Stroke Case Study | Pathophysiology and Care Delivery Plan

Stroke Case Study | Pathophysiology and Care Delivery Plan This paper will discuss the case study relating to the patient, Mrs Amelia Middleton, and answer a series of questions relating to the pathophysiology of stroke, nursing care of the patient, and response to pharmacological issues with her treatment Question 1 Farrell Dempsey (2014b) define the pathophysiological characteristics of an ischaemic stroke as being the disruption to cerebral blood supply due to an obstruction in a blood vessel (p. 1649). This disruption can be described as an ischaemic cascade, which commences with a fall in cerebral blood flow to less than 25mL/100g/min (p. 1649). When this occurs, neurons are unable to maintain aerobic respiration, causing a decrease in adenosine triphosphate (ATP) production. To combat this, mitochondria switch to anaerobic respiration, which produces large amounts of lactic acid, causes changes in cellular pH levels, anaerobic respiration is less efficient, and neurons are not capable of producing sufficient ATP to fuel the depolarisation processes (Farrell Dempsey, 2014b, p. 1649; Craft, Gordon, Tiziani, 2011). With the loss of ATP production, the active transport across the cell membrane ceases, leading to the destruction of the cell membrane, releasing more calcium and glutamate, vaso constriction and generation of free radicals. As the cascade continues, intracellular pressures increase, causing oedema (Craft, et al., 2011, p. 192). This oedema reaches it maximum after about 72 hour, and slowly subsides over the following two weeks. There are four types of haemorrhagic stroke, namely intracerebral, intracranial cerebral aneurysm, arteriovenous malformations, and subarachnoid haemorrhage, all with varying pathophysiology (Farrell Dempsey, 2014b, p. 1661). The most common type is the intracerebral haemorrhage, which is mostly found in patients with hypertension and cerebral atheroschlerosis. Certain types of arterial pathology, brain tumour, and the use of medications may also cause intracerebral haemorrhage (Farrell Dempsey, 2014b). Bleeding related to the condition is most commonly arterial and normally occurs in the putamen and adjacent internal capsule, cerebral lobes, basal ganglia, thalamus, cerebellum and brain stem (Farrell Dempsey, 2014b). Intracranial aneurism is dilation of the walls of a cerebral artery developing because of weakness in the arterial wall (Farrell Dempsey, 2014b). Presumed causes of aneurysms are weakness in arterial walls, congenital abnormalities, hypertensive vascular disease, head trauma, infection, or advancing age. Aneurysms can occur in any area of the brain but commonly occur at the circle of Willis arteries. Arteries affected by aneurysms are the internal carotid artery, anterior cerebral artery, anterior communicating artery, posterior communicating artery, posterior cerebral artery and middle cerebral artery (Farrell Dempsey, 2014b). Arteriovenous malformations are caused by abnormalities in embryonic development or are the result of trauma. It is the formation of a mass of arteries and veins without a capillary bed, whose absence, leads to dilation of arteries and veins with eventual rupture. This type of haemorrhage is common in younger people (Farrell Dempsey, 2014b). Subarachnoid haemorrhage may occur because of arteriovenous malformation, intracranial aneurysm, trauma or hypertension. Most common causes are leaking aneurysms in the area of the circle of Willis or a congenital arteriovenous malformation of the brain (Farrell Dempsey, 2014b). Both ischaemic and haemorrhagic stroke have modifiable and non-modifiable precipitating factors. Modifiable factors are those that can be changed and include: (Al-Asadi Habib, 2014; Jarvis, 2012) Non-modifiable factors are those that cannot be changed or altered, and in concert with modifiable risk factors, can indicate populations at higher risk. The factors are: (Al-Asadi Habib, 2014; Jarvis, 2012) Question 2 The nursing care required for the patient within the first 24 hours would initially include a neurological assessment, especially if thrombolytic therapy has been administered (Hinkle McKenna Guanci, 2007). Nurses need to use the Glasgow coma scale (GCS), check vital signs pupil reaction and limb assessment. If the GCS falls during or after treatment, patients need to have an urgent CT scan to exclude haemorrhagic stroke. These observations need to be recorded every 15 minutes for the first 2 hours after thrombolytic therapy, then every hour for the next 24 to 48 hours (Hinkle McKenna Guanci, 2007). Oxygen therapy will only need to be administered if the patient becomes hypoxic, which occurs if the oxygen saturation (SaO2) levels fall below 95% saturation. Blood sugar levels need to be monitored, as it is common for post stroke patients to become hyperglycaemic. Patients also need to be in an electric bed with the cot sides up and the head at a 30-degree angle, which reduces the ri sks of choking and falls (Catangui Slark, 2012). Suction should be available at the bedside in case of angioedma. Electrocardiograms need to be performed regularly to detect any abnormal changes in heart rhythm. The patient is already in atrial fibrillation but this may alter if thrombolytic therapy is administered, as such, this requires assessment on an hourly basis. The nurse should also take the time to provide information to family members regarding the patient’s treatment (Felicilda-Reynaldo, 2013). The patient and family need to be informed why thrombolytic therapy is needed, what the desired outcomes are and if there are any adverse effects. When this treatment is needed, it is often in an emergency and can be frightening for family members to see their loved one in pain or distress (Felicilda-Reynaldo, 2013). Question 3 Thrombolysis is the division of a blood clot or thrombus by the infusion of a fibrinolytic agent (drugs that are capable of breaking down fibrin, the main constituent of blood clots) into the blood (Tiziani, 2013). Thrombolytic agents act by activating plasminogen to form a proteolytic enzyme, plasmin, which attaches to fibrin, and consequently, breaks down the clot (Tiziani, 2013; Catangui Slark, 2012); this process is called clot resolution. Thrombolytic agents vary in there action, for example, Alteplase and Reteplase, are recombinant tissue plasminogen activator (r-tPA) drugs that have fibrin specific actions, adhering to fibrin bound plasminogen, Tenecteplase, a genetically engineered tissue plasminogen activator (tPA) shares similar traits (Tiziani, 2013; Catangui Slark, 2012). In contrast, Streptokinase is a non-specific plasminogen activator, which attaches itself to both fibrin bound plasminogen and unbound plasminogen (Tiziani, 2013). The use of thrombolytic agents on stroke patients is time-critical. Catangui Slark (2012), supported by Hinkle McKenna Guanci (2007) and Farrell Dempsey (2014b), describe a set of contraindications for the use of thrombolysis in stroke patients, these include age, blood pressure greater that 185mmHg/110mmHg, GCS score less than 8, time from onset of symptoms less than 4Â ½ hours, or previous stroke or myocardial infarction. This is not an exhaustive list, but is relevant to the case study patient. From these indicators it can be shown that the patient falls into a category that contraindicates the use of thrombolysis in the treatment of her condition, i.e. her blood pressure is 200mm/Hg/110mm/Hg, and that it has been at least 6 hours since onset of conditions. Question 4 Aspirin is both a non-steroidal anti-inflammatory (NSAID) and anti-platelet drug (Tiziani, 2013, p. 4 511). In its NSAID function, the drug acts to inhibit prostaglandin production, which is a mediator of inflammatory response and thermoregulation (McKenna Lim, 2012). The anti-platelet properties of the drug inhibit the production of thromboxane A2, which is a vasoconstrictor that normally increases platelet aggregation (McKenna Lim, 2012). Contraindications for this drug are for people with allergies to Salicylates, haemorrhage, and gastrointestinal bleeding (Tiziani, 2013; McKenna Lim, 2012). Administration is by oral pathway. In the context of this case study, because the patient is not eligible for thrombolysis, aspirin would be beneficial in lowering the risk of further stroke by reducing the chance of further thrombosis forming through its anti-platelet properties. The risks in this context are exacerbation of her hypertension and possible bleeding; however, in this circums tance the prescription of aspirin is appropriate. Carvedilol is a lipophilic vasodilating non-cardioselective ÃŽ ²-blocker (Leonetti Egan, 2012). This drug is used to treat hypertension by blocking norepinephrine binding to ÃŽ ±1-adrenergic receptors in addition to both ÃŽ ²1-adrenergic and ÃŽ ²2-adrenergic receptors (Leonetti Egan, 2012). Contraindications for this drug include bradycardia, heart block, diabetes, and bronchospasms (McKenna Lim, 2012). Administration is by oral pathway. In the context of the case study, the administration of carvedilol is desirable because of her hypertension. It is further suggested that carvedilol contributes to a reduction in cardiac arrhythmias such as atrial fibrillation (Watson Lip, 2006). The risk associated with this drug include hepatic failure, oedema, and deterioration if the patient is in heart failure (McKenna Lim, 2012; Tiziani, 2013) Atorvostatin is a hydroxymethylglutaryl co-enzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolaemia or hyperlipidaemia (McKenna Lim, 2012). The drug acts to inhibit production of cholesterol by blocking HMG-CoA reductase from completing the synthesis of cholesterol (Tiziani, 2013). Administration is by oral pathway. In the context of this case study, Atorvostatin is not indicated for administration without further investigation into potential underlying causes, such as, heart disease or hypercholesterolaemia. Question 5 In the context of this case study, atrial fibrillation could indicate heart disease, but further investigation would be necessary to determine this. Factors such as age, hypertension, ischaemic stroke, family history of myocardial infarction, and erratic pulse are evident and are all indicators towards heart disease (Bordignon, Corti Bilato, 2012). McKenna Lim (2012, p. 676) also associate coronary artery disease, myocardial inflammation, valvular disease, cardiomegaly, and rheumatic heart disease with atrial fibrillation. Pharmacologically, the drugs considered for intervention include heparin, warfarin, and carvedilol (Watson Lip, 2006). Both Heparin and Warfarin are anticoagulant drugs. Heparin is a fast acting, intra-venous or subcutaneously administered anticoagulant used in the acute setting, with changeover to orally administered warfarin, whose anticoagulant effect is evident after 36-72 hour, for longer-term use (Tiziani, 2013; McKenna Lim, 2012). In context of the case study, aspirin use would be discontinued if heparin and warfarin were administered, as these drugs are recorded as having an adverse reaction (Tiziani, 2013; McKenna Lim, 2012). These drug types have contraindications for active and potential bleeding, so issues such as haemorrhoid bleeding may exclude these drugs from administration (Tiziani, 2013). As previously stated, Carvedilol is a nonselective ÃŽ ²-blocker (Leonetti Egan, 2012). This drug is administered orally and are safe in combination with heparin or warfarin (Tiziani, 2013). Contraindications for this drug include bradycardia, heart block, diabetes, and bronchospasms (McKenna Lim, 2012). This drug had both antihypertensive properties and has been shown to reduce cardiac arrhythmias such as atrial fibrillation (Watson Lip, 2006). The risk associated with this drug include hepatic failure, oedema, and deterioration if the patient is in heart failure (McKenna Lim, 2012; Tiziani, 2013). Conclusion This paper has discuss and identified the pathophysiology of stroke, discussed the nursing care of the stroke patient, and identified and discussed pharmacological interventions available to treat the patient. Page 1 of 6 20/09/2016 2:53:40 PM

Defining Good Use :: Teaching Writing Education Essays

Defining Good Use In my opinion good use can depend on what you are writing, who you are writing for, and your purpose for writing. Good use can change from writing to your friend in North Carolina to writing a business memo for your boss to writing a paper for an English class. The good use of language can differ from one situation to another. Many of the writers we discussed in class had many different ideas on what good use is. Emerson wanted us to believe that "truth and sincerity unsullied by ulterior motives" constituted good use. The only problem in that is even though you may be telling the truth, does it actually make it "good"? As in the exercise we did for class that showed how using different words we could make the same place sound attractive and then not so attractive. In both cases, we were telling the truth, but can we consider one description "better" than the other. The truth of one person may not be the same as the truth for another person depending on their perspective. Robert Hall stated good use as "the most efficient way of saying whatever's being said." But is efficiency really good use? You may accomplish being efficient, but are you really saying exactly what you want to say. Maybe by being efficient you are leaving out important thoughts or feelings that could be used to relate what you are saying and cause your receiver to understand exactly what you are saying. Being efficient is not always being effective. Wouldn't you rather have the reader understand more fully what you are saying rather than being vague just to be efficient? Orwell considers good use as "letting the meaning choose the word, and not the other way about." To me, that seems somewhat more to what good use is. Your meaning in a letter to a friend and your meaning in a business memo to your employer may be different, and thus you need to choose words that fit your meaning. The words you write on a piece of paper should not dictate what you want to say but express your meaning in the words you write. I agree with the statement that "language is perceptive." Writing the same thing to two different people can cause different images for each person depending on the reader's perspective. A more descriptive paragraph may make a clearer picture for someone who is educated in that field and may cause a foggier picture for someone who knows nothing about the topic. Defining Good Use :: Teaching Writing Education Essays Defining Good Use In my opinion good use can depend on what you are writing, who you are writing for, and your purpose for writing. Good use can change from writing to your friend in North Carolina to writing a business memo for your boss to writing a paper for an English class. The good use of language can differ from one situation to another. Many of the writers we discussed in class had many different ideas on what good use is. Emerson wanted us to believe that "truth and sincerity unsullied by ulterior motives" constituted good use. The only problem in that is even though you may be telling the truth, does it actually make it "good"? As in the exercise we did for class that showed how using different words we could make the same place sound attractive and then not so attractive. In both cases, we were telling the truth, but can we consider one description "better" than the other. The truth of one person may not be the same as the truth for another person depending on their perspective. Robert Hall stated good use as "the most efficient way of saying whatever's being said." But is efficiency really good use? You may accomplish being efficient, but are you really saying exactly what you want to say. Maybe by being efficient you are leaving out important thoughts or feelings that could be used to relate what you are saying and cause your receiver to understand exactly what you are saying. Being efficient is not always being effective. Wouldn't you rather have the reader understand more fully what you are saying rather than being vague just to be efficient? Orwell considers good use as "letting the meaning choose the word, and not the other way about." To me, that seems somewhat more to what good use is. Your meaning in a letter to a friend and your meaning in a business memo to your employer may be different, and thus you need to choose words that fit your meaning. The words you write on a piece of paper should not dictate what you want to say but express your meaning in the words you write. I agree with the statement that "language is perceptive." Writing the same thing to two different people can cause different images for each person depending on the reader's perspective. A more descriptive paragraph may make a clearer picture for someone who is educated in that field and may cause a foggier picture for someone who knows nothing about the topic.

Dramatic scene Essay

The courtroom scene of act two is described as the most dramatic scene of the play. How does Miller make it dramatic? In your opinion is it more dramatic than act 4?  The Crucible was written in 1953 by Arthur Miller who was born on the 17th October 1915 in New York City, and wrote many plays including No Villain and All My Sons. The play is based on real events that happened in Salem Massachusetts, and even uses real people for characters in the play such as John Proctor and Abigail Williams, although some details like Abigail’s age has been changed to make the play more acceptable. In 1692 mass hysteria took over due to the witch trials as a group of girls started falling ill and accused people of being witch’s and claimed they where helping the devil, casting spells, sending their spirits out, and various other acts of witchcraft. By the time the trials where over, 140 people where accused in Salem alone and 19 where hanged, 13 died in jail and 1 man named Giles Co rey, who is a minor character in the play, was crushed to death. When Miller visited Salem he was able to look at the court papers, and other resources which helped him to write the play. The crucible was written during McCarthyism when Senator Joseph McCarthy, chairman of the HUAC (House of Un-American Activities Committee), started searching for Communist within the American public. People with grudges would accuse their own neighbours of being involved with communism. Senator McCarthy and special congressional committees would then investigate and the accused would have to go to court and be put on trial where it would be decided whether or not they would go to prison as a consequence, which has a similar structure of that to what happened in Salem. Miller had been interested in the witch trials in Salem since he had started writing plays at the University of Michigan and saw the parallel between the two events and wrote â€Å"The Crucible†. Critic’s newspaper etc immediately saw this as an act against the court, and so in 1956 he was called to court accused of being involved with communism. These chapters of his life where capturing those of a mixture of the characters in his play, as when Miller was asked to give names of those he had seen at a communist meeting, he refused even though it could of resulted in prison. Fortunately Miller did not go to prison. The trials had started to come to an end so that could of effected the result of his trial, but he was also married to Marilyn Monroe at the time who was a well known wealthy celebrity who had contacts who where high up in court and so, that may of also had an helped keep him out of prison. The play starts of inside Reverend Paris’s house. His daughter Betty is lying unconscious on the bed and he is praying at her bedside. The doctor has suggested that her illness may be unnatural, and there are rumours of witchcraft going round the village. Parris is scared to go down and talk to them as it could put his position as minister in jeopardy. We find out that Betty had been dancing in the woods with her cousin Abigail Williams, Tituba who is a black slave from Barbados, and other girls in the village, and Parris suspects that it was what caused Betty’s condition, and challenges Abigail about it. She tells him â€Å"it were only sport† and that Betty took fright and fainted when he jumped out at them. Ruth, the daughter of the Putnam’s is also ill and Mrs Putnam talks of her seven dead babies and tells us she thinks they where murdered by a witch. She introduces the theme of revenge as she believes Rebecca Nurse, who was her midwife and praised throughout the village, killed her babies and wants revenge on her for that. Once the girls are alone Abigail threatens them not to tell of what they did in the woods â€Å"Let either of you breath a word, or the edge of a word, about other things, and I will come to you in the black of some terrible night and bring a pointy reckoning that will shudder you†. Abigail goes on to talk about what happed to her parents, who where murdered in front of her by Indians â€Å"I’ve seen some reddish work done at night† and we feel so I sympathy for her, and understand why she would be so aggressive. Betty wakes up screaming and Abigail violently tries to shut her up. When John Proctor arrives on the scene Mary Warren is intimidated and he tells her to leave, the rest of the girls soon follow leaving Abigail and Proctor alone. Like Abigail John is also aggressive, especially towards Mary as at the end of act 2 he puts her in a position where she must choose between him and Abigail, and throws her to the floor where she is left in hysterics as she is being threatened by two powerful and aggressive people who are both threatening to hurt her is she doesn’t side with them â€Å"(In terror) I cannot I cannot they will turn on me -â€Å".

The Movie Crash Essay - 1031 Words

Writer-director Paul Haggis Movie â€Å"Crash† written in 2004, tells an interconnecting story of what Whites, Blacks, Latinos, Iranians, cops and criminals. Regardless of their Social Economic Academic or Political background, they are all defined in one way or another by racism. Crash represents the modern condition as a violent bumper car ride (Variety) which connects stories based on coincidences serendipity, and luck as the lives of the characters crash against one another. The movie presumes that most people feel prejudice and resentment against members of another group. Crash has a world pool of all-star actors and actress, who are all from different ethnic minorities, however they are all prejudiced in some way. Haggis tries to convey†¦show more content†¦Ã¢â‚¬Å"The character is wordy and didactic, yes, but not the film. He is also — as he proves when he and his partner carjack a young District Attorney (Brendan Fraser) and his wife (Sandra Bullock) â⠂¬â€ everything he despises white people for suspecting he is.† (Empire) Along his side is his friend Peter Waters who is played by Larenz Tate, they together begin to steal cars to make a living. Anthony is the dominant one of the two, since he is older. The film Crash fits into the categories of Drama, Indie, and Crime. Crash relates to the categories by including all the characters emotion and how they are individual lives are impacted. How crime is related in the film is by the carjacking, sexual assaults and as well as the shooting of Mr. Pena’s daughter. The film is not part of a classic. Crash is based on a real life experienced instead of a true story, â€Å"It originated in a dream that I had. I woke up in the middle of the night thinking about these two guys who 10 years before had jacked my car. I was really curious about who these two kids were.† (HUFFPOST) The film is unique to its categories, because it covers so many different story lines, and it forcers the viewer to look deep inside themselves and choose which side they would be on. The viewer can be in this situation at any given time, and it would be up to the viewers to say would I do this or would I act in a unique way to change my life and someone e lseShow MoreRelatedEssay On The Movie Crash1440 Words   |  6 PagesThe movie we saw was Crash. Ms H I have to tell you this I could’ve wrote a huge essay on how I enjoyed that movie. From that time the movie has taught and it hit me to when watching. We always need to watch our backs because the society we live in. It showed about racism. I have a real story for you Ms.H what just happened 2 months ago. My parents just went to Ohio; they went to my cousin’s house. My Dad is an open soul happy guy who likes to talk to everyone. 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