Cerebrovascular diseases are the fifth leading cause of death in Australia and one notable form

of cerebrovascular diseases is stroke which is 3rd leading cause of death and disability in
Australia (Australian Institute of Health and Welfare [AIHW] (2015). Stroke occurs due to
interruption of blood blow to the brain region either due to formation of blood clot in the
artery or break down of blood vessels. 80 % of the stroke are ischemic stroke which occurs due
to blockage of artery because of clot formation (Barrett & Meschia, 2013). In the given case
scenario, Mr. Kwon has blood clot in the brain which could be possible reason for left cerebral
vascular accident (CVA). So, this essay aims to analyse and interpret the assessment finding of
Mr. Kwon with reference and will provide care plan according to the interpretation and also,
focuses on discharge plan for Mr. Kwon.

Interpretation of Assessment Finding in Mr. Kwon

Diagnosis of cerebrovascular can be done thorough comprehensive history taking, physical

assessment and diagnostic investigation. In the given case Mr. Kwon is a chronic smoker and
has history of diabetes, hypertension and congestive heart failure which are the modifiable risk
factor of CVA. These factor leads to vascular changes in blood vessels leading to small vessels
occlusion (Chen et al.,2016). Additionally, increase in blood pressure and blood sugar level
leads to increase in oxidative stress and release of endothelial mediators which results in
endothelial injury and glycosylation of protein, leading to accumulation of advanced
glycosylation end products (AGE). AGE result in thrombus formation and contribute to emboli
(Mohr, 2011). Congestive heart failure (CHF)is associated with a two- to threefold increased
relative risk of ischemic stroke (Scherbakov et al., 2015). This contribute to decrease in ejection
fraction and also, increases risk of diabetes, arterial hypertension, and atrial fibrillation leading
to formation of cardioembolic stroke. On the other hand, CHF also cause to produce basal
crackles in lungs in stroke patient like Kwon (Sarkar, Madabhavi, Niranjan & Dogra, 2015).
Stroke is the sudden onset of neurological symptom and symptoms vary according to the part
of brain affected and artery involved. The warning signs of a strokes are face drooping,
weakness of one side of body, speech difficulties, unexplained dizziness, severe headache and
blurred vision (Stroke Foundation, 2019) Manifestation of clinical features are related to the
right and left-brain damage and also with specific cerebral artery involvement. Brain is central
part of nervous system which control overall body activities however, one side of the brain is
responsible to control opposite side of the brain due to which damage of left side of the brain
will manifest neurological complication to the right side of body such as weakness and
numbness of right side of body, weakness of facial muscle, problem seeing and swallowing in
right part (American Stroke Association, 2019).

Moreover, left hemisphere of the brain is dominant for language, and patient experience
difficulty in speaking and loss of comprehension due to brain damage in dominant hemisphere
(Brown et al.,2015). In contrast, stroke affecting middle cerebral artery exhibit contralateral
weakness or paralysis, aphasia and visual field loss on same side of both eye (homonymous
hemianopsia) (Howard, 2016). Homonymous hemianopsia arise due to vascular lesions of the
cerebral hemisphere so, it is expected to occur in Mr. Kwon. Despite of communication
problem, response of Mr. Kwon with head nodding during communication demonstrate absent
of bilateral hearing loss. Besides that, during brain imaging, non-contrast CT scan of infracted
middle cerebral artery(MCA) show hypodensity of parenchymal, local mass effect and hyper
density of (MCA) which is positive in CT scan report of Mr. Kwon and also support stroke due to
occlusion of blood supply in middle cerebral artery in given case scenario ( Muir & Santosh,
2005) .

During observation Mr. Kwon has blood pressure of 140 over 105 mm of Hg and systolic blood
pressure more than 140 mm of Hg and diastolic more than 90 mm of Hg is consider as
hypertension (Brown et al, 2015). The risk of stroke is directly proportional to the elevation of
high blood pressure and blockage of artery in stroke leads to increase in arterial pressure
resulting in high blood pressure in stroke patient like Kwon (Aiyagari & Gorelick, 2016).
Management plan

Management of patient following neurological impairment involve interdisciplinary team

member in order to organize care and tailored to the patients need. Multidisciplinary team
members for caring Mr. Kwon comprises, nurses, physiotherapist, physician, radiologist, speech
therapist, social workers and dietician (Brown et al.,2015). For the management of stroke,
patients care should be coordinate and integrated across multidisciplinary stroke team
members and care should be focused on patients’ preferences, needs and desires in ordered to
obtained better outcome (Redfern, Mckevitt, & Wolfe ,2006). This also include shared decision
making, physical comfort and emotional support of patients and family members.

While caring critically ill patient with stroke, the necessity of ethical principles in relation to
patient’s autonomy, nonmaleficence and beneficence is highly demanded for the professional
duty and common law and that mainly include informed consent, privacy and patient’s safety
(Rincon & Lee,2013). While, in certain cases stroke team may face ethical issues regarding truth
telling and non-maleficence due to uncertain outcome of stroke (Rincon & Lee, 2013). It is also
stated that after an acute stroke, patients are usually treated in an emergency or in intensive
care unit which required an appropriate consent process. Likewise, radiologist should ask
consent from the patient prior to brain imaging (CT, MRI) which is done to make definite
diagnosis of ischemic stroke (Mamo, 2014). Patient have legal right to make decision regarding
care and have right to get sufficient information about treatment process to make an informed
judgement and must be agreed for treatment. However, neurological deficit in stroke
jeopardize patient ability to give consent so, family members should be informed about
treatment process (Kedivar et al., 2017). While, in case of emergency and absence of family
members as like in case scenario, physician should proceed treatment on the basis of an
emergency consent or implied consent (Fisher & Schneider, 2014).

In the case scenario, Mr. Kwon is suffering from ischemic stroke and for the immediate
treatment of ischemic stroke, general practitioner should prescribe anti thrombolytic agent (r-
tPA) within 3-4 hours of onset of stroke and anticoagulants to dissolve clot after 24 hours of
thrombolysis therapy (Holt,2010). Because of few risks associated with thrombolytic therapy
and anticoagulant therapy discussion about risk and benefits of medicine should be done with
the patient and family members. Patient safety is multidimensional and grounded in ethical and
legal imperatives (Fisher & Schneider, 2014). Hence, for the safety of patient doctor and nurses
should focus on stabilization of the airway, breathing and circulation, followed by an
assessment of the neurological deficits and risk management (Hinkle & Cheever, 2015).

In case scenario, Mr. Kwon breathing should be stabilized by monitoring oxygen saturation and
maintaining at more than 95 % with oxygen therapy if necessary. Further, hyperglycemia is
considered risk for hemorrhagic transformation of infract so, endocrinologist should be
consulted to maintained blood glucose level (BGL) between 6-9mmol/L in Mr. Kwon and nurses
should monitor BGL every two hourly (Hinkle & Cheever, 2015). Whereas, elevated blood
pressure maintains cerebral perfusion in ischemic stroke and is not necessary to correct in case
of Mr. Kwon unless if more than 220mm of Hg over 130 mm of Hg. Similarly, cardiologist should
review Mr. Kwon for heart condition and to maintain blood pressure in optimum level.
Moreover, patient is likely to have dehydration and starvation because of dysphagia which is
very harmful in acute stroke so hydration should be maintained through fluid replacement
(Brown et al., 2015). This also justify non-maleficence principle by ensuing patient safety by
preventing injury and avoiding complication.

Stroke patient are at risk for multiple complication and their rehabilitations begins on the day patient
has a stroke. Thus, management should be focused on the prompt initiation of rehabilitation for any
impairment and required a multidisciplinary team effort (Donnellan, Martins, Conlon, Coughlan, O'Neill,
& Collins, 2013). It is imperative for stroke team to know general condition of patient, mental and
emotional state and activities of daily living. Stroke patient has physical, social and psychological
impairment so, involvement of patient and family members during care and decision making is essential
for self-care management and better outcome (Donnellan et al.,2013). The main goal of management
for patient and family members is to provide overall support and well-being of the patient which
include positioning, prevention of aspiration, nutritional support, pain management, maintenance of
bowel and bladder, communication, self-management and family coping (Gbinigie et al., 2016). Nurses
should change position of the patient in every two hours to avoid pressure sore and keep patient in
upright position during feeding to prevent aspiration and privacy should be consider in every
intervention (Mohr, 2011). Most stroke patient have swallowing difficulties so, after swallow review of
Mr. Kwon, dietician should adjust diet plan for nasogastric tube feeding to provide nutritional support
(Joice,2012).

Moreover, Patient like Mr.Kwon with one sided paralysis and homonymous hemianopsia usually neglect
the affected side thus, physiotherapist should constantly remind the other side of body and encouraged
to carry all the self-care activities such as, bathing, eating with the unaffected hand (left hand) and
nurses should place the things where patient can see (Holt,2010). This also helps to develop self-efficacy
in patient. To maintain effective communication, speech pathologist should provide augmentative and
alternative communication system for Mr. Kwon language comprehension and sign language can be
used in case of hearing impairment (Joice, 2012). On the other hand, patient family may have difficulty
in accepting patient’s disability so, for better family coping, family members should be encouraged to
participate in counselling and also, assurance should be given that their emotional support is part of
patient therapy (Brown et al.,2015).

Furthermore, patient centered approach of care also focuses on the risk management to
prevent stroke reoccurrence through health promotion and prevention. This include lifestyle
modification, patient and family education, risk factor detection and prevention of medical
complications (Chen, Ovbiagele & Feng, 2016). Patient and family members should be informed
about early identification of signs and symptoms of stroke and encouraged for habit of healthy
eating that is food rich in dietary fiber, low salt diet, cessation of smoking , reducing alcohol
consumption, regular exercise for weight loss and timely monitoring of blood glucose level,
blood pressure, regular intake of medication, regular follow up and healthy coping (Lemone,
Luxford & Fagan, 2011).
Discharge Planning

Effective discharge planning enables continuous transfer of care and promotes better outcome
for patient. Discharge planning process include early assessment and identification of patient
requiring assistance, stroke team members collaboration with patient and family to plan for
discharge, referring and recommending option for the continuity of care, coordinating with
community agencies and follow up service and providing encouragement and support to the
patient and family members (Lin et al., 2012). Discharge planning criteria is usually set at the
time of admission and each health profession review patient current condition and identifies
area of improvement (Dorocher et al., 2016).

To discharge Mr. Kwon multidisciplinary team member has set some milestones which needs to
be fulfilled. In order to fulfill those criteria in case of Mr. Kwon, medical officer and registered
nurses should assess and able to maintain patients vital sign, adequate perfusion, oxygen, blood
pressure and blood glucose level within normal range before discharge (Hinkle & Cheever,
2015). Likewise, it is crucial to cease intravenous infusion and assess the continence status of
patient which should be manageable at home environment with ongoing support and
assessment. For the unsteady gait of Mr. Kwon, physiotherapist should assess efficiency, speed,
ease of movement and activity of daily living and therapy should focus on regaining balance and
retraining gait with the use of treadmill training (Guy et al, 2004). Moreover, speech therapist
should develop adapted menus for dysphagia and communication tool for people involved in
caring Mr. Kwon (Legard et al., 2015). Further, to obtain specialized treatment of Homonymous
hemianopia in Mr. Kwon, ophthalmologist consultation should be done and ongoing
management for vision should be planned. Medical officer should. Further, to make definite
diagnosis and assess any changes in brain blood vessels radiologist should perform brain
imaging and should make appropriate referral to surgeon in case of failure to dissolve clot with
medical therapy.

Secondly, patient and their care givers should be encouraged to participate in decision making
and are provided with all information about patient condition in order to optimized health
outcomes (Reeves et al., 2017). Patient should be made aware about the common self-
management program before discharge from the hospital and should be supported to access
those programs once they return to home and specific program related to stroke should be
provided for patient who need more specialized programs for self-management at home
(National Stroke Foundation, 2011).

Stroke can be particularly challenging because of long term adjustment with social inactivity
thus, lifelong involvement social workers is needed to assist in the process of disability by
assisting patient with personal care, providing emotional support with counselling, encouraging
for lifestyle modification (Padberg et al., 2016). Social workers also coordinate with stroke
liaison workers to help Mr. Kwon to function at optimum levels after he return to home.

Conclusion

CVA is a complex disease with several impairment on the patient’s overall condition and require
multidisciplinary team members to obtain better outcome. Care of stroke patient includes
various ethical situation however, it is crucial to involve ethical, legal and patient centered
approach while providing care. In order to minimize reoccurrence of stroke, health promotion
and prevention strategy should be informed to patient and family members and
multidisciplinary team members should make clinically appropriate discharge planning.
 Reference

Australian Institute of Health and Welfare. (AIHW). (2015). Cardiovascular diseases. Canberra: AIHW.
Retrieved from https://www.aihw.gov.au/getmedia/a43dd111-1304-4abf-9946-
b8513a57981b/phe195-cerebrovascular.pdf.aspx

Aiyagari, V., & Gorelick, P. (2016). Hypertension and Stroke Pathophysiology and Management (2nd
ed., Clinical Hypertension and Vascular Diseases).

American Stroke Association. (2019). Effects of stroke. Retrieved from

https://www.stroke.org/en/about-stroke/effects-of-stroke

Barrett, K., & Meschua, J. (2013). Stroke (Neurology in practice). Wiley-Blackwell: Chichester, West
Sussex.

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2015). Lewis’s Medical-Surgical Nursing: Assessment
and Management of Clinical Problems. Elsevier Health Sciences.

Chen, R., Ovbiagele, B., & Feng, W. (2016). Diabetes and Stroke: Epidemiology, Pathophysiology,
Pharmaceuticals and Outcomes. The American journal of the medical sciences, 351(4), 380–386.
doi:10.1016/j.amjms.2016.01.011

Lin, C., Cheng, S., Shih, S., Chu, C., & Tjung, J. (2012). Discharge Planning. International Journal of
Gerontology, 6(4), 237-240. DOI 10.1016/j.ijge.2012.05.001

Donnellan, C., Martins, A., Conlon, A., Coughlan, T., O'Neill, D., & Collins, D. R. (2013).
Mapping patients' experiences after stroke onto a patient-focused intervention
framework. Disability and Rehabilitation, 35(6), 483-491. Retrieved from https://doi-
org.ezproxy.une.edu.au/10.3109/09638288.2012.702844

Durocher, E., Gibson, B., & Rappolt, S. (2017). Rehabilitation as "destination triage": A critical
examination of discharge planning. Disability and Rehabilitation, 39(13), 1271-1278. Retrieved
from https://doi-org.ezproxy.une.edu.au/10.1080/09638288.2016.1193232

Fisher, M & Schneider, P. (2014). Stroke and law. Stroke, 41, 3141 – 3146. Retrieved from
https://doi.org/10.1161/STROKEAHA.114.002864

Gbinigie, I., Reckless, I. P., & Buchan, A. M. (2016). Stroke: Management and Prevention. Medicine
(United Kingdom), 44(9),521-529. Retrieved From
https://doi.org: 10.1016/j.mpmed.2016.06
Guy, S., Clarke, L., Bryant, H., Robinson, G., Stewart, T., Segaran, E., & Ross, M. (2004). An
interdisciplinary team approach to acute stroke rehabilitation. Acute Stroke Rehabilitation.
Taylor & Francis: London.

Holt, R. (2010). Cerebrovascular Disease. In Textbook of Diabetes (pp. 698-709). Oxford, UK: Wiley‐
Blackwell.

Howard, S. R. (2016). The management of ischemic stroke. Anaesthesia and Neurointensive Care
Medicine, 17(12), 591-595.

Hinkle, J. L., & Cheever, K.H. (2015). Brunner & Suddarth’s Textbook of Medical Surgical Nursing (vol-2).
Lippincott Williams & Wilkins.

Joice, S. (2012). Self-management following stroke. Nursing Standard, 26(22), 39-46.

Retrieved
from:http://search.proquest.com.ezproxy.une.edu.au/docview/920390442?accountid=
17227

Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal
aspects of patient's safety: a clinical case report. Journal of medical ethics and history of
medicine, 10, 15. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150915/

Legrand, J., Pascal, M., Chauvy, A., Wallart, L., Pollez, B., Hamon, V., & Briere, D. (2015). Partners of the
speech therapist in management of swallowing disorders; establishment of an interdisciplinary
project. Annals of Physical and Rehabilitation Medicine, 58, E3. Retrieved from
https://doi.org/10.1016/j.rehab.2015.07.013

LeMone, P., Luxford, Y., & Fagan, A. (2011). Medical-surgical nursing: Critical thinking in client care (1st
Australian ed.). Frenchs Forest, N.S.W.: Pearson Australia.

Mohr, J. (2011). Stroke pathophysiology, diagnosis, and management (5th ed.). Philadelphia:
Elsevier/Saunders.

Mamo J. P. (2014). Issues with Consent in Stroke Patients. The West Indian medical journal, 63(5), 510–
513. doi:10.7727/wimj.2013.134

Muir, K.W., & Santosh C. (2005). Imaging of acute stroke and transient ischemic attack
Journal of Neurology, 76,19-28. Retrieved from https://jnnp.bmj.com/content/76/suppl_3/iii19.info

National Stroke Foundation. (2011). Clinical guidelines for stroke management. Stroke Foundation.
Retrieved from
 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&ved=2ahUKEwi-
6t79w8PkAhW_6nMBHdNYB3EQFjAIegQIBBAC&url=https%3A%2F%2Fstrokefoundation.or
g.au%2F-
%2Fmedia%2F27E4DDB3AEA74FA58C409F462A0BF9E8.ashx%3Fla%3Den&usg=AOvVaw10
_dRdjssLiGmG1b2Z1lE0

Padberg, I., Knispel, P., Zollner, S., Sieveking, M., Schneider, A., Steinbrink, J., . . . Meisel, A. (2016).
Social work after stroke: Identifying demand for support by recording stroke patients and carers
needs in different phases after stroke. BMC Neurology, 16(1), 111.
DOI:10.1186/s12883-016-0626-z

Redfern, J., Mckevitt, C., & Wolfe, C. (2006). Risk management after stroke: The limits of a patient-
centred approach. Health, Risk & Society, 8(2), 123-141. Retrieved from
https://doi.org/10.1080/13698570600677266

Rincon, F., & Lee, K. (2015). Ethical Considerations in Consenting Critically Ill Patients for Bedside
Clinical Care and Research. Journal of Intensive Care Medicine, 30(3), 141-150. Retrieved from
https://doi-org.ezproxy.une.edu.au/10.1177/0885066613503279

Reeves, M. J., Hughes, A. K., Woodward, A. T., Freddolino, P. P., Coursaris, C. K., Swierenga, S. J., …
Fritz, M. C. (2017). Improving transitions in acute stroke patients discharged to home: the
Michigan stroke transitions trial (MISTT) protocol. BMC neurology, 17(1), 115.
doi:10.1186/s12883-017-0895-1

Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015). Auscultation of the respiratory
system. Annals of thoracic medicine, 10(3), 158–168. doi:10.4103/1817-1737.160831

Scherbakov, N., Haeusler, K., & Doehner, W. (2015). Ischemic stroke and heart failure: Facts and
numbers. ESC Heart Failure, 2(1), 1-4. https://doi.org/10.1002/ehf2.12026

Stroke Foundation. (2019). Stroke symptoms. Retrieved from https://strokefoundation.org.au/About-

Stroke/Stroke-symptoms