ABSTRACT

By 2020, due to longer life spans and aging baby boomers, the number of Malaysian aged 65 and older will more than double to 5 million, comprising roughly 20% of the Malaysian population. Currently, 80% of older Malaysian is living with at least one chronic condition, and 50% have at least two. Stroke has been included as one of chronic illness that has to be concerned by nation. With these facts, the continual rise of several chronic diseases, it is important to consider the prevention program and the intensive geriatric centre research for the elderly so as the stroke wouldnt be the number one of the killer illness.

By the way, this was a case study which I had assigned to do some researches about stroke and practically had to option one patient and did the several diagnoses and also helped the staff in establishing the nursing care and rehabilitation to the patient. Typically this case study can be divided into two main parts which was the first part regarding to the stroke itself and the second part thoroughly touch about the history of patient, nursing diagnosis and not left behind the treatment and the rehabilitation care.

An elderly who I had took into my observation and nursing careness was Mrs Mariam @ JaimahbtAwang who had alleged fall after unsteady gait then had slurred speech and facial asymmetry. She looked so fatigue and unable to ambulate by herself when entered the ward. Previously she didnt had any pre-stroke or TIA but as diagnosed by physician she had a history of HPT and DM.

GENERAL INTRODUCTION OF PATIENT

Mrs Mariam @JaimahbtAwang was the one of my patient during my practical visit at Hospital Melaka. It is hard to know what goes on in Mrs Mariam mind as she lies awake, immobilized in an adjustable hospital bed, her eyes staring blankly at the closed window shutters.She worked as food seller at PekanJasin with her beloved husband. Typically Mrs Mariam can be viewed as average sized of Malay woman who had been attacked of acute ischemic stroke. Frankly speaking, when she was referred to this ward from Hospital Jasin, she looked so exhausted and tiresome. She never gave some words replies when I asked her a question. It could be because she didnt want to interact with those people who were unrecognized by her memory. As gerontologist care taker, I tried my best to seize her attention by stimulating her with certain topic that she understood and had an interest on it. After went through the ADL with her along the time she was in the ward, she started to believe me and initially conversed to reply my request on certain fact that I tried to probe about her history. Actually as the other stroke patients, she was underlying under the depression mode and didnt want to do ADL by herself. She tended to let her husband or her daughter to complete her wearing, showing, eating and many more. By the way, she had a very caring husband and children as well. They frequently accompanying Mr Mariam along her journey to fight the illness that she faced. I always tender my assistance to her family by giving the support and the home-careness learning so as they could manage the situation when she ready to go home.Her husband is up by nine every morning to prepare breakfast and medication for his wife. He keeps his bedridden wife free from bedsores and her bedroom odour-free by changing her diapers three to five times a day, and giving her a sponge bath every morning. For meals, the devoted husband sometimes gives his wife bite sizes of her favourite noodles. To show of her caring, her husband said to me that my wife loves noodles before but now she has difficulty in swallowing and having falling in appetite. I will cut the noodles into small pieces, and feed her a little at a time. I hope she will recover soon. Good luck for them. As gerontologist care taker, I hope Mrs Mariam will initiate to learn and gradually get back what she loses now.

DEFINITION OF STROKE

Stroke is very terrible illness that we have to bear in our mind. In order to describe more about patient careness, I would brief about the stroke first so as the respective explanation about patient can be more convincing and agreeing the medical facts about the stroke.

In accordance to World Health Organization (WHO), stroke defined as neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours. A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a haemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

THE TYPE OF STROKE

There are two major types of strokes: ischemic stroke and hemorrhagic stroke, and variations within both. A third type of stroke, called a transient ischemic attack, or TIA, is a minor stroke that serves as a warning sign that a more severe stroke may occur.

Ischemic Stroke The most common type of stroke is known as an ischemic stroke. Nearly nine out of 10 strokes fall into this category. Ischemic strokes making up about 83 % of all strokes. An ischemic stroke occurs when a blood vessel becomes blocked, usually by a blood clot. Clots can form when blood vessels become clogged with fat and cholesterol, a condition known as atherosclerosis. In an ischemic stroke, blood can't reach the brain, and brain cells suffer from the lack of nutrients and oxygen that they would normally get. There are actually two different types of ischemic stroke, depending on where the clots form. Clots that form inside a blocked blood vessel in the brain cause a thrombotic stroke. Embolic strokes result from clots that form elsewhere in the body and travel toward the brain until they become lodged in a narrow artery, causing a blockage. Ischemic stroke may also be caused by a deformity in the valves of the heart or as a result of a condition called endocarditis, in which the lining inside the heart becomes inflamed. Clots can form on these abnormal surfaces and later travel to and lodge in a small artery in the brain.

Hemorrhagic Stroke Hemorrhagic strokes are less common but far more likely to be fatal. They occur when a weakened blood vessel in the brain bursts. The result is bleeding inside the brain that can be difficult to stop. Hemorrhagic stroke can most often be traced to high blood pressure, but it may also be caused by an aneurysm. This is when a weakened portion of a blood vessel balloons out, ruptures, and causes bleeding in the brain. Another possible cause is an arteriovenous malformation, or AVM, a group of malformed blood vessels that can rupture, again resulting in bleeding in the brain. The build-up of the protein amyloid inside the arteries is also a common cause of hemorrhagic stroke, especially in older individuals.

Mini-Stroke (TIA) A transient ischemic attack (TIA), often called a mini-stroke, which is more like a prestroke. Blood flow is temporarily impaired to part of the brain, causing symptoms similar to an actual stroke. When the blood flows again, the symptoms disappear. A TIA is a warning sign that a stroke may happen soon. It's critical to see our doctor if we think we've had a TIA. There are therapies to reduce the risk of stroke.

THE SIGN AND THE SYMPTOM OF STROKE.

Mark Alberts, MD, Professor of Neurology at the North-Western University Feinberg School of Medicine and director of the stroke program at North-Western Memorial Hospital in Chicago, lists these common stroke signs:
y

Trouble with speech or having difficulty talking you may struggle with finding words, slur your speech, or find yourself unable to speak

y y

Trouble understanding what other people are saying to you Feeling weak or numb on one side of your body, especially if it strikes you suddenly you can't move your face, one leg, or one hand

Sudden vision changes in one or both eyes.

Having trouble with coordination on one side of the body, especially when it happens all of a sudden

y y

Seeing double or having trouble focusing on objects or people An excruciating headache that comes out of nowhere

Headache is a stroke symptom that many people may not know about, but it's a serious warning sign. We may dismiss a headache as an everyday occurrence, but a stroke headache is one that hits you hard and fast, and with no apparent cause. And while migraine headaches have been linked to increased stroke risk, this doesn't feel like our average migraine either. It can be describedas the sudden onset of the worst headache of our life. If we get that symptom Call 999 and get to the hospital if we notice any of these symptoms.Don't waste any time by contacting ourpersonal doctor instead.

Every second counts when seeking treatment for a stroke. When deprived of oxygen, brain cells begin dying within minutes. There are clot-busting drugs that can curb brain damage, but they have to be used within three hours of the initial stroke symptoms. Once brain tissue has died, the body parts controlled by that area won't work properly. This is why stroke is a top cause of long-term disability.

RECOGNIZING STROKE

A neurologist says that if he can get to a stroke victim within 3 hours he can totally reverse the effects of a stroke...totally. He said the trick was getting a stroke recognized, diagnosed, and then getting the patient medically cared for within 3 hours, which is tough.

There arethree steps called STR:-

Sometimes symptoms of a stroke are difficult to identify. Unfortunately, the lack of awareness spells disaster. The stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. Now doctors say a bystander can recognize a stroke by askingthree simple questions: S* Ask the individual to SMILE . T* equally abbreviated from the word of TALK. Ask the person to speak simple question coherently(eg "It is sunny out today" ). R* Ask him or her to RAISE BOTH ARMS .

If he or she has trouble with ANY ONE of these tasks, call 999 immediately and describe the symptoms to the dispatcher.

Another 'sign' of a stroke that can help the us to recognise; 1.Ask the person to 'stick' out their tongue. 2.If the tongue is 'crooked', if it goes to one side or the other that is also an indication of a stroke.

RISK FACTOR OF STROKE

About 50 % of people who survive a stroke will be disabled in a way that prevents them from being completely independent and taking care of everyday activities. The good news? Nearly 80 % of all strokes can be prevented if you know your risk factors, and make changes that can decrease your risk. Stroke Risk Factors: What We Can't Control There are a number of risk factors for stroke that you can't do anything about, except to be aware of them and take other steps to improve your overall health:
y

Our age. If we are 55 or older, you're at an increased stroke risk, and that risk rises every year as you age.

Our gender. Women recently seem to be edging ahead of men in overall number of strokes; whats more, women are consistently more likely than men to die from a stroke.

Our race. African-Americans are more likely than Caucasians to die from ischemic stroke, the most common type, and Hispanics are more likely to die from hemorrhagic stroke.

Our family history. If we have a close relative, a parent, grandparent, or sibling who has had a stroke, your stroke risk goes up.

Our medical history. If we have already had a stroke, a transient ischemic attack (TIA, or a warning stroke), or a heart attack you are at greater risk of having a stroke. People who have atrial fibrillation (a disease in which the heart beats abnormally) or sickle cell anaemia (a disease in which the malformed shape of red blood cells mean less oxygen reaches organs and tissues throughout the body) are also at increased risk

for stroke. Sleep apnea, a condition that causes breathing to temporarily stop during sleep, can also increase your risk of stroke. If you have any of the above stroke risk factors, you should be especially careful to alter the ones you can do something about.

Stroke Risk Factors: What We Can Control Some of the biggest risk factors for stroke are things that we DO have control over:
y

Health conditions. If we have conditions like high blood pressure, high cholesterol, diabetes, atherosclerosis, or heart disease, do everything possible to keep them well controlled to reduce your risk of stroke. For instance, medication, diet, and exercise can really help you manage high blood pressure and high cholesterol and some of the other conditions.

Atherosclrerosis

Bad Life Style

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Our diet. Filling up on unhealthy foods that are high in fat, calories, and sodium can contribute to high cholesterol and high blood pressureand to an increased risk of stroke. Switching to a heart-healthy diet can quickly bring results.

Being sedentary. If we are not getting up and moving around enough, and not getting regular activity most days of the week, we are putting our self at a greater risk for stroke, as well as for a whole host of other health conditions. Get moving!

Obesity. If we are overweight, we are increasing our risk of stroke. And if we are a women past menopause, keep an eye on your waistline which is a measurement over 35 inches puts you at higher risk for stroke.

Smoking. Cigarettes cause damage to our cardiovascular system that can increase our stroke risk. Quit now.

Taking hormones. Hormone replacement therapy, also called HRT, or birth control pills can up our stroke risk by increasing our risk of developing a blood clot.

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DIAGNOSIS OF STROKE Different treatment is required for each type of stroke so a rapid diagnosis will make treatment more straightforward.

CT and MRI scans Two common methods used for brain imaging are a computer tomography (CT) scan and a magnetic resonance imaging (MRI) scan.

A CT scan is like an X-ray but it uses multiple images to build up a more detailed, three-dimensional (3D) picture of brain. An MRI scan uses a strong magnetic field and radio waves to produce a detailed picture inside the body.

The type of scan may have in hospital depends on the type of symptoms. In people with suspected major stroke, a CT scan is sufficient to identify whether the stroke is due to bleeding or clotting. It's quicker than an MRI scan and improves the chances of rapidly delivering treatments such as clot-busting (thrombolysis) that might be used in appropriate cases but which are time-limited and require the results of the scan before the treatment can be given safely.

For people with more complex symptoms, where the extent or location of the damage is unknown, and in patients who have recovered from a transient ischaemic attack, an MRI scan is more appropriate. This will provide greater detail of brain tissue, allowing smaller or more unusually located strokes to be identified.

All patients with suspected stroke should receive a brain scan within 24 hours. Some patients should be scanned within the hour, especially those who:
y

have had a suspected thrombotic stroke and might benefit from clot-busting drugs (thrombolysis) such as alteplase or early anticoagulant treatment

y y

are already on anticoagulant treatments have a lower level of consciousness

12

After the injection of a dye into an arm vein, both CT and MRI can be used to take pictures of the blood vessels in the brain, as well as the blood vessels in the neck that take blood to the brain from the heart. This is known as a CT or MR angiogram and is often done immediately after taking picture of the brain itself.

Swallow tests A swallow test is essential for anybody who has had a stroke.Swallowing problems affect over a third of people after a stroke. When a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and then into the lungs (called aspiration), which can lead to chest infections and pneumonia.

The test is simple. The person is given a few teaspoons of water to drink. If they can swallow this without choking and coughing they will be asked to swallow half a glass of water.

If they have any difficulty in swallowing, they will be referred to the speech and language therapist for a more detailed assessment. They will usually be kept nil by mouth until they have seen the therapist and may therefore need to have fluids or food given by an intravenous drip or nasogastric tube.

Heart and blood vessel tests Further tests on the heart and blood vessels might be carried out later to confirm what caused the stroke. These may include:
y

Ultrasound (carotid ultrasonography)

An ultrasound scan uses high frequency sound waves to produce an image of the inside of the body. The doctor may use a wand-like probe (transducer) to send high-frequency sound waves into the neck. These pass through the tissue creating images on a screen that will show if there is any narrowing or clotting in the arteries leading to the brain.This type of ultrasound scan is sometimes known as a Doppler scan or a duplex scan. Where carotid ultrasonography is needed, it should happen within 48 hours.

13

Catheter angiography (arteriography)

Dye is injected into the carotid or vertebral artery via a catheter. This gives a detailed view of the arteries than can be obtained using ultrasound, CT angiography or MR angiography.
y

Echocardiogram

In some cases an echocardiogram may be used to produce the image of heart using an ultrasound probe placed on your chest (transthoracic echocardiogram). In addition, transoesophageal echocardiography (TOE) may also be used. This involves an ultrasonic probe which is passed down the foodpipe (oesophagus), usually under sedation. Because it's directly behind the heart, it produces a clear image of blood clots and other abnormalities that may not get picked up by the transthoracic echocardiogram.
y

Physical examination

The doctor may check for risk factors of stroke by taking blood tests, checking pulse and blood pressure and using a stethoscope to listen to the sound of blood in the neck arteries.

PREVENTION OF BEING STROKE The best way to prevent a stroke is to eat a healthy diet, exercise regularly and avoid smoking and excessive consumption of alcohol.

Diet A poor diet is a major risk factor for a stroke. High-fat foods can lead to the build-up of fatty plaques in your arteries and being overweight can lead to high blood pressure. A low-fat, high-fibre diet is recommended, including plenty of fresh fruit and vegetables (five portions a day) and whole grains. We should limit the amount of salt that we eat to no more than 6g (0.2oz) a day because too much salt will increase our blood pressure. Six grams of salt is about one teaspoonful. There are two types of fat: saturated and unsaturated. We should avoid food containing saturated fats because these will increase our cholesterol levels.

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Exercise Combining a healthy diet with regular exercise is the best way to maintain a healthy weight. Having a healthy weight reduces our chances of developing high blood pressure. Regular exercise will make our heart and blood circulatory system more efficient. It will also lower our cholesterol level and keep our blood pressure at a healthy level. For most people, 30 minutes of vigorous exercise a day at least five times a week is recommended. The exercise should be strenuous enough to leave our heart beating faster, and we should feel slightly out of breath. Examples of vigorous exercise are going for a brisk walk or walking up a hill. If we are recovering from a stroke, we should discuss possible exercise plans with the members of our rehabilitation team. Regular exercise may be impossible in the first weeks or months following a stroke but we should be able to begin exercising once our rehabilitation has progressed.

Smoking Smoking doubles our risk of having a stroke. This is because it narrows our arteries and makes our blood more likely to clot. If we stop smoking, we can reduce our risk of having a stroke by up to half. Not smoking will also improve our general health and reduce our risk of developing other serious conditions, such as lung cancer and heart disease.

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Alcohol Excessive alcohol consumption can lead to high blood pressure and an irregular heartbeat (atrial fibrillation). Both are major risk factors for stroke. Because alcoholic drinks are rich in energy (high in calories) they also cause weight gain. Heavy drinking multiplies the risk of stroke by more than three times.

Medication For people with a high risk of stroke, doctors often recommend medications to lower this risk. Anti-platelet medicines, including aspirin, keep platelets in the blood from sticking together and forming clots. Anti-clotting drugs, such as warfarin, may be needed to help ward off stroke in some patients. Finally, if we have high blood pressure, our doctor will prescribe medication to lower it.

Surgery In some cases, a stroke results from a narrowed carotid artery which are the blood vessels that travel up each side of the neck to bring blood to the brain. People who have had a mild stroke or TIA due to this problem may benefit from surgery known as carotid endarterectomy. This procedure removes plaque from the lining of the carotid arteries and can prevent additional strokes.

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Balloon and Stent Doctors can also treat a clogged carotid artery for TIA case without major surgery in some cases. It would prevent the TIA patient from getting the major stroke. The procedure, called angioplasty, involves temporarily inserting a catheter into the artery and inflating a tiny balloon to widen the area that is narrowed by plaque. A metal tube, called a stent, can be inserted and left in place to keep the artery open.

TREATMENT OF STROKE

Emergency treatment Emergency treatment of stroke from a blood clot is aimed at dissolving the clot. This "thrombolytic therapy" currently is performed most often with tissue plasminogen activator(tPA). t-PA must be administered within three hours of the stroke event. Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined. t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients. t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months. Patients with clotrelated (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases. Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or mannitol plus hyperventilation is the most common treatment.
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Corticosteroids also may be used. Patients with reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders reversed, if possible. Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access. Ruptured vessels are closed off to prevent rebleeding. For aneurysms that are difficult to reach surgically, endovascular treatment may be used. In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm. Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery.

CARE AND REHABILITATION

Stroke is the third leading cause of death and the leading cause of long-term disability in the world. In addition, there are millions of husbands, wives, children and friends who care for stroke survivors and whose own lives are personally affected.

According to the National Stroke Association:

y y y y y y

10% of stroke survivors recover almost completely 25% recover with minor impairments 40% experience moderate to severe impairments that require special care 10% require care in a nursing home or other long-term facility 15% die shortly after the stroke Approximately 14% of stroke survivors experience a second stroke in the first year following a stroke.

Successful rehabilitation depends on:

y y y

Amount of damage to the brain Skill on the part of the rehabilitation team Cooperation of family and friends. Caring family/friends can be one of the most important factors in rehabilitation

Timing of rehabilitation the earlier it begins the more likely survivors are to regain lost abilities and skills

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The goal of rehabilitation is to enable an individual who has experienced a stroke to reach the highest possible level of independence and be as productive as possible. Because stroke survivors often have complex rehabilitation needs, progress and recovery are unique for each person. Although a majority of functional abilities may be restored soon after a stroke, recovery is an on-going process.

Effects of a Stroke 1. Weakness (hemiparesis) or paralysis (hemiplegia) on one side of the body that may affect the whole side or just the arm or leg. The weakness or paralysis is on the side of the body opposite the side of the brain affected by the stroke. 2. Spasticity, stiffness in muscles, painful muscle spasms 3. Problems with balance and/or coordination 4. Problems using language, including having difficulty understanding speech or writing (aphasia); and knowing the right words but having trouble saying them clearly (dysarthria) 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention) 6. Pain, numbness or odd sensations 7. Problems with memory, thinking, attention or learning 8. Being unaware of the effects of a stroke 9. Trouble swallowing (dysphagia) 10. Problems with bowel or bladder control 11. Fatigue 12. Difficulty controlling emotions (emotional liability) 13. Depression 14. Difficulties with daily tasks

Types of Rehabilitation Programs

y y y y

Hospital programs: in an acute care facility or a rehabilitation hospital Long-term care facility with therapy and skilled nursing care Outpatient programs Home-based programs

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Rehabilitation Specialists
y

Physicians: physiatrists (specialists in physical medicine and rehabilitation), neurologists, internists, geriatricians (specialists in the elderly), family practice

y y

Rehabilitation nurses: specialize in nursing care for people with disabilities Physical therapists: help to restore physical functioning by evaluating and treating problems with movement, balance, and coordination

Occupational therapists: provide exercises and practice to help patient perform activities of daily living.

y y

Speech-language pathologists: to help improve language skills Social workers: assist with financial decisions and plan the return to the home or a new living place

y y

Psychologists: concerned with the mental and emotional health of patients Therapeutic recreation specialists: help patients return to activities they enjoyed before the stroke.

Although some risk factors for stroke cannot be changed (e.g. age) others such as high blood pressure and smoking can be altered. Patients and families should seek guidance from their physician about lifestyle changes to help prevent another stroke.

Normal Stroke Rehab: Speech Therapy Rehabilitation is the centrepiece of the stroke recovery process. It helps patients regain lost skills and learn to compensate for damage that cannot be undone. The goal is to help restore as much independence as possible. For people who have trouble speaking, speech and language therapy is essential. A speech therapist can also help patients who have trouble swallowing

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Normal Stroke Rehab: Physical Therapy Muscle weakness, as well as balance problems, is very common after a stroke. This can interfere with walking and other daily activities. Physical therapy is an effective way to regain strength, balance, and coordination. For fine motor skills, such as using a knife and fork, writing, and buttoning a shirt, occupational therapy can help.

Normal Stroke Rehab: Talk Therapy It's common for stroke survivors and their loved ones to experience a wide range of intense emotions, such as fear, anger, worry, and grief. A psychologist or mental health counsellor can provide strategies for coping with these emotions. A therapist can also watch for signs of depression, which frequently strikes people who are recovering from a stroke.

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BIOGRAPHIC DATA

Name NIRC Age Sex Race Religion Marital Status Past Medical Background Medication Intake

: : : : : : : : :

Mariam @ JaimahbtAwang 420711-04-5258 68 years Female Malay Islam Marriage HPT and DM On Tab MTF 1gm Bd, Tab Simvastatin 4 mg ON, Tab aspirin 15 mg OD NIL NIL

Past Surgical History Allergies

: :

INTODUCTION OF MRS MERIAM

According to her husband, Mrs Mariam is the youngest members out of her seven siblings. She completed her study till standard 6 of primary school. She can read and write very well. Routinely, she and her husband wake up very early in the morning to prepare a variety of food to be sold in their small stall which is located in PekanJasin. She is very outgoing and frequently having her conversation with neighbours in the late afternoon. She blessed with the existence of her caring husband while having patient children who always accompanying her in the ward without any tiresome faces. After being attacked by stroke, she totally looked so depressed physically and did not want to chat with any people even the staff in the ward. After went through the moment with her, I found that she noticeably so tired and exhausted while lying on the bed. In case of that, she also denied to go through the ADL activity even we had been requested frequently. In order to seize her attention, my friend and I trying to convince her that we as staff there, could manage to aid her enormously.

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As gerontologist care taker, I also trying to probe whether the nutrition provided in her foods are sufficient or not. Unfortunately, her appetite obviously decreased towards the illness that she has been faced. Any meals provided were just abundant in front of her. She just swallows a little bit but sometime she spews out the food back into the tray. I did some research by reviewing her meals history. Before she was attacked by stroke illness, she took unbalanced diet due to the several habits. Regularly in the morning, Mrs Mariam and her husband took nasilemak or roti canai as option. At afternoon, she occasionally took the lunch but for dinner, she took me soup or rice with vegetable dish, fish or chicken. She hardly cooks at home. Therefore, she tends to take her breakfast and dinner at restaurant rather than prepared by her own at home. In relation to that, we can bear in our mind that the entire sodium, fat and sugar intake could not be controlled as suggested by the physician due to the food was prepared by the restaurant caterer who doesnt knows anything about the right nutrition for HPT or DM patient.The physiotherapist and occupational therapies have given a broad way for her to adapt the situation when she comes back to her house especially for doing her daily life. As the gerontologist care taker, I have pre-teach him the way to cook in safe mode with appropriate nutrient for elderly. As her husband had told me that they always having their meals outside, I suggested to him that the meals provided outside will not count their fat intake even the sodium that are very important thing should be concerned especially to prevent the second stroke that may appear due to the clots come from the cholesterols intake. I have suggested to her husband that they have to prepare their own food by minimising the oil intake, avoiding the dish that containing coconut milk and excessing the green vegetable and fruit intake. The grain also should be served adequately to give her sufficient energy. The suggestion was received very well by her husband and he told that they have 5 children out of 8 children who stay with them and still single. They can take care of their mother as suggested by us and prepare meals that appropriate for elderly life.

As reported by her husband, she faced instability today and having history of fall. Mrs Mariam was diagnosed that she unable to wake up and found there was no injury. Sudden onset, she have generalised body weakness and having slurred speech and facial asymmetry. She had no any sleeping apnea and can sleep very well.

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Reviewing the shelter for stroke patient is the one of careness that would give the best way of gerontologist care taker to advise. Mrs Mariams house situated in the village where is near to PekanJasin. Her house was built using the combination of wood structure and bricks. It would make it easy for Mrs Mariam because there is no any stairs provided in her house. There are four rooms provided with two toilets. The toilets not facilitate any railing and grab bar. This will make it uneasy for her. We have advised their husband to buy the railing and grab bar in the toilet so as his wife could manage her life process very well in term of excretion and defecation.

Mrs Mariam is known case of DM on OHA and also the HPT as well. When she admit the emergency room, there were several vital sign that had been recorded which her BP was noted to the peak of 218/110 along with his HR 72 /min. The respiration stated 16/min, spor 100% on room air and the GM was recorded to 6.9 mmol/L.

My AssesmentVia The Record Diagnosis

GDS MMSE SWALLOWING TEST GET UP AND GO TEST MORSE FALL SCALE NORTON SCALE

: : : : : :

11/15 (Depressed) 28/30 (She didnt have cognitive impairment) Moderate 3 Inquired physiotherapy and rehabilitation

60 (Tendency for fall noted as high risk) 16/20 (Noted as not a risk of getting pressure sore) : 78 (Mild Dependency Level)

MODIFIED BARTHEL INDEX

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PATIENTS GENOGRAM

Die due to the old fatal

74

70

68
Patient 8 children

Patient did not remember the main cause of her siblings death.

40
Single (clerk)

38
Single (General worker)

37
Married 3 children (Factory)

35
Single (Factory)

33
Married 5 children (House wife)

32
Single (Trader) (trade

31
Single (Trader)

30
Married 3 children (House wife)

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WHAT ACTUALLY HAPPENDED WITH HER? A HISTORY OF ADMITTANCE

She was admitted on 17 May 2011 referred from Hospital Jasin. When I checked his history in her referring note, she previously can manage on his daily activity life independently. He had alleged fall after unsteady gait then have slurred speech and facial asymmetry. He was admitted to emergency room at 1625 hr from Hospital Jasin. Her complaints of headache but there was no any vomiting and injury found on patient. Sudden onset and generalised body weakness. Patient looked so weak and unable to ambulate by herself.

On examination

Complaint of having 9/10 headache pain scale. Noted by physician that there was no any ENT bleeding. No nausea or vomiting recorded. Patient told that left upper and lower limb gradually more weaken as compared his healthy history and she unable to walk. Spasticity, stiffness in muscles, painful muscle spasms Problems with balance and/or coordination Able to take orally Problems using language; knowing the right words but having trouble saying them clearly (dysarthria) Tongue diverged to right. Could not wrinkle his forehead. No up rolling of eyeballs and any drooling of saliva Reactive to the light Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention) Pain, numbness or odd sensations Being unaware of the effects of a stroke Trouble swallowing (dysphagia). She can swallow the food in average scale but in small bite. Patient could not swallow the food as usual. Problems with bowel or bladder control.She always wore diaper.

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Fatigue (Looked so exhausted and tiresome) Difficulty controlling emotions (emotional liability) Depression Difficulties with daily tasks GAG reflex was noted as normal

Imaging Result

CT Brain report: Cerebral atrophy, Right Occipital Atrophy.

Now after treatment and the rehabilitation, patient still could not really good in gaiting and griping. She depressed of her instability when trying to stand. She looked so fatigue along the rehab and didnt give the very well cooperation when doing the rehabilitation and physiotherapies. She not discharged yet till I saw her on 20 May 2011.

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NURSING DIAGNOSIS 1: Impaired Physical Mobility

Nursing Goals : To maintain and improve functional abilities (by maintaining normal fuction and alignment, preventing edema of extremities, and reducing spasticity) and to prevent complications.

1.

Encourage active range-of-motion exercises for unaffected extremities and perform passive range-of-motion exercises for affected extremities every 4 hours during day and evening shifts and once during the night shift. Support the joint during passive range-of-motion exercises. Active range-ofmotion exercises maintain or improve muscles strength and endurance, and help to maintain cardiopulmonary function. Passive range-of-motion exercises do not strengthen musclesbut do help maintain joint flexibility. Both active and passive exercises increase venous return.

2.

Turn the Mrs Mariam every 2 hours around the clock, following a posted schedule for side-to-side and supine-to-prone position changes to verify the prone positioning with the physician. Maintain body alignment and support extremities in proper position with pillows. Turning on a regular basis, accompanied by proper positioning, maintains joints function. Alleviates pressure on bony prominences that can lead to skin breakdown, decreases dependent edema in hands and feet, and lessen the risk of complications resulting from immobility.

3.

Monitor the lower extremities each shift for symptoms of thrombophlebitis. Asses for Mrs Mariams sign: Asses for increased warmth and redness in calves and also to measure the circumference of the calves and thighs. If she got the bed rest (especially those with loss of muscle strength and tone)are particularly prone to the development of deep vein thrombosis. Symptoms of thrombophlebitis should be promptly reported.

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4.

Do not use a footboard. I just use only hand splints only as directed by the physician and physical therapist to prevent flexion contractures of the fingers and wrist. The use of footboards is no longer recommended and may actually cause increased dorsiflexion as the patient slides down in bead. Hand Splints may in some instances increase spasticity.

5.

Collaborate with the physical therapist as patient gains mobility. I had used consistence techniques to move Mr Mariam from the bed to the wheelchair and to help her ambulate. The use of consistent techniques facilitate rehabilitation.

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NURSING DIAGNOSIS 2: Self-Care Deficit

Nursing Goals : To perform as much of their own physical care and grooming as possible to promote functional ability, increase independence, decrease feeling of powerlessness and improve self-esteem. Before establishing a plan to increase self-care, I had determined which hand was dominant before attacked by the stroke. If the patients dominants side is affected by stroke, self-care would be more difficult.Mr Mariam told that left upper and lower limb gradually more weaken as compared his healthy history and she unable to walk. Based on the examination, her dominant hand before CVA is right hand and the right part of body didnt include in weaken part of body.

1.

Encourage Mrs Mariam to use the unaffected arm to bath, brush teeth, comb hair, dress and eat. Use of the unaffected arm promotes functional ability and independence.

2.

Teach Mrs Mariam and family to put on clothing by first dressing the affected extremities and then dressing the unaffected extremities. This technique facilitates self-dressing with minimal assistance.

3.

Collaborate with the occupational therapies in scheduling times for training for upper extremity functioning necessary for activities of daily living Encourage to use of assistive devices (if required) for eating, physical hygiene and dressing. Following a regular schedule in daily routines promotes learning. The use of assistive device promotes independence and decrease feeling of powerlessness. Optimal grooming facilitates positive self-concepts.

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NURSING DIAGNOSIS 3: Impaired Verbal Therapies

Nursing Goals : To determine the specific nature of the impairment so that the nurse can plan individualized interventions and help the family members to understand the specific problems. Although the speech therapist is usually most involved with the patients speech rehabilitation, nurse must plan intervention to meet communication needs during all phases of care.

1.

Use the guidelines when communicating with Mrs Mariam.: Approach and treat Mrs Mariam as an adult. Do not assume when Mrs Mariam does not respond verbally she cannot hear. I have to ensure that I did not raise my voice when addressing with her. Allowing adequate time for her to respond. Face her and speak slowly When I did not understand what she had been talk about, I have to be honest to tell her that I did not understand. Us short, simple statements and questions.  Accepting the patient and providing the dignity and respect enhances the nurse-patient relationship. Allowing adequate response time and using short verbal statements or questions while facing the patient motivates the patients to communicate and decrease frustration.

2.

Accept Mrs Mariams frustration and anger as normal reaction to the loss of function. Anger represents her frustration at the inability to control the loss of function.

3.

Try alternating the methods of communication, including writing tablets, flash cards, computerized talking boards. Patients who are unable to communicate verbally may use other methods effectively.

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NURSING DIAGNOSIS 4: Altered Urinary Elimination and Constipation

Nursing Goals : Patient can re-establish normal bowel and urinary elimination patterns.

1.

Asses for urinary frequency, urgency, incontinence, nocturia, and avoiding in small amounts. In addition, asses Mrs Mariams ability to respond to the need to void, the ability to use the call light, and the ability to use toileting equipment. I must identify the underlying problem before beginning the teaching problem.

2.

Establish bladder retraining through one or more of the following Have the patient void every 2 hours. Encourage bladder training by having patient void on schedule rather than in response to the urge to void. Teach the patient to perform Kegel exercise (10 repetitions three times a day). To perform Kegel exercises, the patient contracts the perineal muscles asthough stopping urination holds the contraction for 5 seconds, and then releases. Use positive reinforcement (verbal praise) for successful management of urinary elimination. Voiding every 2 hours or on schedule promotes bladder tone and urine storage. Kegel exercises increase pubococcygeal muscle tone and bladder control, decreasing incontinence. Positive reinforcement can be useful part of the teaching program.

3.

Discuss pre-stroke bowel habits, as well as the pattern of bowel elimination since having the stroke, with Mrs Mariam and his family. Establish a bowel routine. If patient is able to swallow without difficulty, encourage the patient to drink fluids (up to 2000 ml per day) and eat high-fiber diet. Increased fluids and fiber stimulate intestinal motility. Increase physical activity as tolerate. Help the patient to use toilets facilities at the same time each day (based on usual pattern of bowel elimination), ensuring privacy and having patient sit in upright position if at all possible. Establishing a regular daily time for bowel

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movement in the upright position and in privacy promotes normal bowel elimination. Administer prescribed stool softeners if the patient is following a bowel elimination routine or is not drinking sufficient fluid. Stool softeners help prevent the formation of hard stool that is more difficult to expel.

NURSING DIAGNOSIS 5: Impaired Swallowing

Nursing Goals : Maintaining safety by preventing aspiration and on ensuring adequate nutrition.

Stroke may impair the patient ability to swallow. Weakness or lack of coordination of the tongue, attention deficits, and deficits involving the swallowing reflex all play arole. Dysphagia may result in choking, drooling, aspiration or regurgitation. Nursing intervention with rational follow;

1.

Ensure safety when Mrs Mariam eating. Make sure that Mrs Mariam is sitting upright. Be sure her neck is slightly flexed. Order pureed or soft food. Feed or teach her to eat by putting food behind the front teeth on the unaffected side of mouth and tilting the head slightly backward. Teach Mrs Mariam to swallow one bite at atime. When the patient has finished eating, check the mouth for pocketing of food, especially in the affected cheek (stroke) Have suction equipment available at the bedside in case of choking or aspiration.

Sitting upright with the head and neck first slightly flexed and then tilted back helps the patient to swallow. The patient can usually swallow pureed or soft foods more easily than liquid or solid foods. Using the unaffected side of the mouth helps prevent food from collecting in the mouth and makes swallowing safer. In addition, food is less likely to fall out of the mouth.
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2.

Minimize distraction and if necessary, give step by step instruction for eating. Distraction increases the risk of aspiration. Complex activities are easier to perform when broken down into small steps.

CONCLUSION

Nurse caring for the patient who has stroke require knowledge and skill to meet patient needs during both the acute and the rehabilitative phases of care. The patient with stroke often has multiple loses. Nursing care that is holistic and individualized is essential in all settings and focuses on promoting the achievement of maximum potential and quality of life. Teaching the family as well as the patient how to participate in the recovery process facilitates meeting goals and outcomes outlined in the plan of care.

After went through the case study of Mrs Mariam @ Jaimah, Ive learned a lot of practical knowledge that I have to apply in nursing process especially in gerontologist unit. Since I was leaving the ward, she still there to run a few therapies and treatments before she will allow going home. By the way, I felt so honoured to do some nursing treatments and care for her. I hope she will recover soon. This case study has brought me to view the reality in caring the elderly. We have to treat them as our own family without denying a different of religious and races. As gerontologist caretaker, this nursing process will aid me to handle those who are attackedby stroke and many more of elderly illness.

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REFERENCES

1. Bates BE, Stineman MG (2000) .Outcome indicators for stroke: application of an algorithm treatment across the continuum of postacute rehabilitation services. Arch Phys Med Rehabil.page 14681478. 2. Cifu DX, Stewart DG (1999). Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil.Page S35S39. 3. Evans RL, Connis RT, Hendricks RD, Haselkorn JK. (1995)Multidisciplinary rehabilitation versus medical care: a meta-analysis. SocSci Med.Page 16991706. 4. Gresham GE, Duncan PW, Stason WB, et al. (1995) Post-Stroke Rehabilitation. Clinical Practice Guideline, No. 16. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 5. Reker DM, Duncan PW, Horner RD, Hoenig H, Samsa GP, Hamilton BB, Dudley TK. (2002) Postacute stroke guideline compliance is associated with greater patient satisfaction. Arch Phys Med Rehabil.Page 750756. 6. Scottish Intercollegiate Guidelines Network (SIGN). Management of Patients with Stroke Part III: Identification and Management of Dysphagia, No. 20. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 1997. 7. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke.Cochrane Database Syst Rev.2002 8. Uniform Data System for Medical Rehabilitation. FIM Instrument. Buffalo, NY: University of Buffalo; 1997. 9. Veterans Health Administration. Medical Rehabilitation Outcomes for Stroke, Traumatic Brain, and Lower-Extremity Amputee Patients. VHA Directive 2000-016. Washington, DC: Department of Veterans Affairs, Veterans Health Administration; June 5, 2000.

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