Research Paper

Care Plan Template
Patient Name:
Date of Birth
Assessment Nursing Diagnosis/Problem (remember ‘PES’) Goal ( SMART) Interventions with rational ( what actions will be required to address the identified problem)

Evaluation

CASE SCENERIO
Sylvester Charles
Mr Sylvester Charles is a 58 year old gentleman who lives with his wife Susie in a bungalow on the outskirts of a busy costal town. They have one daughter who lives 20 miles away with her family, they are very close and she phones her parents every evening and visits them twice a week. Up until 3 months ago he was a Senior Manager of a well-known insurance company but he was becoming increasingly stressed due changes in the company that may have resulted in him being made redundant. He therefore took early retirement so he could enjoy a better quality of life with his Susie, who works as a nurse part-time at the local district hospital. Sylvester was determined to be more physically active in his retirement by tending to his garden, which had been neglected recently and was planning on playing golf more frequently. Sylvester has a history of hypertension, diabetes type 2 and hypercholesterolemia. He gave up smoking 12 months ago.
One morning, Susie found Sylvester collapsed in the garden, he was mumbling incoherently, unable to move the right side of his body and had vomited. She realised he had experienced a stroke and quickly called 999 and he was taken to hospital. Sylvester was diagnosed with an left sided ischaemic stroke and given rTPA in the ED and admitted to the stroke unit.
6 weeks later, Sylvester is at home, having made a good recovery from the left sided ischaemic stroke. He is experiencing some degree of Anomia and Aphasia, but can make himself understood. He is self-caring, but still has some residual weakness in the right side of his body which makes his mobility challenging at times. Susie has taken time off work to be at home with him. As the weeks have progressed, she has noticed that he is becoming intermittently confused with a poor attention span, and he does not interact with her as well as he used to. He has no interest in his garden or meeting with friends and family. In addition, he is not sleeping very well at night which means he spends the daytime dozing in his chair. Susie has talked to him to try and find out what is wrong as they were a very close couple, however he tells her “there is nothing wrong”. She thinks that he may be depressed in addition to his intermittent confusion and she is very concerned about him. Susie thought that when he was discharged and at home things would continue to progress positively and she is becoming more upset by the current situation.
Medications:
Clopidigrel 75mg od
Atorvastatin 40mg nocte
Ramipril 5mgs od
Metformin 500mg bd
Aspirin 75mg od
Omeprazole 20mg od
You have been asked to review Mr Charles at home by the GP and will be required to carry out an assessment using an appropriate framework and formulate a care plan identifying your prioritised choice of 2 nursing problems.
THE TWO AGGREED CHOSEN NURSING PROBLEMS USING THE NANDA’S DIAGNOSIS
1. Acute impaired physical mobility related to the inability to move the right side of his body as evidenced by left-sided ischaemic stroke with difficulty in walking.
2. Verbal communication impairment related to anomia and aphasia as evidenced by Intermitted confusion, poor attention span, poor interaction and lack of interest for garden activities
3. The Nursing Care plan must be written again especially the Assessment process, as the full ADLs (12 process) has to be explained individually in the assessment section. Please I have attached a copy of how the care plan should be done in the file.

Learning Outcomes
On completion of this module the successful student will be able to:
1. Demonstrate the use of the nursing process to prioritise the needs of the patient with complex care needs
2. Critically appraise the decision making process, utilising problem solving skills and formulating an appropriate plan of care for the patient with complex care needs
3. Articulate significant clinical judgement in a variety of care settings
4. Demonstrate an appreciation of the complexities of advanced practice.
ASSESMENT TYPE
A 2500 word case study analysis essay that will assess the student’s ability to conduct a comprehensive assessment of a patient with complex care needs and include critical analysis of the nursing care. In addition you will need to formulate a nursing care plan that identifies and prioritises 2 nursing problems – this must be attached as an appendix to the essay when submitted.
Assessment structure, format and detail
The student will choose one scenario on which to base their assignment. The assessment has two interrelated parts:
Essay: The essay must clearly demonstrate critical analysis of the nursing care you have decided to implement for the chosen scenario. It must have a clear introduction stating the aims of case study essay, what will be discussed and how it will conclude, which must be followed through in the work. It must discuss in a succinct manner critical appraisal of the assessment framework (ACTIVITIES OF DAILY LIVING; ADL’s by Roper-Logan-Tierney Model ) used and how this informed your decision-making in the planning of the care underpinning this discussion with relevant literature and clinical guidelines. Critical appraisal of decision making in patient care will include the use of appropriate assessment tools e.g. Waterlow score, NEWS2, VIP score, nutritional and anxiety measurement tools. These will combine important subjective and objective data to produce an accurate picture of the patient’s complex care needs. This must be integrated throughout the essay.
The discussion will need to critically analyse the cause of the two identified nursing problems and factors that influence the care planned for the patient. The essay content must be underpinned with a rationale appropriate for Level 6 study for the nursing care/interventions; show application of relevant pathophysiology and include application of relevant pharmacological/non-pharmacological interventions. Discussions must be underpinned with and show critical appraisal of relevant and up-to-date supporting literature/evidence/clinical guidelines to show knowledge and understanding from the taught module content and application to practice.
Where relevant a concise discussion of the roles of any MDT members that would be involved should be included. The conclusion of the essay must address an evaluation of the nursing care to show an appreciation of the need to evaluate nursing care. It will need to debate achievement/non-achievement of the nursing goals and the evidence to support this. Safe care must be shown throughout the essay content.
Care plan: The student will need to formulate a nursing care plan utilising the template provided for the module, which will demonstrate all stages of the nursing process (assessment, diagnosis, plan, implementation and evaluation). It is up to the student to decide and rationalise the choice of assessment framework and for this to be explicit in the assessment section of the care plan. The care plan must identify in order of priority, what you consider to be the two most important actual nursing problems, goals, interventions and evaluation. The nursing problems must be distinct from each other e.g. in the case of a breathless patient you cannot identify “acute shortness of breath” and “acute cough” as these are both related to the respiratory system and as such will mean that you will end up producing a nursing care plan that will contain repetitive nursing interventions.
The nursing problems should be stated in a recognised format of PES (problem, aetiology and symptoms) e.g. “Acute lower abdominal pain related to difficulty in passing urine as evidenced by……..
Goals must be SMART, the nursing interventions, rationale and evaluation must be in context with the patient environment e.g. primary or secondary care. The nursing care plan should not be a reproduction of the essay; it should contain key information only. The care plan in landscape format must be submitted as an appendix and should be referred to throughout the essay discussion.

Student’s Name
Professor’s Name
Course
Date
Complex Care
Abstract
Ischemic stroke refers to a dangerous injury in the brain that results in a high rate of mortality and often causes the loss of functionality. The understanding of the pathophysiology of the ischemic stroke risk, the loss of function as well as the rate and probability of mortality is very important, especially when it comes to developing of new therapy plans. Factors, such as the sex of a person as well as the age can also contribute to the risk of stroke as both have an interactive and complex effect on pathophysiology as well as the risk of ischemic stroke. Age causes modification in terms of the influence of ischemic stroke when it comes to an individual’s sex such that men tend to have ischemic strokes while younger. However, the risk of this kind of stroke seems to be high in older women. Other factors, such as smoking and lack of physical activities as well as diseases that include hypertension, diabetes, and even hyperchloroestronomia also contribute to the risk of ischemic stroke.
Introduction
The case study in this paper centres on Sylvester, a patient who suffers from an ischemic stroke and anomic aphasia. He, however, has several other medical problems that might have caused his condition. Looking at his last working environment from the job that he just resigned to his medical history, a few things can be deduced to have caused his terrible condition. The goal of this case study is to find out what led to the stroke and anomic aphasia in the fast place, and find out the right proper intervention to deal with his case. The discussion in this case study will be focused on the factors that caused the stroke, his medical history and the previous medical interventions that he had been exposed to, the proper medication that will cater for his medical condition without having severe side effects and the proper nursing plan to track and help in his recovery. In the conclusion of the case study there will be a recommendation for a new drug or different nursing care plan to track his recovery in case the one being implemented does not work just fine. This case study will be based on the ADL model by Roper-Logan-Tierney to monitor the recovery progress of the patient as well as the medical administration to the patient. Since the recovery of Sylvester will take place at home, the nurse will be there to help with his recovery as well as to track his medical.
Literature review
Sylvester’s case was reported to the doctors by his wife, who had found him collapsed in the garden. She also observed that he had difficulty moving his right side of the body and had vomited as well. Being a nurse, she realised that her husband was experiencing a stroke and immediately called 911(American Stroke Association) via the F.A.S.T. guideline. He was taken to the Emergency Department, where he was given an r-TPA (Bivard). This is an enzyme, which helps in dissolving of the clots in the blood, which causes strokes in the first place, and as a result, its recommended for patients with strokes and heart attack.
However, when he was discharged six weeks later, his wife observed that he had lost interest in tending to the garden, he experienced anomia, which caused him to forget information and aphasia, which made his speech quite difficult, he also had a sense of confusion all these together with the need to isolate as he lacks interest in meeting up with friends and family, he also talked to her differently from the one he used to, all these are psychosocial change in behaviour (Stroke). He also experienced a lack of sleep and would, therefore, dose throughout the day. A patient recovering from ischemic stroke also exhibited signs, such as emotional distress and that is why when Sylvester is asked with his wife what is wrong, he says, “there is nothing wrong“ ,even though his wife could see that something is.
During the medical examination, it was found that Sylvester has diabetes. According to McGlinchey and Rudolph (2011) diabetes increases the occurrence of a stroke as it causes functional and structural change thereby increasing the chances of a stroke. Per the American Heart Association (AHA), it was found that 16 per cent of all the patients, who have diabetes died from a stroke. Diabetes is one of the risk factors that cause ischemic stroke (Boris). Since diabetes is a disease that is associated with lifestyle, most patients, who have it, often have other additional factors that can cause stroke, such as dyslipidemia, obesity, and even high blood pressure (Dutton and Lewis). According to the American Diabetes Association, a person with diabetes has 1.5 higher chances of having a stroke. This is because the frequent changes in the level of sugar in the blood can affect the cardiovascular system.
According to the Center for Disease Control and Protection, adults who are above the age of 55 years (Sylvester was 58 y.o.) are at a higher risk of getting stroke, since the chances of stroke doubles every ten years after that age. Age and sex are also intertwined when it comes to the risk factor of having an ischemic stroke, since they influence it pathophysiologically, treatment efficiency and even epidemiology. Men tend to have a higher risk of getting ischemic stroke all through most of their life. One clinical study came up with a finding that minocycline which inhibits the death of cells was found to improve outcomes in terms of functionality (Nazarbaghi and Rezaei). This, therefore, shows that it is important to put a patient’s sex into consideration (McCullough and Li).
According to the information provided, Sylvester had been a smoker until the last twelve months, where he stopped. According to PubMed (1988), smoking was found to be one of the biggest risks of stroke. Stroke (2008) indicates that for those, who are smoking, the risk of stroke continues throughout their life. Cigarette smoking is found to increase the rate of the heart, the developing of atherosclerosis blood pressure and even cessation, all of which have been found to have a slight decrease after the first year when someone quits smoking (Bonita and Wolf). Even though Sylvester had stopped smoking twelve months ago, he was still at risk of stroke because of past smoking. In a certain analysis of 32 cases studied, smoking was found to contribute to 50% of stroke cases (Beevers and Shinton).
During the medical examination, it was also discovered that the patient has a medical history of hypertension, which, according to research, was found to increase the risk of ischemic stroke. Research has found that there is a very strong relation between hypertension for both the male and female gender at every age. However, within the mid-life span of a person’s life, hypertension increases the risk of getting a stroke by 1.9 times in women and 1.7 times in men (Vasan et al.)
During the medical examination, the patient was found to have hypercholesterolemia, which is the accumulation of cholesterol in the fatty deposits in the arteries. This causes the arteries to become narrow or sometimes even blocked thereby stopping or sometimes slowing the flow of the blood to the vital organs in the body, especially the brain and the heart. This disease is associated with atherosclerosis, which when it blocks the blood supply to the brain, might lead to a stroke.
According to Sylvester’s case study, up until three months ago he had been a senior manager at his place of work but had to resign early due to stress. According to research Psychosom Med 2007, job stress, depression, and marital strain are associated with stroke, heart disease, and even mortality. Depression is linked to health behaviours that are not healthy, such as a change in diet, inactivity and even an increase in smoking. When one gets to the mid-life age, this behaviour tends to expose on to a high risk of stroke. Looking at Sylvester’s case, his job exposed him to a very high level of psychosocial stress due to the many changes in the management. The risk of a stroke for someone experiencing psychosocial stress increases with the presence of diabetes 2, depression and dietary score (Lancet). According to large individual-participant of research, it was found that strain that comes from an occupational job and the chances of stroke were found to have a 20% increase in the risk of ischemia stroke (Stroke 2015). He was not taking care of his physical health as is stated that he wanted to play golf more and tend to the garden. The lack of physical health is also a major contributor to strokes.
Management and outcome
According to ADL’s by Roper-Logan-Tierney model (1991) Sylvester’s daily activities were monitored to assess his care all through the period that he is still recovering. This model is used to assess how patients’ life changes due to an illness. It supports interventions that lead to independence for that patient. According to Sylvester’s wife Sussie, he has been taking good care of himself. He had been taking Atorvastatin 40mg, which is found to be effective in preventing the recurrence of stroke (Moye and Rutherford). He had also been taking Asprin 75mg bd, which was found to reduce the rate of mortality in patients with ischemic stroke Am J Med 2000. Stroke Associated Pneumonia (SAP) refers to the infection in the pulmonary parenchyma, which leads to inflammation (Chin J 2010) Asprin 75mg bd was administered to prevent the infection of this disease as its results were fatal. Upon his return home and the weeks that followed, he made a good recovery with his left side of the body. The level of anomia and aphasia was to a low extend and as such he could still be understood.
According to the NEWS2 model, Sussie observed that the health of Sylvester was deteriorating. This model is used to detect the early signs of deterioration in patients, who are in recovery. As the weeks passed by, Sussie observed that Sylvester had become more confused and his attention span was getting poorer by the day. Sylvester also tended to isolate himself and as a result, he neither wanted to meet up with friends nor family. His sleeping habits had also become very poor such that he barely had any sleep during the night and would, therefore, spend his day dozing. This is a sign of deterioration in his health and a result that she is upset because she thought that he would be getting better. This suggests a higher risk of a recurrence of a stroke and as the chances are extremely increased Ramipril 5mg od is administered, as it is used to lower the blood pressure and preventing atherosclerosis occurrences as examined in his medical history.
The pathophysiology of stroke is a complex process that involves inflammation of pathways, ionic imbalance, neuroprotection as well as excitotoxicity mechanisms.ischemic stroke is oftentimes initiated by the death of neuron death. Therapeutic interventions are however divided with two major goals; to restore cerebral flow and to reduce the amnesia effects of ischemia on neurons. The administration of rTPA remains to be one of the most effective ways of dealing with stroke. However, it’s effectiveness is limited by the short window period that the drug should be administered in. his psychomotor ineffectiveness, anomic aphasia confusion, and poor attention span are all due to the death of brain cells and according to the VIP score, there is no definite plan for total recovery but intervention can lead to manageable effects.
Emotions refer to reactionary prototypical states which can be either negative or positive. In Sylvester’s case, the emotions are negative as he is no defence over what he is feeling. He may also be in isolation because he is either angry or experiences fear at meeting the people that knew him before he was sick (Russell and Barrett). Research has found an association between depression and high level to selenium exposure (Colangelo et al.), low levels of vitamin D (Polak et al.), as well as the consumption of whole foods (Akbaraly et al.).
Following his early examined medical history, Sylvester was found to have diabetes 2. To contain this disease during his recovery of the stroke, Metformin 500mg bd is administered as it is found to contain insulin (Maric). The mortality rate due to cardiovascular occurrences as well as diabetes was greatly reduced (Scarpello). According to Water’s low score, this exposed him to his risk of the reoccurrence of a stroke and as such the interventions had to be implemented.
In conclusion, the full recovery of ischemic stroke in patients is possible. However, there are mild effects that may still be experienced by the patient in terms of mobility and other motor functions, such as slight tremors in the hand, a limb in their walk especially on the side that was affected by the stroke and also mild amnesia. In the recovery of such patients, the patient is a key because it takes a long time for the full recovery to happen. In Sylvester’s case, even though his wife is a nurse, a different nurse should take care of his assessment and recovery because the emotional attachment of Sussie to her husband is leading to her being upset and this may end up in negative emotions, such as anger, aggression or even bitterness at the unreciprocated love and thus translate to the kind of care that Sylvester will receive. This may harm him especially when it starts causing his stress, a sense of helplessness or even distress and thus, lead to further deterioration of his health.

Care Plan
Patient Name: Charles
Date of Birth
Assessment Nursing Diagnosis/Problem Goal Interventions with rational ( what actions will
be required to address the identified problem)
Breathing

Maintaining a safe environment

Communication

Eating

Elimination

Washing

Dressing

Controlling

Mobilization

Work

Playing

Expressing

Sexuality

Sleep

Death and dying

No difficulty in breathing

Inability to maintain a safe as is seen by how emotionally exhausting he is to his wife environment
Inability to communicate well due to speech problem
Inability to communicate well due to anomia
Inability to eat well due to the paralysis on his right side of the body.

Proper elimination

Inability to wash due to paralysis caused by a stroke to the left side of the brain

Inability to dress due to paralysis caused by a stroke to the left side of the brain

Inability to exercise control due to lack of movement in the right part of the body caused stroke to the left side of the brain

Difficulty in mobilization due to paralysis caused by a stroke to the left side of the brain

Difficulty in working due to paralysis caused by stroke

Difficulty in working due to anomia and aphasia caused by a stroke to the left brain

Difficulty in playing to paralysis on the right side of the body caused by a stroke to the left brain

The inability to express himself due to aphasia caused by an ischemic stroke
Inability to express himself due to anomia caused by a stroke to the left brain.

Difficulty in sexual activities due to immobilization in the right side of the body caused by a stroke to the left side of the brain
Difficulty in sleep caused by hormonal imbalance and depression

The possible occurrence of death caused by the deteriorating health caused by the presence of residual effects of stroke such as depression, anomia, aphasia, and confusion

Emotional stabilization

Ability to learn how to communicate

Mobility function to enable patients to move about.

Help the patient gain mobility function on their right side of the body

Patient to be helped gain back control of their body

Mobility in the right side of the patient’s body
Mobility in the patient’s body to enable the patient to work

Help with cognitive to
development and memory to the patient

Help in motor skills to enable movement

Help the patient learn how to talk
Help the patient overcome amnesia

Help in boosting patient’s sexual appetite and erection

Increase the ability of the patient to fall asleep
Reduce the possible occurrence of death and recurrence of a stroke.

Emotional therapy to help him deal with trauma
caused by the stroke
Antidepressants to help him deal with depression
Speech and language therapy should be provided to help him learn how to pronounce words and improve slurred speech.

The use of pictures to help him remember things

Motor rehabilitation to help the patient learn how
to eat on their own

intervention is not needed.

Motor rehabilitation is used to help patients
learn how to how to perform basic motor
skills

motor rehabilitation should be applied to enable
the patient learn how to dress themselves

Physical therapy is advised to enable the patient
to gain back control of their body

Physical therapy and motor rehabilitation to be
given to the patient to enable them to gain back
their motor function

Physical therapy and motor rehabilitation to
enhance movement that will allow for work

Psychological therapy to help jog the memory
of the patient

motor rehabilitation to enable the patient to move
the body enough so they can learn to play games
within their motor range

speech and language therapy to help the patient
pronounce words properly.
Use of pictures to enable the patient to remember
things

Physical therapy to help them find their mobility
in their sexual organs. The use of Viagra and other medications that cause a boost in their sexual arousal.

Use of sleeping pills to help with sleep

The use of aspirin to minimize the occurrence of
another stroke, and reduce the escalation of the
effects being experienced.

Evaluation
Following the care plan provided according to the ADL’s framework, the patient is likely to recover without any
complication as long as the nurses observe this plan strictly and the risk for occurrence is lowered.

References

Bivard, Andrew, Longting Lin, and Mark W. Parsons. Review of stroke thrombolytics. Journal of stroke, 15.2 (2013): 90.
Fussman, Chris, et al. Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey. Stroke, 41.7 (2010): 1501-1507.
Gepner, Adam D., et al. Longitudinal effects of a decade of aging on carotid artery stiffness: the multiethnic study of atherosclerosis. Stroke, 45.1 (2014): 48-53.
Grundy, Scott M. National cholesterol education program: second report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel II). Circulation, 89.3 (1994): 1329-1443.
Leritz, Elizabeth C., et al. Cardiovascular disease risk factors and cognition in the elderly. Current cardiovascular risk reports, 5.5 (2011): 407.
Marić, Andreja. Metformin-more than gold standard in the treatment of type 2 diabetes mellitus. Diabetologia Croatica, 39.3 (2010).
Russell, James A., and Lisa Feldman Barrett. Core affects, prototypical emotional episodes, and other things called emotion: dissecting the elephant. Journal of personality and social psychology, 76.5 (1999): 805.
Scarpello, John HB, and Harry CS Howlett. Metformin therapy and clinical uses. Diabetes and Vascular Disease Research, 5.3 (2008): 157-167.
Sui, Rubo, and Lei Zhang. Risk factors of stroke-associated pneumonia in Chinese patients. Neurological research, 33.5 (2011): 508-513.
Vasan, Ramachandran S., et al. Antecedent blood pressure and risk of cardiovascular disease: the Framingham Heart Study. Circulation, 105.1 (2002): 48-53.
Wolf, Philip A., et al. Cigarette smoking as a risk factor for stroke: the Framingham Study. Jama, 259.7 (1988): 1025-1029.