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Case Study 18: StrokeUnderstanding the Disease and PathophysiologyDefine Stroke. Describe the differences between ischemic and hemorrhagic stroke. Stroke: An occlusion or hemorrhaged of a cerebral artery resulting in impaired function, tissue damage or death. Sudden diminution or loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction (as by a clot) of blood vessel of the brain.Hemorrhagic Stroke: A stroke resulting from the hemorrhage of a cerebral artery. Caused by the rupture of a blood vessel with bleeding into the tissue of the brain.Ischemic Stroke: A stroke resulting from cerebral arterial occlusion. This stroke is also caused by thrombosis or embolism. What does Mrs. Noland’s score for the NIH Stroke Scale Indicate?The NIH Stroke Scale is an assessment instrument used to evaluate the effect of acute cerebral infarction. The NIH Stroke Scale assessment include 15 neurologic-based questions/tasks are scored from 0-3 or 5 with possible to 34. High scores usually indicate high states of impairment while 0 or low scores indicate normal ability. Because Mrs. Noland obtained a score of 14 that indicates a significant impairment. Mrs. Noland’s motor skills took the hardest hit.What are the factors that place an individual at risk for stroke?Family History/Race: Stroke risk is usually higher if a parent, sister, brother, or grandparent has had a stroke; African Americans are also higher at risk than Caucasians.Gender: More common in men than womenAge: The chance of obtaining a stroke increases every ten years over the age of 55 years oldHeart Attack: Heart Attack weakens the body in such a way that the risk of stroke is significantly increased.Hypertension: High blood pressure is the leading cause of stroke.Cigarette Smoking: Nicotine and carbon monoxide in cigarette smoke can damage the cardiovascular system which can increase the risk for stroke.Poor Diet: Diets that are high in saturated fat, Trans fat, and cholesterol can lead to blood high which can increase the likelihood of a stroke.Alcohol Abuse: Alcohol abuse can lead to medical complications, some of which can lead to strokeDrug Abuse: Drug abuse, especially cocaine, amphetamines, and heroin, can lead to not only medical complications but a stroke as well.What specific signs and symptoms are noted with Mrs. Noland’s exam and history are consistent with her diagnosis?Sudden DizzinessNo Speech or Trouble speakingParalysis of on the ride side of the body and faceWhat is rtPA? Why was it administered?rtPA is the acronym for Recombinant Tissue Plasminogen Activator; commercially sold as Alteplase, which is typically used to alleviate central line blockages caused by clot formation. When used early it can detect the stages of ischemic stroke and alleviate the blockage, which is causing the stroke and, at least partially, restore neurologic function. Which symptoms that you identified in question 4 may place Mrs. Noland at nutritional risk? Explain your rationale. A symptom that I identified that may place Mrs. Noland at nutritional risk is the inability to properly move her face and operate her tongue for speech. This is a nutritional risk because this may prevent her from being able to eat orally and swallow properly. Understanding the Nutrition TherapyDefine dysphagiaDysphagia is define as difficulty swallowingWhat is the primary nutrition implication of dysphagia?The primary nutrition implication of dysphagia is the inability to deliver nutrients to their stomach for absorption. This will reduce intake and the inability to eat or swallow which may become depressing for patient. Describe the four phases of swallowing:Oral preparation: The chewing of food and mixing it with saliva as the tongue mixes it around, forming bolus.Oral transit: The backward movement of the bolus to the rear of the oral cavity by the tongue squeezing against the hard and soft palates. Pharyngeal: The phase begins when the bolus progressed past the faucial arches and is quickly followed in succession by the following steps:Elevation of the soft palate, closing off the nasopharynx (prevents oropharyngeal regurgitation).Elevation of the hyoid and larynx with adduction of the vocal cords, protecting the airway. Contraction of the pharynx while the cricopharyngeal sphincter relaxes, allowing food to pass into the esophagus.Breathing resumes.Esophageal: This is the phase which the bolus continues to travel down the esophagus into the stomach.It is determined that Mrs. Noland dysphagia is centered in the esophageal transit phase, and she has reduced esophageal peristalsis. Which dysphagia diet level is appropriate to try with Mrs. Noland?Mrs. Noland esophagus is working slowly which is causing slow transit of the bolus into the stomach. Therefore, more time will be needed for her to eat her meals. Mrs. Noland should be placed on a level 3 transition to regular diet. This diet consists of food of nearly regular textures but avoiding very hard or crunchy foods. Its encouraged foods are moist and in bite sized pieces. These textures are usually appropriate for patients with mild oral and pharyngeal phase dysphagia. Describe a bedside swallowing assessment. What are the background and training requirements of a speech-language pathologist?The bedside swallowing assessment occurs in several stages: Evaluation of the patient’s medical history for etiology of the swallowing deficiency. Observation of the swallowing function of saliva. Swallowing function of small amounts of material of various consistencies with focus on bolus control and laryngeal elevation and observation of voice quality after swallowing for wetness, an indicator of inadequate bolus clearance and possible aspiration. If you see the presence of choking, gagging, or couching is noted and may be grounds for terminating the assessment. Speech-language pathologist is required to have a master’s degree in a program accredited by the council on academic accreditation. The curriculum covers the anatomy, physiology, and developmental factors affecting speech, language, and swallowing as well as the nature of disorders, principles of acoustics, and the psychological aspects of communication; includes evaluation and treatment in a supervised clinical practicum. General licensing requirements are:Master’s Degree from an accredited program9 months of postgraduate professional clinical experience300-375 hours of supervised clinical experiencePass the National exam on speech language pathology offered through the praxis series of the educational testing service. Describe a modified barium swallow or fiberoptic endoscopic evaluation of swallowing.A modified barium swallow is a series of x-rays that are taken of the oral cavity and esophagus while the patient is eating, drinking food or items of various consistencies that encompass barium. Determining the degree of swallowing difficulty associated with various types.What is the National Dysphagia Diet? Describe the major difference among the four levels of the diet. DietDescriptionExamples of FoodsNDD-1: Dysphagia PureedHomogeneous, very cohesive, pudding like foods that require very little chewing abilityMash Potatoes, hot cereals NDD-2: Dysphagia Mechanically AlteredCohesive, moist, semi-solid foods that requires some chewing.Bananas, NDD-3: Dysphagia AdvancedSoft foods that require more chewing abilityMeatloaf, moist fish, mac and cheese Thickening agents and specialty food products are often used to provide the texture changes needed for the dysphagia diet. Describe one of these products and how they may be incorporated into the diet. Hormel health labs make thick and easy instant food thickener. It is altered corn starch thickener that comes in a bulk powder or individual packets pre measured to turn a 4 ounce of liquid or puree into either honey or nectar consistency. I would most likely add it to a smoothie or fruit juices. Nutrition AssessmentEvaluation of Weight/Body CompositionMrs. Noland’s usual body weight is approximately 165 lbs. Calculate and interpret her BMI.UBW= 165 lbs BMI= 30.2kg (Obese)Calculation of Nutrient RequirementsEquation: 10 (wt.kg) + 6.25 (ht.cm) -5(age) -16110 (75) + 6.25(157.5)-5(77)-161 = 1188 * 1.2 = 1426 TEEProtein = 0.8 x 75 = 60gEstimate Mrs. Noland’s energy and protein requirements. Should weight loss or weight gain be included in this estimation? What is your rationale Intake DomainMrs. Noland is obese and weight maintenance should be emphasized because she will have difficulty when she is going to have taking food and drinks orally.Using Mrs. Noland usual dietary intake, calculate the total number of kilocalories she consumed as well as the energy distribution of kilocalories for protein, carbohydrate, and fat.Mrs. Noalnd typically consumes 1800-2000 kcal dailyFat: 8%Carbohydrates: 60%Protein: 20%Compare this to the recommended intake for an individual with hyperlipidemia and hypertension. Do these recommendations apply to Mrs. Noland at the present?Mrs. Nolands diets seem to be within the DASH recommended guidelines, however she consumes too much sodium a day (3000mg). This is not encouraged for individuals diagnosed with hypertension. Estimate Mrs. Noland’s fluid needs using the following method’s: weight, age and weight, and energy needs.Weight: 75kg x 30 cc = 2250mLAge & Weight: 75 kg x 25mL = 1875Energy Needs: 1200-1300mL **Daily**Which method of fluid estimation appears most reasonable for Mrs. Noland? ExplainI believe that the intake for Mrs. Noland is appropriate for Mrs. Noland because this method accounts for her elevated age and weight. 1875 mL dialy.From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Pre-admission based on 24-hour/typical dietary pattern: Excessive oral food and beverage intakeHospitalization: Inadequate fluid intakeClinical DomainAltered nutrition-related laboratory values: Lipid profileOverweight/obeseReview Mrs. Noland’s labs upon admission. Identify any that are abnormal. Using the following table describe their clinical significance for Mrs. Noland. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term.Select two high priority nutrition problems and complete PES statement for each.Nutrition related to laboratory values causing impaired liver function. Excessive sodium intake related to food and nutrition related education deficit concerning high intake s of sodiumNutrition InterventionFor each of the PES statements that you have written, establish an ideal goal and an appropriate interventionNutrition Monitoring and EvaluationTo maintain or attain normal nutritional status while reducing danger of aspiration and choking, texture and/or viscosity are personalized for a patient with dysphagia. In the following table, define each term used to describe characteristics of foods and give an example.Using Mrs. Noland’s 24 hour recall, make suggestions for consistency changes or food substitutions to Mrs. Noland and her familyDescribe Mrs. Noland’s potential nutritional problems upon discharge. What recommendations could you make to her husband to prevent each problem you identified? How would you monitor her progress?Once discharge Mrs. Noland is going to have a difficult time trying to get around. Mr. Noland is going to definitely have to help her get around as well as learn how to cook to prepare meals that is low in sodium and ADLs as well. She must stick to the DASH diet. Mrs. Noland will need a speech-language pathologist personal to help her as well once discharged Would Mrs. Noland be an appropriate candidate for a stroke rehabilitation program? Why or why not?Mrs. Noland is an appropriate candidate for stroke rehabilitation because she will regain her abilities and learn methods she will need to cope with her limited movement and sensation that she will obtain on one side of her body. ................
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