Cerebral Vascular Accident

This essay, will discuss a recent clinical experience where a patient was diagnosed with cerebral vascular accident (CVA). The main focus of this essay will be about pressure sores management and prevention. Additionally, the conclusion will discuss the learning achieved in wound care and its management process.

In adherence to the NMC code of professional conduct (2012) and confidential provision, I would like to identify my client with a pseudo name (Mary). Mary is a 74 year old woman whom is a resident of a nursing home. We had previous knowledge of a history of left cerebral vascular accident with left hemiparesis due to hypertension on 20th September 2004. See 'appendix one' for the clients profile.

At work, I have observed many clients with CVA who are at higher risk of developing a pressure ulcer. This makes me enthusiastic to learn more about the holistic approach to this problem. In order to assess fully a client's needs, a holistic and humanistic approach should be taken, looking at the physical and psychological aspects of the patient, rather than just the patients' actual health problem. According to Holland et al (2003) "Assessment is the gathering of information and formulation of judgements regarding a person's health, situation, needs and wishes, which should guide further action". Its purpose is to provide an accurate picture of patients, including both their capacity to perform activities of daily living and the stability of their condition. The action was taken to maintain a safe environment because Mary was in shock, in pain and unconscious. She was also at risk from injury due to her weakness and being in a strange environment. Due to the result of CVA she had developed severe cognitive and motor speech problem. She was unable to communicate verbally therefore she used a communicating board to express her feelings. Tracheotomy was inserted to maintain her oxygen saturation level and to prevent a chest infection. Providing adequate oxygenation to the tissues is a nursing priority, as reduced levels of oxygen will influence tissue perfusion (Walsh 1997).

She had a very poor appetite due to an acute phase of sudden illness. Therefore feeding is staged, first on a puree diet, and then she also had a problem with drinking as she could only consume 500ml a day. This was thickened to various consistencies using thickening agents. During an episode of illness Mary's habit of eliminating was changed and she is now incontinent of urine because of increased frequency of micturition due to deterioration in cerebral function in the brain. Therefore she started to wear disposable pads to keep her dry and comfortable. Poor appetite, lack of movement, exercise and low fibre diet intake has resulted in constipation. Therefore, she takes laxative Senna twice a day as prescribed by the doctor to ease the discomfort.

Due to weakness results from CVA Mary has poor strength in the right side of her body. She required assistance from a care provider for all her transfers. She can walk 100-200 yards distance with one assistant also using a Zimmer frame. Mary preferred to have a wash in the bathroom and likes to have a shower twice a week. She can wash her face and front, just needed help to wash her back and legs. Every morning she loves to brush her teeth, clean her face and apply makeup n perfume if possessed.

Mary's body temperature is under normal range; the body's internal temperature remains remarkably consistent at around 37.5 degrees Celsius. Jamieson et al (2002) suggests the average temperature of an adult should be 36-37.5 degrees Celsius. She sleeps 7-8 hours a night and expresses no issue of dying. She doesn't want to discuss this issue further as she is willing to achieve as much independence as she can whilst on her own conditions. During the assessment on her admission to the hospitals, sacrum pressure ulcer was identified as an actual problem.

The aspect of care, I have chosen for the above client was based on identifying the actual problem that is the pressure sore. I choose this aspect of care because I have observed that pressure ulcer affect clients socially, physically as well as psychologically. It carries high human cost as they can result in pain, misery, systematic illness, discomfort, anxiety, frustration, increased length of hospital stay, extended absence from work and normal activities, low self-esteem and altered body image (Hampton and Collins 2004).

In a recent European survey based in the UK, 18.1% of hospital patients were found to have pressure ulcers (Clark, Bours and Deflour 2003). The true economic cost of pressure ulceration is unknown, particularly in the community; however a recent estimate of the total cost has been given as $1.4-2.1 billion annually that is 4% of the total National Health Services expenditure (Gunnewicht and Dunford 2004).

Chapman & Chapman (1986:106) define pressure ulcer as "A localised area of cellular damage resulting either from direct pressure on the skin, causing pressure ischemia or from shearing forces causing mechanical stress to the tissue."

Stevens (1994) state 3 main factors contribute to tissue breakdown are: friction, shearing stresses and tissue maceration. However, Reid and Morrison (1994) state other contributory factors including poor nutrition, incontinence and age of the patient aged over 70 years old.

In order to learn wound care, after assessing the patient as a whole, it is important to assess the wound itself. A comprehensive wound assessment is critical to care since it establishes a baseline for subsequent comparison, permit differential diagnosis, and provide the basic for a treatment plan and facilitates timely referral to other health care providers (Faulkner 2000). Malik et al (2004) suggests when assessing the wound itself, the following should be noted. My mentor was discovering the location, the size and shape of the wound, the characteristics of the wound bed, the degree of exudates, and the presence of infection odour from the wound, pain and condition of the surrounding skin.

The process of pressure ulcer assessment of Marys included the following stages which are explained below. Anatomical location of Mary's pressure sore was on her sacrum. According to the European Pressure ulcer advisory panel guide to pressure ulcer, Marys pressure ulcer is classified as grade 3 because of the involvement of epidermis, dermis and subcutaneous layers was extension down to and including muscle. The ulceration is deep, foul smelling with a necrotic patch combined with slough and undermining of tissue and the borders are hyper pigmented. The size of the ulcer is approximately 1.5cm in diameter traced onto a plastic film to obtain a visual record of the wound size. And the maximum wound depth is measured using sterile probe which is 1cm