Carers' Corner

Caring Stroke Patients

Stroke can cause various degrees of brain damage that may lead to different levels of physical, cognitive and speech impairment. Such disability affects the daily living and selfcare of stroke patients. Applying the appropriate care is of utmost importance in helping the stroke patient to cope with these disabilities and to improve their quality of life.

Caring goals:

1. To help the patient to adapt to the disability and gain independence. 2. To maintain the body in optimum status to prevent complications. 3. To improve the patient's quality of life.
Points to Note when Caring for Stroke Patients:

1. Encouragement of self-care
Encourage patients to take responsibility of their personal hygiene such as combing and changing clothes according to their functional ability. Provide them with a wellventilated, warm and clean living environment.

2. Psychology of stroke patients

A warm, caring approach is important in helping stroke patients to cope with the tremendous changes and challenges ahead. Professional help should be sought if patients develop symptoms or signs of depression.

3. Nutritional care
A balanced diet using the principles of the food-guide pyramid should be offered to the patient in order to ensure adequate nutrition and to maintain ideal body weight. Easily digestible food is preferred.

4. Bowel and bladder care

Identify the causes of incontinence so as to provide specific management. For those using urinary catheters, the catheter should be properly fixed and changed whenever necessary. Check for any sign and symptom of urinary tract infection and seek medical advice when necessary.

5. Limb exercises
Performing mobilization exercises and maintaining a good posture help to maintain the range of joint movements and prevent contractures.

6. Communication
A patient with speech or comprehension difficulties may experience significant communication problems. Patience and appropriate encouragement helps the patient to communicate more effectively. The use of simple words, body language, real objects, and word cards may help the patient in overcoming his communication problems.

Prevention of complications

1. Pressure sore
Being bed-ridden together with reduced activity increase the risk of localized skin damage due to prolonged pressure. Prevention: o elieve localized pressure over the skin by turning every 2 hours and massaging. o Protect the skin by keeping it dry, clean and soft. o Perform regular exercises and improve nutritional status. 2. Chest infection Being bed-ridden and lacking in physical activities, stroke patients often have weakened body resistance and reduced ability in clearing secretions from their lungs. Hence, they are usually more prone to chest infections. Prevention: o Increase body resistance by performing exercise and eating a balanced diet. o Change body positions frequently, sit upright when eating, increase fluid intake and perform deep breathing exercises. 3. Choking Patients may have difficulties in swallowing after a stroke. Prepare food according to health professional's advice and closely observe the patients when they eat. Prevention: o Encourage patients to take in small amounts at a time and prepare food in small pieces for easy swallowing. o The following types of food should be avoided or to be taken with care Types of food Sticky Examples Peanut butter, mashed potatoes, melted cheese

Too hard Chewy or hard to control

Nuts Marsh mallow, caramel, chewing gum, peas

CHF Patients

Care Model The care model (Figure B) dominates when Nurses provide hands on care to congestive heart failure patients. Hands on care for patients produces an environment of comfort and trust and promotes open communication between nurses and patients. Open communication encourages expressions of thoughts and fears and decreases anxiety. Patients develop feelings of security and verbalize concerns of disease management, emotional, and/or social issues in relation to the lifestyle changes they are experiencing secondary to congestive heart failure (Touhy & Birnbach, 2001). Patient education and discharge planning begins in the care model. During this phase, nurses have the primary role of answering questions and address concerns in relation to disease process, disease management. Congestive heart failure patients needs are addressed as nurses and patients develop both interpersonal and professional working relationships (Touhy & Birnbach, 2001). Cure Model The cure model (Figure C) dominates when nurses perform physical assessments and care management plans for congestive heart failure patients. During this phase, nurses assess patients ability to perform activities of daily living based on physical changes that occur during walking, talking or bathing (Touhy & Birnbach, 2001). Nurses monitor patients fatigue level, respiratory status, blood pressure and oxygen saturation to determine patients tolerance level and need for supplemental oxygen. Lung sounds are osculated for diminished breath sounds or crackles for signs of fluid congestion. Congestive heart failure patients pulse strength, edema, and temperature are assessed to monitor circulation status secondary to decrease cardiac output and potential of pooling of fluid in the lower extremities (LeMone & Burke, 2004). Education to congestive heart failure patients is essential to increase their understanding of their disease process and to improve medication compliance. It is important that nurses review medications and stress the importance of compliance to medication schedules. Improved compliance can improve the quality of life for the congestive heart failure patient and result in decreased hospital readmissions (Coelho et al., 2005). Diet compliance also improves the status of congestive heart failure patients. Patients who understand their ordered diet understand the importance of compliance to prevent

weight gain due to fluid overload. Patients who recognize the symptoms that accompany their disease understand when to notify the physician of weight gain, increased shortness of breath, fatigue, or dizziness (LeMone & Burke, 2004). Core Model The core model (Figure D) of the framework dominates when nurses and patients are able to discuss emotional concerns and distress to physical and mental changes due to patients disease process. Patients address emotional concerns and distress due to their perceived ability or inability to manage their disease, living alone, and general fear of their disease process. These emotions and concerns effect compliance to the medical plan and quality of life (Touhy & Birnbach, 2001). An essential role of nurses in the healthcare plan is to assist with management of congestive heart failure patients by providing medical, physical, and social care. The framework of Lydia Hall is used in the following care plan to assist in meeting the personal, medical, and social needs of congestive heart failure patients (Touhy & Birnbach, 2001). Congestive Heart Failure Plan of Care Care: Problem 1: Potential for inability to care for self related to weakness and decreased mobility Intervention 1. Asses patients ability to bathe and dress self 2. Assist with activities of daily living as needed for personal care 3. Teach importance of rest when bathing and dressing Goal 1. Patient will have increased strength to bathe and dress self 2. Patient will have assistance as needed for personal care 3. Patient will verbalize and demonstrate the importance of rest when bathing and dressing

Problem 2: Potential for decreased social interaction secondary to fear, anxiety, and trust Intervention 1. 2. 3. 4. Goal 1. Patient will verbalize stress and anxiety issues and have decrease fear 2. Patient will feel comfort and support during care 3. Patient will communicate openly 4. Patient will verbalize strengths in ability to care for self Cure: Problem #1: Activity intolerance secondary to decrease cardiac output and weakness Intervention 1. 2. 3. 4. Goal 1. Pulse, blood pressure and respiratory rate with be within patients limit 2. Respiratory effort, oxygen saturation with be within patients normal limit 3. Patient rest during activity and verbalizes importance of rest Problem #2: Fluid volume excess secondary to decreased circulatory status/cardiac output Assess vital signs Monitor respiratory status Encourage rest periods during activity Assess need for oxygen and stress importance of compliance of oxygen use Identify cause(s) of stress/anxiety Provide comfort and support Encourage open communication Identify strengths

Intervention 1. Teach patient to monitor daily weight, pulse, edema and respiratory effort 2. Teach patient medication protocol and importance of medication compliance 3. Teach importance of diet compliance 4. Teach importance of notifying the physician of status change Goal 1. Patient will verbalize the importance of monitoring weight, pulse, edema, and respiratory effort 2. Patient will verbalize medication schedule and importance of compliance 3. Patient will verbalize importance of diet compliance 4. Patient will verbalize the importance of notifying the physician Core: Problem #1: Ineffective coping secondary to disease process Intervention 1. Assess patients image of body/health changes 2. Identify patients strengths in caring for self 3. Assess patients ability to care for self Goal 1. Patient will understand and begin to accept changes related to disease process 2. Patient will verbalize strengths and weakness 3. Patient will have care needed to promote optimal health Problem #2: Potential for non-compliance secondary to knowledge deficit and low self esteem

Intervention 1. Assess patients knowledge of disease process, treatment and medication schedule 2. Assess patients feelings of ability to care for self 3. Promote patients strengths and self esteem Goal 1. Patient will understand disease process, treatment and medication schedule 2. Patient will verbalize feeling of ability to care for self and assist in discharge planning of disease process 3. Patient will increased self esteem in ability to care for self and disease management (RN Central, 2005) Discharge Planning Discharge planning during the core phase provides patients with essential emotional support and serves to decrease anxiety and fear (Touhy & Brinbach, 2001). Social isolation and the fear of dying affect the survival of cardiac patients. Patients may not have access to quality care or support needed to manage their disease. During this phase, nurses can provide emotional support and assistance by arranging home health care that best suits the needs of patients when they are discharged to home (AsadiLari, Parkham, & Gray, 2003). Conclusion Nurses work with the medical team to assist in evaluating congestive heart failure patients understanding of symptoms of their disease, compliance to diet and medication regimens, and the importance of informed follow up with their physician or nurses. Nurses can promote trust and facilitate open communication with patients when providing hands on care (Touhy & Brinbach, 2001).

Glasgow Coma Scale

The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. To assess the degree of consciousness. The total score is the sum of the scores in three categories. For adults the scores are as follows:

Eye Opening Response

Spontaneous--open with blinking at baseline Opens to pain, not applied to face None Oriented Confused conversation, but able to answer questions

4 points

Opens to verbal command, speech, or shout 3 points 2 points 1 point 5 points 4 points

Verbal Response

Inappropriate responses, words discernible 3 points Incomprehensible speech None Obeys commands for movement Purposeful movement to painful stimulus Withdraws from pain Abnormal (spastic) flexion, decorticate posture Extensor (rigid) response, decerebrate posture None 2 points 1 point 6 points 5 points 4 points 3 points 2 points 1 point

Motor Response

For children under 5, the verbal response criteria are adjusted as follow
SCORE 2 to 5 YRS 0 TO 23 Mos. 5 Appropriate words or phrases Smiles or coos appropriately 4 Inappropriate words Cries and consolable 3 Persistent cries and/or screams Persistent inappropriate crying &/or screaming 2 Grunts Grunts or is agitated or restless 1 No response No response

How the Glasgow Coma Scale Works

Given that the GCS is based on a 15-point scale, patients "scores" are determined by assigning points to their various physical responses. Visual ability, verbal responsiveness and motor skills are all examined and evaluated in the GCS. Consult the table below for a breakdown of how the Glasgow Coma Scale's points are assigned.

Physical Points 1 Response Assigned l/ -> Visual Response Eyes remained closed. Silence.

Pain causes eyes Voices cause Eyes open to open. eyes to open. randomly.

N/A

N/A

Verbal Ability

Minimal, indistinguishable sounds. Pain causes extension movements.

Mumbles obscenities.

Incoherent rambling.

Normal conversation.

N/A

Motor Skills

Immobile.

Pain causes flexion movements.

Pain causes movement away from stimuli.

Complicated movement in response to pain.

Moves on command.

Because small children can suffer from loss of consciousness just as adults can, the Glasgow Coma Scale also includes an addendum to the verbal ability portion of the scale. This adjustment categorizes verbal responses according to the following point-scale:

y y y y y

1 point: Silence, unresponsive 2 points: Grunts 3 points: Incessant crying (For babies, crying will occur independent of unpleasant stimuli.) 4 points: Mumbles illogical words (Babies will cry appropriately and respond positively to consolation.) 5 points: Speaks appropriately (Babies will smile and chatter appropriately.) Keep in mind that, although the descriptions of what a "point" entails may be straightforward, it's not always easy for medical professionals to assess in which category patients fall. For example, swollen eyes due to head trauma may prevent doctors from evaluating visual responsiveness. Consequently, both doctors and nurses regularly use the Glasgow Coma Scale multiple times on individual patients to determine their evolving needs and changing conditions.