Nursing Mary Young is a 71-year-old Aboriginal Australian female. She has present with a number of different health issues, including osteoporosis, hypercholesterolaemia, atherosclerosis, atrial fibrillation and Type 2 diabetes. She has been feeling fatigued for the past several months, and her current admission was on account of increasing dizziness, blurred vision and persistent headache. She was found to have suffered an ischaemic stroke, of moderate to severe status. This paper will outline the primary admission diagnosis, the nursing problems, nursing management strategies and discharge planning for Mary.

Primary Admission Diagnosis

Mary was admitted to the ED with left-sided hemiparesis, aphasia, and hypertension. She had an irregular pulse rate. An ECG revealed atrial fibrillation. A thrombotic ischaemic stroke was suspected and confirmed on CT. She has now been stabilized, and has been admitted to the medical ward for clinical management and rehabilitation.

Thrombotic ischaemic strokes are caused by a number of factors. Among them, Mary has Type 2 diabetes, hypertension and atrial fibrillation. Thus, Mary possesses several risk factors that not only could have caused this stroke but may cause future strokes as well, if these factors are not addressed. Hinkle (2007) notes that this type of stroke involves blood flow to the brain being constricted. There are several potential outcomes that can affect care after the patient has been stabilized. The patient's airway can be constricted, and they should have a swallow screen applied when receiving anything by mouth, including water and medications (Hinkle, 2007). The patient's ability to communicate can be affected by the stroke, and should be monitored. Mary worked for the SA Police Dept so she should be able to communicate in English, but does not appear to be able to do so at this point in time, so this is something that should be addressed prior to discharge (Hinkle, 2007).

Nursing Problems

There are a number of nursing diagnoses that can be made at this point for Mary. She has impaired physical mobility/impaired walking because she cannot bear her own weight. She has fatigue, and was facing this prior to the stroke. She has impaired verbal communication. She is at risk for powerlessness, because of her deteriorating physical condition. Mary wants to continue with her job, and making contributions to her community, and may struggle emotionally and mentally with being unable to continue in these functions during her recovery. She is also at risk for social isolation. This is going to occur especially as her mobility is compromised, and if she does not recover her ability to communicate in English. The Aboriginal languages that she speaks have very few if any fluent speakers, and in any case there has not been an assessment as to how well she speaks them in her present state. There is risk that she will become socially isolated if she cannot move or communicate verbally.

Nursing Management

The first problem to examine is Mary's fatigue. Mary was experiencing fatigue prior to her stroke, and as the result of her stroke she is expected to continue to experience fatigue. One of the problems with post-stroke fatigue is that there is not much evidence to guide practice. There is a sizeable body of work on chemotherapy-related fatigue but not on stroke-related fatigue. Collo (2007) notes that fatigue is common in stroke survivors and is linked to reduced independence, both of which are nursing issues. Some of the research that has been done is inconclusive in nature (Michael, et al., 2006), but fatigue has been shown to be related to balance, and to falls, which themselves a significant health risk in older individuals such as Mary. Strokes have been linked to falls, especially where there is fatigue (Schmid et al., 2010).

However, with little knowledge about how to combat this type of fatigue, only generalized assistance can be given. First, the patient needs to be made aware of the risks of fatigue, and her daughter does, too. This includes the risks of falling, so that perhaps her home can be adequately equipped to minimize the risk of falling. Dietary factors need to be taken into consideration. Furthermore, there needs to be some physiotherapy or rehabilitation done so that Mary can regain as much of her mobility as possible. The more she can regain, the better she will be with respect to fatigue. That said, at her age, it may come down to finding the right coping strategies, such as her daughter helping her around the house more, organizing some sort of home...

Her inability to communicate effectively may be related to the stroke. It is worth inquiring with the daughter if her mother is normally this quiet. Having difficulty in communicating is something that occurs in stroke victims. Moreover, it can lead to other outcomes such as social isolation, or even the inability to communicate with health care professionals. Therapy is usually recommended in this situation, rather than drugs, to help the patient regain her ability to communicate. The Aboriginal counsellor is not going to be able to help much, as Mary speaks languages that few people speak. Further, if she is unable to communicate in English, it is worth trying the indigenous languages to see if it is just English that is difficult or all languages. Therapy to ensure that Mary regains her ability to communicate will be an important nursing intervention to ensure that she is able to recover better, and not feel the social isolation that she is now at risk of.
There are many other interventions. The Stroke Association (2016) recommends infographics to aid in communication where aphasia is present post-stroke. The Stroke Foundation recommends that a speech pathologist is brought in to evaluate a patient after a stroke when communication problems are suspected (Stroke Foundation, 2016). Gordon notes that nurses often communicate with patients in a functional manner, but that this communication may not be perceived accurately by a post-stroke patient. In particular interaction asymmetry did not allow for the nurse to understand the patient and what the patient might have been trying to communicate. One nursing intervention is therefore to bring in the speech pathologist to try to gain perspective on the communication problems that Mary is having so that all the nurses can respond according, and in lieu of that just to understand the issues at hand when dealing with Mary -- her brain's ability to formulate communication might be severely inhibited (Gordon, Hill & Ashburn, 2008).

Discharge Planning

The nursing issues identified above provide guidance for discharge planning. Mary is unable to support her weight, and therefore needs assistance at all times to help her move. She should not be discharged into a situation where there is nobody to care for her. That said, if early supported discharge is available, then it is something to consider, as there is evidence to support this (Saka et al., 2009). But if supported discharge is not available, then Mary will need to be able to look after herself. That means being able to support her weight, and to have seen a speech pathologist to work on her post-stroke communication problems.

Further, Mary will benefit from education about the different factors that possibly led to the stroke in the first place. For example, she has Type 2 diabetes that has gone untreated, hypertension, and other issues that were poorly managed. A significant amount of time will need to be taken with Mary and her daughter to ensure that she has the tools and medications available to treat these different issues from which she suffers. Otherwise, she could be at risk for another stroke in the future.

Conclusion

Mary faces a number of different challenges, relating to her stroke but also to the factors that led to the stroke in the first place. She has communication challenges, as well as balance and fatigue issues. Mary seems a long ways from discharge at present, as she is unable to care for herself. She feels anxiety, which is normal given the damage done to her by the stroke, and the stressful situation she is now in. Her multiple health issues have come to a head. Mary needs the services of a speech pathologist to determine the nature of her aphasia. She will require a treatment plan for her diabetes and hypertension. She is at risk of social isolation, and of not being able to care for herself. Caution must be taken with respect to discharge. Mary may not understand instructions at this point. Her daughter may or may not be reliable -- she seems it, but this should be evaluated because Mary does not appear to have anybody else to rely on, and she might not be able to take care of herself. If there is assistance available for Mary, to help her after she is discharged, with basic functions, that will be required, because at present she cannot go to the bathroom by herself, and is therefore not a suitable candidate…