Currently there are around 1.2 million stroke survivors in the UK, which is every year an estimated 152,000 people. More than half have been left with disabilities that affect their daily life. Stroke can affect anyone, no matter what their age. Around a third of all strokes happen to people under the age of 65, and around 400 children (0-18) have a stroke each year. Furthermore stroke is the largest cause of complex disability in adults. (Stroke Association 2012).
A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue (WHO 2012).
Mary is a 75 year old white British lady who suffered from a Cerebrovascular Accident (Stroke) approximately five years ago. She is a divorced lady who lives alone in a two storey house, however she has three children and numerous grandchildren who live within walking distance and whom visit on a daily basis. Mary was admitted to hospital as she had sustained a fall, fortunately nothing was broken, but she had suffered with severe bruising to her face and left side of her body resulting in loss of confidence.
Mary currently takes medication for hypertension and hypercholesterolemia which her G.P monitors quite closely. On assessment it was identified that Mary has been finding it hard to accept her diagnosis, she was hoping that she would return to the same quality of life that she had before the stroke as she had never been poorly or took medication prior to this happening. CHSS (2012) state that denial initially protects you from being overwhelmed by the changes in your life. Some people may become stuck in denial.
The author has chosen this condition/illness as her grandmother suffered from a stroke 10 years ago and fights everyday with her disability, because of this experience the author decided to join the nursing profession and possibly work on a stroke unit or neurology department. This assignment will help to support, educate and contribute to patients ability to care for themselves after being diagnosed with any long term illness and will be part of life long learning, the Royal College of Nursing explain that nurses are committed to lifelong learning and continuous professional development (RCN 2012).
Clinical reasons for choosing this condition/illness are that on this placement the author was allocated with the stoma nurses which gave her the opportunity to work on the wards of her choice on the final two weeks of the placement, she chose the stroke unit which also allowed her to complete many achievements and outcomes for example proficiency 2.4 was met which involved working with patients and families in order to use their strengths to achieve their goals and aspirations.
As a nurse it is vital that patient centred care is met in todays NHS and the care management of patients with a long term condition meaning putting the patient and their experience foremost, through communication, discussion of treatment options, potential outcomes and possible psychological effects also empowering the patient and allowing them to make choices about their healthcare (Nursing Standard 2011).
As Mary was admitted with a fall investigatory questions needed to be asked to find out whether trips and falls are a common occurrence within Marys life and whether any member of the multi disciplinary team has implemented any changes to prevent these from happening. Through engaging in a therapeutic relationship allowing us to gain mutual respect and collaboration to develop with Mary she informed us that she has had many trips in her own home and only this one major fall outside, along with her worries and concerns which were listened to attentively. Nicol, J (2011) explain that as a nurse managing risk and promoting health and wellbeing whilst aiming to empower choices to promote self-care must be a priority therefore certain referrals need to be put in place.
Firstly a referral to the physiotherapist was made within the hospital in order to improve posture and balance and make sure it is safe for Mary to return home to her own surroundings, as this was not managed post stroke admission and it is within the nurses role to make sure the patient and family are comfortable with there discharge. It is known for stroke suffers to have problems such as weakness, clumsiness or paralysis usually to one side of the body or loss of balance (Stroke Association 2008) which is why Mary has not received any further treatment from a physiotherapist after her stroke five years ago as treatment is stopped when it is no longer producing any marked improvement to your condition (NHS Choices 2012).
Although from this admission it is recommend from the physiotherapist that a cane will be useful to Mary in order for her to gain more strength and move about more freely when walking outside within her limitation. A lot of time and advice was given to Mary and her family through discussion, education and effective communication, in order to help her in the decision making process and allowing Mary to realise that regaining independence requires patience (National Stroke Association 2011).
Furthermore from a staff nurses experience in the past a referral to the Falls clinic was also put in place which was deemed successful from previous stroke survivors who have been left with similar disabilities to Mary and found this useful in the rehabilitation pathway. The Falls Clinic, (2011) aims to reduce your risk of falling and falls-related injuries and review your progress every two months for the first year. From this it enables Mary to be followed up in others ways apart from the GP ensuring that nothing significant is being missed in her care. Good engagement and collaboration allows the patient to gain full confidence and allows the nurse to develop a therapeutic nurse patient relationship providing care in a manner that enables the patient to be an equal partner in achieving wellness, which Mary had never felt before.
However the family stepped forward at this point and informed the nursing team that they felt that Mary is starting to struggle around her usual housing environment and made it clear that they had no knowledge of any movement aids or assistive device until this hospital visit and talking to other families with the same problems. A referral to the Occupational Therapist was then put in place to assess and treat the physical condition using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life (NHS Careers 2012). From this referral it was decided that assistive grab bars, shower seats, supportive hand rails were put in place for easier movement around her home and further safety. This helped put her family at ease as she lives alone and copes by herself.
Many stroke survivors continue to improve over a longer time in many different ways. Their recovery is in fact a long period of rehabilitation, as they learn to deal with the effects the stroke has had on them, however the psychological impact of living with a long term condition are very popular such as 30% of patients will suffer from depression at some point post-stroke (British Psychological Society 2010) and a significant proportion these remain undiagnosed or inadequately treated ( Hackett ,Yapa, Parag & Anderson 2005). Therefore as a nurse it is vital all the common problems after a stroke are investigated in depth.
Upon Marys admission these psychological issues were assessed, Mary revealed that she had a feeling of hopelessness as she was unable to look after her younger grandchildren, worrying all the time and unable to sleep furthermore she felt like a burden to her family as they now had to do her housework and her weekly shop. Feelings of loss of energy were also described and a feeling of being isolated from her friends .As this attitude from a nurses perspective is not seen as a positive one the signs and symptoms of depression after stroke were researched.
Stroke Association (2012) suggest that it is vital to seek help if four or more symptoms are present which include feeling worthless, avoiding people, feeling anxious or feeling blue and patients with long term conditions being more likely to develop depression, A Two Question Screening Tool was used which also determined that depression was a strong possibility NICE (2009) recommend a two question screen tool to determine who may have depression. These questions link to the key symptoms required for a diagnosis to be made and with both questions answered yes it meant things can be put in place to manage this. However this diagnosis for Mary and her family was hard to accept as she had felt like this for numerous years and nothing had been done about it.
The nursing referral to GP for further screening in the community was put in place which has to include the diagnosed stage of depression which for this patient is mild disorder and the treatment and management needed. Then it is the GPs responsibility to set up an active review which includes self help, cognitive behavioural therapy and exercise (CSIP 2006)
NIMH (2011) suggest cognitive behavioural therapy (CBT ), a type of psychotherapy, or talk therapy, that helps people change negative thinking styles and behaviours that may contribute to their depression, from this as a nurse a recommendation of a day hospice was suggested to Mary, as similar patients from the nurses experience had thoroughly enjoyed there time visiting a hospice weekly. This form of empowerment allows Mary to take greater control over decisions and actions affecting her health facilitating choice, self care and self management.
Using Gibbs model of reflection (1988) it was clear to me from a student nurse perspective that Marys psychological needs were not adequately addressed, as it took six years to pick up on this adjustment in her life the healthcare in this case was not acceptable. It was upsetting to observe the patient and her family feel frustrated that nothing was done as continuing health care in stroke is a primary need and stroke survivors are eligible for NHS funding for all the individuals assessed needs ( Department of Health 2009)
In order to improve nursing the stroke patient the nursing role should involve preventative care which includes providing adequate information on stroke, risk factors and any lifestyle modifications, followed by curative care which involves accurate assessments, planned care that is person centred, physiological monitoring and risk assessment. Finally Rehabilitative/ promotive care which entails the carry on role (therapies), safe discharge planning and excellent communication with family/carers in which most of these steps should involve depression awareness and the importance of it as those people who have a Stroke and become depressed, failure to treat results is a less than optimal rehabilitation outcome (Stroke Recovery Association 2010).
In addition to this nursing staff should aim to facilitate psychological adjustment and to support understanding of the emotions associated with recovery as the interaction of psychologists and nurses provides an opportunity to normalise patients reactions to post-stroke difficulties also they can exchange evidence-based and patient knowledge with each other (Vohora & Ogi 2008). In Marys case I found that this aspect of her care was dealt with very well as Mary found it a challenge to accept this change in her life the and nurses spent endless amounts of time and dedication to help Mary come to terms with her disabilities.
It may be argued that staff nursing levels were a relating factor to Marys poor post stroke care, from working on a stroke unit previously the workload is very heavy and consists of many clinicians with appropriate levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech- language pathology, social work and clinician nutrition. Additional disciplines may include pharmacy, (neuro) psychology and recreation therapy, however it is within the nurses role to ensure all of these clinicians see there patient. In which some cases this maybe missed therefore implementing higher staffing levels may avoid this and signs of Marys depression could have been picked up amongst all of the reviews.
In 2005 Lankshear published a systematic review of international research since 1990 that looked at relationships between nurse staffing and patient outcomes. Across the 22 studies covered the report stated that, [The results] strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably (Royal College of Nursing 2010). This would also be applied when the patient returned to there own home as people who have had a stroke and their carers value continuity, being kept informed, being included and having a clear, consistent point of contact with all the clinicians and services available.(Department of Health 2007).
Another implementation that could be put in place not only for Marys psychological needs but also her physical needs is that Stroke specialist professionals could be involved in application and review of eligibility for Continuing Health Care in the community so that complex or hidden post stroke deficits which may be missed by generic staff can be considered. This could be included in the six week, six month and annual stroke reviews, and form part of the joint health and social care plan. (Department of Health, 2009).
With this put in place Marys fall may have been prevented and her home could have become safer for her earlier putting her family at ease and allowing Mary to become more independent and less reliant on help. If the situation arose again and these changes were implemented then Holistic care, which is essential in nursing skills would be successful taking into consideration the psychological, environmental and spiritual needs of the patient, as well as the physical so that people are treated as whole human beings and the impact of the illness on their quality of life is met.(Nursing Standard, 2011).
To conclude the role of the nurse in the management of care delivery for the patient and their family is to share their skills and knowledge with patients and their carers, acting as a key resource and providing a route to other services and professionals ( DOH 2005). As a person centred approach was used on this admission for Mary and her family it was clear that she was discharged more aware of services available to her in the community and the care given was beneficial in her life long rehabilitation process, leaving the Multidisciplinary Team confident they have done all they can for the patients individual needs.