations should be

expected or watched out for:

Changes in behavior

Doing easy tasks

Memory

Moving one side of the body

Muscle spasms

Paying attention

Sensation or awareness of one part of the body

Swallowing

Talking or understanding others

Thinking

Seeing to one side (hemianopia)

2.b. Activities

Significant others should help with many daily activities. Make sure your home is safe. Ask

your doctor, therapist, or nurse about making changes in the home to make it easier to do

everyday activities. Learn to make your home safer if the patient has memory problems from

the stroke and could wander away inside the home or away from the home. Find out about

what you can do to prevent falls and keep your bathroom safe to use. 

Family and caregivers may need to help with:

Exercises to keep elbows, shoulders, and other joints loose

Watching for joint tightening (contractures)

Making sure splints are used in the correct way

Making sure arms and legs are in a good position when sitting or lying

If using a wheelchair, follow-up visits to make sure it fits well are important to prevent skin

ulcers.

Check every day for pressure sores at the heels, ankles, knees, hips, tailbone, and elbows.

Change positions in the wheelchair several times per hour during the day to prevent

pressure ulcers.

If you have problems with spasticity, learn about what makes it worse. The patient and

significant others can learn exercise to keep your muscles lose.

Prevent pressure ulcers.

2.c. Thinking and speaking

Tips for making clothing easier to put on and take off are:

Do not provide too many choices.

Velcro is much easier than buttons and zippers. All buttons and zippers should be in the

front of a piece of clothing.

Use pullover clothes and slip-on shoes.

People who have had a stroke may have speech or language problems. Tips for talking with

the patient are:

Keep distractions and noise down. Move to a quieter room.

Give the person plenty of time to answer. After a stroke, it will take them longer to

process what has been said.

Use simple words and sentences, speaking slowly. Keep your voice lower. Repeat if

needed. Use familiar names and places. Tell them when you are going to change the

subject. Do not yell or shout.

Make eye contact before touching or speaking if possible.

Ask questions in a manner that they can be answered with a yes or no. When possible, give clear choices. Use props or visual prompts when possible. Do not give too many options.

When giving someone instructions after a stroke:

Break down instructions into small and simple steps.

Allow time for them to be understood.

Try using other ways of communicating:

You may be able to use pointing or hand gestures or drawings.

It may help the person with aphasia and their caregivers to make a book with pictures or

words about common topics or people so that they can communicate better.

2.d. Bowel care

Nerves that help your bowels work smoothly can be damaged after a stroke. Have a routine.

Once you find a bowel routine that works, stick with it.

Pick a regular time, such as after a meal or a warm bath, to try to have a bowel

movement.

Be patient. It may take 15 to 45 minutes to have bowel movements.

Try gently rubbing your stomach to help stool move through your colon.

Avoid constipation:

Drink more fluids.

Stay active or become more active.

Eat a diet with lots of fiber.

2.e. Medication

It is very important that you take your drugs the way your doctor told you to. Do not take any

other drugs, supplements, vitamins, or herbs without asking your doctor about them first.

Do not just stop taking any of these drugs, as well as drugs for your diabetes, high blood

pressure, or any other medical problems you may have.

If you are taking a blood thinner, such as warfarin (Coumadin), you may need to have extra

blood tests.

2.f. Staying Healthy

If you have problems with swallowing, you must learn to follow a special diet that makes

eating safer. Ask your doctor what the signs of swallowing problems are.

Avoid salty and fatty foods.

Stay away from fast food restaurants

Try to limit how much alcohol you drink. Ask your doctor when you may start. Even if you

are allowed to drink, limit yourself -- women may have one drink a day and men may have

two drinks a day.

Keep up to date with your vaccinations. Get a flu shot every year. Ask your doctor if you

need a pneumonia shot.

Do not smoke cigarettes. Ask your doctor for help quitting if you need to. Do not let anybody

smoke in your home.

Try to stay away from stressful situations. If you feel stressed all the time or feel very sad

and blue, talk with your doctor or nurse.

Many patients who have had a stroke feel sad or depressed at times. Talk to friends or family

about this. Ask your doctor about seeing a professional to help you with these feelings.

2.g. Call your doctor if you have:

Problems taking drugs for muscle spasms

Problems moving your joints (joint contracture)

Problems moving around or getting out of your bed or chair

Skin sores or redness

Pain that is becoming worse

Recent falls

Choking or coughing when eating

Signs of a bladder infection (fever, burning when you urinate, or frequent urination)

These are emergency situations in case of CVA:

Numbness or weakness of the face, arm, or leg

Blurry or decreased vision

Not able to speak or understand

Dizziness, loss of balance, or falling

Severe headache

3. Current Trends in Management/ Treatment

Blood pressure medications given right after stroke not beneficial

Major study has found that giving stroke patients medications to lower their blood pressure

during the first 48 hours after a stroke does not reduce the likelihood of death or major disability.

The study is published in the Journal of the American Medical Association. At least 25 percent

of the population has high blood pressure, which greatly increases the risk of stroke. Lowering

blood pressure has been shown to reduce the risk of stroke. The study investigated whether there

also would be a benefit to lowering blood pressure immediately after a stroke.

The study included more than 4,000 stroke patients in 26 hospitals across China, who were

randomly assigned to receive blood pressure medications or to discontinue blood pressure

medications. At 14 days or hospital discharge, there were no statistically significant differences

between the groups in mortality or disability.

Blood pressure often is elevated following a stroke. “But in most cases, treatment is unnecessary

because the blood pressure declines naturally over time, and lowering blood pressure may be

contraindicated,” said stroke specialist Jose Biller, MD, chair of the Department of Neurology of

Loyola University Medical Center. “It is important not to overtreat and cause low blood pressure,

because the most important objective is to maintain adequate blood flow to the brain.”

Substance naturally found in humans effective in fighting brain damage from stroke

Molecular substance that occurs naturally in humans and rats was found to "substantially reduce"

brain damage after an acute stroke and contribute to a better recovery, according to a newly

released animal study by researchers at Henry Ford Hospital. The study, published in the journal

of the American Heart Association, was the first ever to show that the peptide AcSDKP provides

neurological protection when administered one to four hours after the onset of an ischemic

stroke. This type of stroke occurs when an artery to the brain is blocked by a blood clot, cutting

off oxygen and killing brain tissue with crippling or fatal results.

"Our data showed that treatment of acute stroke with AcSDKP alone or in combination with tPA

substantially reduced neurovascular damage and improved neurological outcome." Commonly

called a "clot-buster," tPA, or tissue plasminogen activator, is the only FDA-approved treatment

for acute stroke. However, tPA must be given shortly after the onset of stroke to provide the best

results. It also has the potential to cause a brain hemorrhage.

The Henry Ford study found that this narrow "therapeutic window" is extended for up to four

hours after stroke and the therapeutic benefit of tPA is amplified when tPA is combined with

AcSDKP. Further, the researchers discovered that AcSDKP alone is an effective treatment if

given up to one hour after the brain attack. The researchers tested the actions of both substances

on laboratory rats in which acute stroke had been induced. It was already known that the peptide

AcSDKP provides anti-inflammatory effects and helps protect the heart when used to treat a

variety of cardiovascular diseases. The Henry Ford scientists reasoned that the peptide may have

similar neurological benefits. Significantly, they found that AcSDKP can readily cross the so-

called "blood brain barrier" that blocks other neuroprotective substances. A battery of behavioral

tests was given to the lab rats both before and after stroke was induced to measure the effects of

AcSDKP administered alone one hour after onset and combined with tPA four hours after stroke.

Besides finding that both methods "robustly" decreased neurological damage associated with

stroke, they did so without increasing the incidence of brain hemorrhage or the formation of

additional blood clots. "With the increased use of clot-busting therapy in patients with acute

stroke, both the safety and effectiveness of the combined treatment shown in our study should

encourage the development of clinical trials of AcSDKP with tPA," Dr. Zhang says.

4. Findings/Learning

Cerebrovascular accident is a crisis; a stress and a debilitating condition that could affect the

person holistically. It is a condition where, physically, the patient experience permanent

deterioration and disability. CVA also affects the person emotionally, spiritually and

physiologically. Moreover, stroke stands out as the main cause of mortality in the Philippines

and in the world. Besides the epidemiological importance of strokes, this disease entails a wide

range of neurological deficits, depending on the injury location, the size of the inadequate

perfusion area and the quantity of the collateral blood flow. Dysfunctions like anxiety,

depression, sleep and sexual disorders, motor, sensory, cognitive and communication disorders

are prevalent alterations in stroke patients. This situation makes them dependent on nursing

interventions.

It is highlighted that, the larger the number of patient needs are affected, the greater the urgency

to plan care, as the systemization of actions aims for the organization, effectiveness and validity

of care delivery. These considerations support the interest in an integrative review of nursing

interventions delivered to stroke patients. Nurses play an important role in enhancing stroke

patients and their families' understanding about the course of the disease, possibilities for

improvement and recovery, limitations, besides providing information about the disease,

treatment, rehabilitation and expectations for the future.

As given the goals that the nurse could base from with her interventions which includes health

promotion, rehabilitation and prevention of further disease progression, this will permit nurses to

summarizing their knowledge on the theme and facilitating decision making on interventions that

can result in more effective care, especially for stroke patients.

Considering the above and with a view to contributing and adding up efforts to improve nursing

care for the clients under analysis, studies have been made and it was stated that blood pressure

medications were found ineffective after a stroke, as well as, a substance found in the body,

AcSDKP, could be added with tPA for a clot-busting effect. These studies, if found effective and

applicable, could be a great help for stroke patients into achieving their optimum health.

Gouty

Arthritis

1. Goals for Health Promotion, Rehabilitation and Prevention of Further Disease Progression

1.a. Health Promotion

To maintain a healthy weight. 

To drink plenty of water and water-based liquids. Aim to consume between 8 and 16 8

oz. (237 ml) glasses of water a day.

To limit alcohol consumption. Alcohol inhibits the processing of uric acid in the liver.

To limit your intake of foods rich in purines, which later break down into uric acid during

digestion. These foods include red meat, shellfish, tofu, peas, organ meat, anchovies,

herring, asparagus and mushrooms.

To eat potassium rich foods, such as spinach, avocado, dried peaches, bananas, orange

juice, carrots, a baked potato (with skin), lima beans, yams, cantaloupe or dried

yams. The mineral potassium is important in gout prevention because it regulates urate

levels in the body.

To avoid diuretic medications, as they can reduce the amount of potassium in your body. 

To get tested by a doctor if you have a family history of gout, which can be a hereditary

metabolic disease. The risk rises for men over 40 years old and women after menopause.

Men are at the highest risk for gout.

To consider taking vitamin C supplements that reduced uric acid levels in the body.

1.b. Rehabilitation

•    Minimize pain and control joint swelling

•    Increase physical fitness in affected individuals

•    Bring down stress

•    Improve emotional stability

1.c. Prevention of Further Disease Progression

To take medicines as your doctor prescribes for pain.

To take steps to reduce the risk of future attacks.

To be able to talk to the doctor about all the medicines the patient takes. Some

medicines may raise the uric acid level.

To manage the patient’s weight; get exercise; and limit alcohol, meat, and

seafood.

To take a long-term medicine that reduces uric acid levels in the blood.

Uricosuric agents

Drugs called xanthine oxidase inhibitors

Colchicine

Pegloticase (Krystexxa)

To treat tophi. These are chalky nodules that form from uric acid crystals. Treatment

includes:

Drugs called xanthine oxidase inhibitors, which may shrink the tophi until they

disappear.

In rare cases, surgery to remove large tophi that are causing deformity.

2. Health Teachings for Discharge Summary

Decrease the pain of an acute attack

Rest the affected joint until the attack eases and for 24 hours after the attack.

Elevate painful joints.

Use ice to reduce swelling.

Relieve inflammation by taking nonsteroidal anti-inflammatory drugs (NSAIDs). But

don't take aspirin, which may abruptly change uric acid levels and may make symptoms

worse.

Prevent more attacks

Control your weight. Being overweight increases your risk for gout. If you are

overweight, a diet that is low in fat may help you lose weight. But avoid fasting or very

low-calorie diets. Very low-calorie diets increase the amount of uric acid produced by

the body and may bring on a gout attack. Follow a moderate exercise program.

Limit alcohol, especially beer. Alcohol can reduce the release of uric acid by the

kidneys into your urine, causing an increase of uric acid in your body. Beer, which is

rich in purines, appears to be worse than some other beverages that contain alcohol.

Limit meat and seafood. Diets high in meat and seafood (high-purine foods) can raise

uric acid levels.

Talk to your doctor about all the medicines you take. Some medicines may raise the uric

acid level.

Continue to take the medicines prescribed to you for gout. But if you weren't taking

medicines that lower uric acid (such as allopurinol or probenecid) before the attack, don't

start taking them when the attack begins. These medicines won't help relieve acute pain.

They may actually make it worse.

3. Current Trends in Management/Treatment

Study points to role of nervous system in arthritis

Arthritis is a debilitating disorder with pain caused by inflammation and damage to joints. Yet

the condition is poorly managed in most patients, since adequate treatments are lacking -- and the

therapies that do exist to ease arthritis pain often cause serious side effects, particularly when

used long-term. Any hope for developing more-effective treatments for arthritis relies on

understanding the processes driving this condition.

A new study in the Journal of Neuroscience by researchers at McGill University adds to a

growing body of evidence that the nervous system and nerve-growth factor (NGF) play a major

role in arthritis. The findings also support the idea that reducing elevated levels of NGF -- a

protein that promotes the growth and survival of nerves, but also causes pain -- may be an

important strategy for developing treatment of arthritis pain.

Using an approach established by arthritis researchers elsewhere, the McGill scientists examined

inflammatory arthritis in the ankle joint of rats. In particular, they investigated changes in the

nerves and tissues around the arthritic joint, by using specific markers to label the different types

of nerve fibres and allow them to be visualized with a fluorescence microscope.

Normally, sympathetic nerve fibres regulate blood flow in blood vessels. Following the onset of

arthritis in the rats, however, these fibres began to sprout into the inflamed skin over the joint

and wrap around the pain-sensing nerve fibres instead. More sympathetic fibres were detected in

the arthritic joint tissues, as well.

The results also showed a higher level in the inflamed skin of NGF -- mirroring the findings of

human studies that have shown considerable increases in NGF levels in arthritis patients.

To investigate the role of these abnormal sympathetic fibres, the McGill researchers used an

agent to block the fibres' function. They found that this reduced pain-related behaviour in the

animals.

"Our findings reinforce the idea that there is a neuropathic component to arthritis, and that

sympathetic nerve fibres play a role in increasing the pain," said McGill doctoral student

Geraldine Longo, who co-authored the paper with Prof. Afredo Ribeiro-da-Silva and

postdoctoral fellow Maria Osikowicz.

"We are currently using drugs to prevent the production of elevated levels of NGF in arthritic

rats; we hope that our research will serve as a basis for the development of a new treatment for

arthritis in the clinic," said Prof. Ribeiro-da-Silva.

This research was funded by grants from the Canadian Institutes of Health Research (CIHR), the

Louise and Alan Edwards Foundation, and the MITACS-Accelerate Quebec program in

partnership with Pfizer Canada.

Vitamin C does not lower uric acid levels in gout patients, study finds

Despite previous studies touting its benefit in moderating gout risk, new research reveals that

vitamin C, also known ascorbic acid, does not reduce uric acid (urate) levels to a clinically

significant degree in patients with established gout. Vitamin C supplementation, alone or in

combination with allopurinol, appears to have a weak effect on lowering uric acid levels in gout

patients, according to the results published in the American College of Rheumatology (ACR)

journal Arthritis & Rheumatism.

Gout is an inflammatory arthritis that causes excruciating pain and swelling triggered by the

crystallization of uric acid within the joints. Estimates from the ACR report that more than 8.3

million Americans suffer with gout. Medical evidence reports that long-term gout management

requires treatment with medications that lower urate levels by inhibiting uric acid production

(allopurinol) or increasing uric acid excretion (probenecid) through the kidneys.

"While current treatments are successful in reducing the amount of uric acid in the blood, there

are many patients who fail to reach appropriate urate levels and need additional therapies,"

explains lead author, Prof. Lisa Stamp, from the University of Otago in Christchurch, New

Zealand. "Vitamin supplementation is one such alternative therapy and the focus of our current

study, which looked at the effects of vitamin C on urate levels in patients with gout."

The team recruited gout patients who had urate levels greater than the ACR treatment target level

of 0.36 mmol/L (6 mg/100 mL). Of the 40 participants with gout, 20 patients already taking

allopurinol were given an additional 500 mg dose of vitamin C daily or had the dose of

allopurinol increased, while another 20 patients not already taking allopurinol were either started

on allopurinol or vitamin C (500 mg/day). Researchers analyzed blood levels of vitamin C

(ascorbate), creatinine and uric acid at baseline and week eight.

Study findings show that a modest vitamin C dose for eight weeks did not lower urate levels to a

clinically significant degree in gout patients, but did increase ascorbate. The results differ from

previous research which found that vitamin C reduced urate levels in healthy individuals without

gout, but with high levels of uric acid (hyperuricemia). In fact, the Stamp et al. study found that

reduction of uric acid was significantly less in gout patients taking vitamin C compared to those

who started or increased their dose of allopurinol.

"Though vitamin C may reduce risk of developing gout, our data does not support using vitamin

C as a therapy to lower uric acid levels in patients with established gout," concludes Prof. Stamp.

"Further investigation of the urate lowering effects of a larger vitamin C dose in those with gout

is warranted."

4. Findings/Learning

The primary goal of medical and nursing care of the patient with gouty arthritis is to alleviate

pain and discomfort while reducing the inflammatory process accompanying the attack. Once

that has been achieved, the nurse needs to initiate the patient/family education program to inform

and assist the patient/family with lifestyle modifications that are geared to prevent further acute

attacks. These modifications include actions to reduce serum and urinary purines. Supportive

care will be needed during the initial attack and if further attacks do occur.

The patient with acute or chronic gouty arthritis must incorporate the necessary changes in diet

and lifestyle in order to remain as pain free as possible. Drug therapies are an essential

component of the nursing care plan and require patient education and reinforcement. Studies

have been conducted to be able expand the modalities of treatment of gouty arthritis. It was

stated that a drug could be tested since there is a connection between the nervous system and

arthritis. Moreover, taking Vitamin C of which nurses include in their health teachings was found

to be ineffective with gouty arthritis. These researches could be able to help the patient prevent

further attacks and reduce pain once an attack has occurred. While full mobility and the ability

to continue self-care is possible with a diagnosis of gouty arthritis, the nurses will need to be

vigilant for signs of remission and forgetfulness in observing lifestyle changes. Positive

reinforcement must be ongoing in order to achieve the mutual goals of the patient with gouty

arthritis and the nurses.

Stroke & Gouty Arthritism i d t e r m e x a m i n a t i o n

In partial fulfillment of therequirements inNRS 209

Joy April M. De Leon, R.N.

Submitted to:Mrs. Anna Lyn M. Paano, R.N, M.A.N