The Science of Making Nursing Decisions

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Science of Nursing Decision In practice, nurses encounter patients with numerous health conditions. Some conditions are similar but affect individuals in different ways. Nurses, therefore, need to develop a care plan suitable for individual patients than applying the standard approach to care. This discussion critiques the care plan of a 64-year-old adult client with Acute Ischemic Stroke. The client was brought to the facility by his wife after experiencing a sudden onset of slurred speech, left upper and lower limb weakness, and left side, facial droop. Evaluation of the care plan will focus on key decisions made by the care team and the justification for interventions and treatment. The Biopsychosocial Model will be applied to holistically explore the patient’s needs and impact on the care plan. Appropriate recommendations to the care plan will also be highlighted. Critiquing and evaluating the care plan is critical since it aligns with an evidence-based approach to care delivery (Cherry & Jacob, 2016). This process helps nurses in judging how well specific interventions are working. It also helps identify changes that nurses could implement to improve service delivery.

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Biopsychosocial model The biopsychosocial model is a concept formulated by George Engel in 1977. This concept suggests that to understand a person's health deeply, health care providers must evaluate the biological, psychological, and social factors (Maltzman, 2016). Biological factors refer to physiological aspects of disease while psychological factors address the emotions, thoughts, and behaviors. Social factors, on the other hand, describe the cultural, environmental, social, and economic factors at play in the life of a person (Maltzman, 2016). Clinicians use this model when assessing clients with chronic conditions. Understanding the biopsychosocial creates a base for explaining the condition's progress and developing a suitable intervention plan.

Care plan critique One of the patient’s health problems is reduced coordination. Reduced coordination has a negative impact on several aspects of the client's life. Lai et al. (2020) noted that stroke leads to paresis, muscular weakness, and spasticity of the affected upper arm. The function of the upper extremities depends on bilateral hand coordination. Interlimb coordination enables individuals to walk, grasp objects with both hands, and exchange items between the two hands.

However, stroke symptoms disrupt the control of interlimb coordination thus, increasing dependency in activities of daily living (Lai et al., 2020). The decline in cooperative movement of hands in the patient, therefore, needs to be comprehensively addressed to improve independence. Several studies show that only a few patients fully recover from decreased interlimb coordination. This means that the patient with reduced coordination of the upper limbs might have a chronic movement disorder of bilateral hands cooperative control (Lai et al., 2020).

Managing acute ischemic stroke is an important step of the care plan. Decisions made at this juncture focus on the need for reperfusion therapy, airway management, and establishing

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optimal blood pressure (Herpich & Rincon, 2020). The treatment plan's key goals are to prevent further damage, address partial paralysis, and improve the motor and functional performance of the upper extremities (Herpich & Rincon, 2020). The care plan developed for the patient involves thrombolytic therapy, admission to the Acute Stroke Unit, regular observation, and 24 Hour Monitoring. The care plan could help tackle the health problems facing the patient and improve Thrombolytic therapy, which involves administration with intravenous tissue plasminogen activator (tPA), is a key element of the stroke care plan. Ischemic stroke is associated with a blockage in an artery supplying blood to the brain (Liu et al., 2018). This blockage damages the brain regions involved in coordination. This damage is associated with the degeneration of neurons in the brain stem and the cerebellum due to insufficient blood supply.

Neuron damage in the afferent connections and the spinocerebellar tracts can also reduce coordination (Jayaraj et al., 2019). These damages are attributable to existing health disorders such as genetic defects, alcoholism, brain tumor and multiple sclerosis. The patient has a history of excessive alcohol consumption hence at risk of neural damage. Jayaraj et al. (2019) noted that reduced coordination affects the physiological aspects of a person’s health. For example, due to scrambled brain signals, the patient’s mind and muscles do not work together—the patient experiences muscle weakness and spasticity. Muscle weakness makes it difficult to move some muscles in the extremities. These muscles get tight and become hard to stretch. The patient might have a tightly clenched fist and arm pressed against the body, making it hard to grasp objects and walk.

Administering tPA helps dissolve stroke-causing clots, subsequently improving the flow of blood to all regions in the brain (Liu et al., 2018). The American Health Association

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guidelines on treating ischemic stroke assert that tPA is the most potent intervention for this condition when given within an hour of first symptoms (McDermott, 2019). The goal of treatment is to preserve tissue and establish re-vascularization. Liu et al. (2018) argued that by removing the primary cause of the patient’s condition, tPA might help the patient attain full recovery. However, the patient needs close monitoring due to potential risks of tPA including bleeding in the brain. The clinician decided to administer tPA since the client does not have a history of traumatic brain injury, hemorrhage in the brain and hemorrhagic stroke.

Notably, walking and grasping are easy tasks that many do without thinking. But the brain and the body pull numerous complex movements to achieve these outcomes. Legs bend and move while fingers fold and hands swing during normal activities (Jayaraj et al., 2019).

After a stroke, coordination of the limbs control is affected, and walking and grasping become difficult tasks. The patient realizes that body movement is not as easy as normally presumed by the people. The challenges emanating from reduced coordination might confuse the patient.

They also augment the risk of anxiety, depressive symptoms, and personality processes and identify changes. It is, therefore, logical for the nurse to implement an intervention that helps improve the psychological health of the client besides detecting improvements and identifying deterioration in coordination. The care plan comprised therapy, regular observation and close monitoring which helped reassure the patient, subsequently alleviating psychological symptoms.

Reduced coordination in stroke also negatively impacts the social well-being of the patient. The patient’s inability to engage in activities of daily living reduces the chance of participating in social activities (Kirkevold et al., 2018). The patient might feel helpless, apathetic, and frustrated. In extreme cases, the patient becomes socially alienated and depends on family members for simple tasks. Therefore, after emergency treatment and 24-hour monitoring,

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the care plan must focus on helping the patient recover functionality and return to independent living. The care plan has incorporated intervention for the social needs emanating from the condition. Ischemic care guidelines indicate that an effective care plan must consider social support to enable the client to maintain self-esteem and interest in social activities. The client was referred to a physiotherapist and an occupational therapist. These professionals guide the patient on various physical activities including bilateral arm training that helps improve coordination.

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Recommendations to the care plan The care plan implemented by the clinician focuses more on the biological aspects of the stroke. A holistic care plan is therefore needed to address the psychosocial needs of the client. A stroke rehabilitation program is the best intervention to address these needs holistically.

Rehabilitation helps reverse brain damage, improve physical health, and enhance the client's independence. The components of the rehabilitation program include speech therapy, physical therapy, psychological counseling and occupational therapy. Li et al. (2017) noted that while speech therapy helps the patient relearn how to communicate, physical therapy improves muscular strength, coordination, movement speed, and balance.

Conclusion Stroke patients present numerous symptoms that affect their physical, psychological, and social wellbeing. These symptoms include reduced coordination, slurred speech, slow movement and post-stroke fatigue. To achieve better care outcomes, the clinician must implement a treatment plan that addresses all patient needs. The care plan must remove the physiological causes of the health problem and alleviate psychosocial symptoms. Administering tPA is the first line of treatment for Ischemic stroke. This intervention helps achieve revascularization by removing blood clots affecting the blood supply to the brain. Revascularization preserves tissue and neurons, thus, averting further damage associated with motor symptoms such as reduced coordination. Therapy, regular observation and close monitoring are also critical in the care plan since they create hope and assurance in the patient besides helping the nurse detect changes in coordination. A rehabilitation program comprising counseling, occupational therapy, and physical therapy should be integrated into the care plan to improve recovery and sustain physical health.

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References Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management.

Elsevier Health Sciences.

Herpich, F., & Rincon, F. (2020). Management of Acute Ischemic Stroke. Critical care medicine, 48(11), 1654–1663. https://doi.org/10.1097/CCM.0000000000004597 Jayaraj, R. L., Azimullah, S., Beiram, R., Jalal, F. Y., & Rosenberg, G. A. (2019).

Neuroinflammation: friend and foe for ischemic stroke. Journal of neuroinflammation, 16(1), 1-24. https://doi.org/10.1186/s12974-019-1516-2 Kirkevold, M., Kildal Bragstad, L., Bronken, B. A., Kvigne, K., Martinsen, R., Gabrielsen Hjelle, E., Kitzmüller, G., Mangset, M., Angel, S., Aadal, L., Eriksen, S., Wyller, T. B., & Sveen, U. (2018). Promoting psychosocial well-being following stroke: study protocol for a randomized, controlled trial. BMC psychology, 6(1), 12. https://doi.org/10.1186/s40359-018-0223-6 Lai, C. H., Sung, W. H., Chiang, S. L., Lu, L. H., Lin, C. H., Tung, Y. C., & Lin, C. H. (2019).

Bimanual coordination deficits in hands following stroke and their relationship with motor and functional performance. Journal of neuro-engineering and rehabilitation, 16(1), 1-14. https://dx.doi.org/10.1186%2Fs12984-019-0570-4 Li, F., Shi, W., Zhao, E. Y., Geng, X., Li, X., Peng, C., ... & Ding, Y. (2017). Enhanced apoptosis from early physical exercise rehabilitation following ischemic stroke. Journal of neuroscience research, 95(4), 1017-1024. https://doi.org/10.1002/jnr.23890 Liu, S., Feng, X., Jin, R., & Li, G. (2018). Tissue plasminogen activator-based nanothrombolysis for ischemic stroke. Expert opinion on drug delivery, 15(2), 173-184. https://doi.org/10.1080/17425247.2018.1384464

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Maltzman, S. (Ed.). (2016). The Oxford handbook of treatment processes and outcomes in psychology.. Oxford University Press.

McDermott, M., (2019). Guidelines for Early Management of Acute Ischemic Stroke: Key Points. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/11/06/15/31/ guidelines-for-the-early-management-of-ais

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Appendices Patient name: Vikesh Presenting complaint /symptoms: •

Slurred speech

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Impaired swallow

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Some left-sided neglect and residual weakness to the arm

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Reduced speed of movement.

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Post-stroke fatigue.

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Reduced confidence.

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Reduced coordination.

Medical History:  Asthma - Diagnosed Aged 8  Hypertension Grade 1 - Diagnosed 5 years ago  Prediabetes - Diagnosed 3 years ago  OA both knees Family History:  Father had diabetes and died following an MI  Mother had breast Cancer Medication:  Seretide Accuhaler Ventolin (As Required Not Required for over 1 Year)  Amlodipine 5mg OD Ramipril 10mg OD Pre-Hospital Assessment Vitals: •

Respiratory rate 20 bpm

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BP 140/90 mmHg

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Pulse 75

Physical Exam: o FAST +ve o Left Facial Droop o Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5 o Slurred Speech Acute Hospital Assessment Vitals: • Respiratory 22bpm • BP 145/90 mmHg • Pulse 82 • Temperature 37.3C, • BM — 10.9 mmol/L Physical Exam: • Confusion • Left Facial Droop • Slurred Speech • Left Motor Weakness Upper Limb 0/5, Lower Limb 2/5 • Decreased Tone • Altered Sensation • Mild Left Sided Neglect Medical Tests conducted: Test Conducted Result CT Head 

Hyperdensity in the M1 Segment of the Right Middle Cerebral Artery, with no other signs suggestive of an Ischemic Stroke noted.

A provisional diagnosis of Acute Ischemic Stroke secondary to occlusion of the M1 was made Intervention/Treatment Stroke Unit: •

Admitted to Acute Stroke Unit

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24 Hour Monitoring

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the patient was treated with an intravenous tissue plasminogen activator (tPA) at 1 h 45 min after symptom onset

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Endovascular Thrombectomy Initiated at 3hr

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INR 1.2

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ECG Sinus Rhythm

Ongoing plan in patient notes: Repeat Blood tests  FBC,  Glucose,  HBA1c,  U and Es,  Clotting 

NBM until swallow assessed further

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IV fluids NG Tube insertion if required

Referral Referral to Speech and Language Therapy Referral to Physiotherapy and Occupational Therapy Referral to a dietician