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 wouldn’t 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 didn’t had any pre-stroke or TIA but as diagnosed by physician she had a

history of HPT and DM.

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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 didn’t 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 didn’t 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.

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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.

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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.

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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.

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‘Mini-Stroke’ (TIA)

A transient ischemic attack (TIA), often called a ‘mini-stroke’, which is more like a pre-

stroke. 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:

Trouble with speech or having difficulty talking — you may struggle with finding

words, slur your speech, or find yourself unable to speak

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.

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Having trouble with coordination on one side of the body, especially when it

happens all of a sudden

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.

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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.

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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:

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; what’s 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

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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:

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:

have had a suspected thrombotic stroke and might benefit from clot-busting

drugs (thrombolysis) such as alteplase or early anticoagulant treatment

are already on anticoagulant treatments

have a lower level of consciousness

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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:

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.

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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.

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, trans-

oesophageal 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.

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.

 

Alcohol

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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.

Balloon and Stent

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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(t-

PA). 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 clot-

related (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:

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:

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

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

Physicians: physiatrists (specialists in physical medicine and rehabilitation),

neurologists, internists, geriatricians (specialists in the elderly), family practice

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.

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

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 : Mariam @ JaimahbtAwang

NIRC : 420711-04-5258

Age : 68 years

Sex : Female

Race : Malay

Religion : Islam

Marital Status : Marriage

Past Medical Background : HPT and DM

Medication Intake : On Tab MTF 1gm Bd, Tab Simvastatin 4 mg ON, Tab aspirin 15 mg OD

Past Surgical History : NIL

Allergies : NIL

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 doesn’t 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 Mariam’s 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 : 11/15 (Depressed)

MMSE : 28/30 (She didn’t have cognitive impairment)

SWALLOWING TEST : Moderate

GET UP AND GO TEST : 3 Inquired physiotherapy and rehabilitation

MORSE FALL SCALE : 60 (Tendency for fall noted as high risk)

NORTON SCALE : 16/20 (Noted as not a risk of getting pressure sore)

MODIFIED BARTHEL INDEX : 78 (Mild Dependency Level)

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74 6870

3031323335373840

PATIENT’S GENOGRAM

25

Die due to the old fatal

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

Single(clerk)

Single(General worker)

Married3 children(Factory)

Single(Factory)

Married5 children

(House wife)

Single(Trader)

(trade

Single(Trader)

Married3 children

(House wife)

Patient8 children

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 didn’t 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-of-

motion 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 Mariam’s 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 patient‘s 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 didn’t 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 patient’s 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 Mariam’s 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 Mariam’s 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, I’ve 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

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2. Cifu DX, Stewart DG (1999). Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil.Page S35–S39.

3. Evans RL, Connis RT, Hendricks RD, Haselkorn JK. (1995)Multidisciplinary rehabilitation versus medical care: a meta-analysis. SocSci Med.Page 1699–1706.

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 750–756.

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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