Primary Care Assignment Discussion

Primary Care Assignment Discussion

Additional Subjective Data the Patient will Share.

Taking a thorough medical history from a patient is important as it enables the healthcare provider make a diagnosis on time thus improving the patient outcomes. The patient should be allowed to describe their symptoms in details and using their own words. He should describe the character of the headache, its severity, the site, the exacerbating factors and if they took anything to relieve the headache. Patient might also give a history of blurred vision as the ophthalmic artery is a branch of the carotid artery. A history of a stiff neck and vomiting might also be reported by the patient if the intracranial pressure is raised. The patient will also talk about his compliance to medication and family history of such incidences.

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Additional Objective Data I Will Assess.

A thorough physical examination requires the nurse practitioner to evaluate anatomical findings through inspection, palpation, percussion and auscultation (IPPA). The objective data obtained during this process should be integrated with the patients history to get an impression or differential diagnosis thus guiding the healthcare provider on the investigations to order(Asif et al., 2017)Primary Care Assignment Discussion. The other additional objective data that can be assessed on this patient will include the following; obtaining a pulse rate which usually gives a picture of the cardiac frequency. The rate and regularity of the pulse rate can rule out arrhythmias as a probable cause of the stroke. Getting the body temperature is important as it is indicative of an infectious process (Garcia-Cazares et al., 2020) and hyperthermia in a patient with a stroke has a poor prognosis.

Getting a good description of the patients’ general appearance is important as it can give clues on other underlying conditions apart from the hypertension that can predispose the patient to a stroke. For example, central obesity observed from a patient’s general appearance can predispose one to a stroke. Hair distribution and the appearance of one’s skin can also be indicative of autoimmune diseases such as systemic lupus eythromatous (SLE). General examination can also reveal the parts of the brain that have been affected e.g. asymmetrical appearance of the face or facial drop Primary Care Assignment Discussion

A thorough cardiovascular examination should be done. I will inspect for any signs of a cardiovascular disease such as finger clubbing, Osler nodes, Jane way lesions, cyanosis, pulsating neck veins and the activity of the precordium. I will auscultate for heart sounds since a cardiac embolus can also cause a stroke. Palpation of peripheral pulses such as femoral, radial and posterior tibial is also recommended.

Examination of the central nervous system is important as it can reveal the location of the stroke and can rule out other differential diagnosis. I will check for any abnormalities in the cranial nerves, the muscle tone, bulk and tone of both the normal and the affected limbs and compare the grades. Sensory integrity, cerebellar function and gait of the patient will also be assessed(Tadi & Lui, 2022). The Glasgow coma scale (GCS) will be used not only to assess the patients level of consciousness but their level of confusion and their motor functions. I will test the visual fields and the extraocular muscles. With the use of a fundoscopy I will examine the eyes to rule out any other complications of uncontrolled hypertension such as a retinal hemorrhage.

National Guidelines that are Appropriate to Consider

The American Heart Association/ American Stroke Association guidelines  recommends that vascular risk factors control play a great role in the prevention of  a stroke(Kleindorfer et al., 2021). They include the control of hypertension, diabetes and reducing one’s cholesterol levels. It also recommends that lifestyle factors play a great role in predisposing one to cerebrovascular diseases. These major guidelines are supported by the fact that strokes are mostly linked to non-communicable diseases. Antithrombotic therapy is recommended in almost all stroke patients who have no contraindications Primary Care Assignment Discussion.

 Tests I Will Order.

As highlighted by(Tadi & Lui, 2022) some of the laboratory investigations that can be ordered for Mr. C include a complete blood count with great scrutiny on the platelet levels, cardiac markers such as troponin levels, a lipid profile, basic metabolic panel and a coagulation profile. A lipid profile will reveal if the strove is due to atherosclerosis which usually leads to the formation of plaques secondary to low density lipoprotein cholesterol build up in the body. Imaging investigations are most preferred tests in making a diagnosis of a stroke. The most important imaging investigations to be ordered for this patient include; a CT scan without contrast or a combination of a head CT scan, CT angiography and perfusion imaging. A CT angiogram and CT perfusion studies are useful in locating the exact site of blockage in a blood vessel and identifying the ischemic core and the areas of tissues at risk respectively. A head CT scan of a patient with a stroke will reveal hyperdense areas of the affected vessels.  Other tests that can be of great importance to this patient include an echocardiogram and a neck vessel imaging to determine the cause of the stroke. A carotid ultrasound will be helpful in evaluating the lesion in the carotid

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Will I Consult?

I will seek the consult of other doctors and even refer them to other specialties. This patient will highly benefit from the services of a neurologist and a physician since he has several neurological deficits and his blood pressures are elevated. He will also need a physiotherapist Primary Care Assignment Discussion.

Medical and Nursing Diagnoses

A medical diagnosis explains a disease process while a nursing diagnosis describes a patient’s response to the injury caused by a disease. The most probable medical diagnosis is a cerebrovascular attack or a stoke that has been brought about by poorly controlled hypertensive disease. Hypertensive emergency is also a possible medical diagnosis as evidenced by the marked increase of the patients’ blood pressure with signs of organ damage such as confusion and reduced motor function. A nursing diagnosis of the patient is impaired verbal communication as it was noted by the nurse that he was confused and thus his history was sketchy, the patient has high risks of accidental falls as he has impaired motor functions and can also have feelings of powerlessness and lose of hope. The patient has inability to perform his daily activities and his sensory perception has also been affected. Interrupted family processes an acute pain are also important nursing diagnosis. Of importance to note is that a nursing diagnosis main aim is to offer the patient holistic care while a medical diagnosis is meant to give the etiology of the disease.

Legal/ Ethical Considerations

Given the fact that a cerebrovascular accident  is an acute and unexpected disease with unknown prognosis, ethical issues in the care of this patient should be adhered to(Mahanes, 2020)Primary Care Assignment Discussion. Since the patient is confused, he should be thoroughly assessed and evaluated to determine if he can make sober decisions pertaining his care. Nurses are expected to try and communicate effectively with the patient and make clear documentations incase medico-legal issues arise. They can involve a care giver or a family member in decision making to prevent conflict. With the possibility that the patient may develop disabilities, treatment options and their outcome should be made available for the patient and their family to make a decision with the help of healthcare providers.

Plan of Care

The main aim of management of a patient with a stroked is restoration of blood flow to the affected brain tissue(Herpich & Rincon, 2020). While managing a patient with an acute stroke, time is an important factor as such a patient loses a big number of brain cells per minute. The most important step is to stabilize the patient and this is done by conducting a primary survey and ensuring that his airways are patent, he is breathing and he is not in any respiratory distress. His circulation status is determined by checking his pulses and blood pressure (ABC). Some of he drugs to be given to this patient will include antihypertensives such as intravenous labetalol 10mg to control the high blood pressures. According to (Hui et al., 2022)it is important to note that hypotension should be avoided in this patient since the perfusion of the brain depends on the elevated mean arterial pressure(MAP). Thrombolytics such as alteplase 0.9mg/kg will be helpful in dissolving blood clots that blocked blood vessels thus preventing the progression of the symptoms and restoring perfusion to the brain cells. Administer antiplatelets as they are not only useful in the management of acute disease but they also prevent the incidence of other strokes in the future (Kuriakose & Xiao, 2020)Primary Care Assignment Discussion. Administer statins which are effective against dyslipidemia. They are also antithrombotic, anti-inflammatory and protects the endothelium.

The nursing care plan focuses on the holistic care of a patient to ensure survival, prevention of further complications and improving a patient’s quality of life. The nurse should screen the patient for any risks of getting a stroke, put the patient in a comfortable and neutral position with their head slightly elevated to improve cerebral perfusion, make sure the patient is getting enough bed rest and is in a relaxing environment to reduce continuous stimulation of the brain. A nurse should make sure that patient does not strain while passing stool (administer stool softeners) to reduce the risk of another bleed. If the patient is saturating low at room air administer supplemental oxygen to reduce hypoxemia. Administer other medications as prescribed by an attending doctor.

As highlighted by (Stubbe, 2018) complementary and alternative therapies offer patients a chance to participate in their therapy thus leaving them empowered and having a sense of self identity even when facing a fatal illness. Some of the complimentary medicine options available include yoga, acupuncture which should be offered by trained personnel by inserting needles into some parts of the body to relieve pain and reduce muscle stiffness, Tui-na and Thai massage. Acupuncture has been shown to reduce the rate of mortality and dependency, Tui-na reduces the modified Asworth scale in several muscles while Thai massages improves blood flow to affected areas and herbal treatments improves the Barthel index Primary Care Assignment Discussion.

According to (Venketasubramanian, 2021) yoga has great benefits for one’s mental health as it improves the memory of a stroke patient, relieves their anxiety while Tai -chi a Chinese exercise that involves slow movements while one is in a squatting position improves their walking abilities and balance. Herbal supplements such as Ashwagandhda which has antioxidant properties treats and prevents another stroke episode, garlic prevents clotting, Asian ginseng improves memory while bilberry and turmeric lowers the cholesterol levels in the body. Rehabilitation of this patient is important to optimize post stroke outcomes (Hasan et al., 2021, p. 4). Rehabilitation is usually done to improve motor functions, speech changes, sensory deficits and cognitive impairments. Rehabilitation in this patient should be started immediately to prevent deformities and

Healthy People 2020 Objectives that should be Considered.

Healthy people 2020 is a governments plan for building a healthier nation. According to (Heffernan et al., 2019) healthy people 2020 suggests educational programs that can be employed to educate health practitioners  and the nation on how to be healthy. It aims at offering quality healthcare, preventing lifestyle diseases, preventing injuries and preventing avoidable deaths. The healthy people 2020 plan has several objectives addressing cardiovascular diseases and stroke.MR C is exhibiting signs of a stroke thus he can be enrolled in programs that will reduce his risk factors of getting another stroke such as engaging in physical activities. Physical activities will not only help in maintaining his body weight but will also eliminate the risk of him getting disuse atrophy of his affected limbs. Proper nutrition should also be considered in this patient as it boosts his immunity and keeps his weight in check. Primary Care Assignment Discussion

Using the Circle of caring, What or Who Else Should be Involved to Truly Hear the Patients Voice, getting him and the family involved in the care to reach optimal health?

In order to offer patients quality healthcare, several parties have to be involved. The circle of care model is a framework for understanding how social and behavior changes interventions particularly communication to offer quality care to improve patient outcomes. The circle of caring recommends a support behavioral maintenance and also recommends improvement of provider behavior which allows healthcare workers to provide care to their patients that is culturally acceptable preventing personal beliefs that may lead to biases in care.

Additional Patient teaching Needed.

A stroke is an acute illness that greatly changes the lives of not only the patient but also his or her relatives. Both the patient and their relatives or their primary care givers are therefore required to acquire skills that will make it easier for them to cope with this illnesses and to prevent a recurrence of such in the near future(Morin et al., 2021)Primary Care Assignment Discussion.Therefore stroke patients and their care givers should be educated on the clinical presentations of a stroke, preventive measures, the available treatment options and the recovery process(Kahu, 2022).They should be educated on the importance and how to manage the risk factors of a stroke. A DASH (Dietary Approaches to Stop Hypertension) diet which is high in fruits and vegetables and low in fats will also be valuable to this patient. The patient should be advised on the importance of complying to his antihypertensive, the importance of proper nutrition, engaging in physical exercises and even the role that genetics and certain lifestyle choices such as smoking plays in their condition.

Billing Codes I Would Recommend

According to(Korb & Jones, 2017) it is important for a healthcare provider to code a disorders accurately in order to offer the correct and quality care to patients and for maintaining accurate medical records. I would recommend the use of CPT category 169 codes which shows the outcome of stroke. Codes 160-167 are indicative of hemiplegia and hemiparesis.

Follow up.

Follow up of patients is important as it ensures continuation of patient care. A post stroke patient should return to a neurologist few weeks after they are discharged from the hospital. During the visit the healthcare practitioner should inquire if the neurological deficits have resolved or are getting worse, inquire on the patient’s compliance to medication and how they are coping given the fact that they have neurological deficits. Repeat vital signs, imaging studies such as CT scan of the head, neck ultrasound and an  echocardiogram. Laboratory studies such as INR, full hemogram, should be repeated. Counsel on the importance of lifestyle changes to prevent another event. Primary Care Assignment Discussion

References.

Asif, T., Mohiuddin, A., Hasan, B., & Pauly, R. R. (2017). Importance Of Thorough Physical Examination: A Lost Art. Cureus, 9(5), e1212. https://doi.org/10.7759/cureus.1212

Garcia-Cazares, R., Merlos-Benitez, M., & Marquez-Romero, J. (2020). Role of the physical examination in the determination of etiology of ischemic stroke. Neurology India, 68(2), 282. https://doi.org/10.4103/0028-3886.284386

Hasan, T. F., Hasan, H., & Kelley, R. E. (2021). Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines, 9(10), 1486. https://doi.org/10.3390/biomedicines9101486

Heffernan, M., Fromknecht, C. Q., McGowan, A. K., Blakey, C., & Oppenheimer, C. C. (2019). Healthy People for the 21st Century: Understanding Use of Healthy People 2020 as a Web-Based Initiative. Journal of Public Health Management and Practice, 25(2), 121–127. https://doi.org/10.1097/PHH.0000000000000784

Herpich, F., & Rincon, F. (2020). Management of Acute Ischemic Stroke. Critical Care Medicine, 48(11), 1654–1663. https://doi.org/10.1097/CCM.0000000000004597

Hui, C., Tadi, P., & Patti, L. (2022). Ischemic Stroke. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499997/

Khaku, A. S., & Tadi, P. (2022). Cerebrovascular Disease. In StatPearls. StatPearls Publishing.

Kleindorfer, D. O., Towfighi, A., Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., Kamel, H., Kernan, W. N., Kittner, S. J., Leira, E. C., Lennon, O., Meschia, J. F., Nguyen, T. N., Pollak, P. M., Santangeli, P., Sharrief, A. Z., Smith, S. C., Turan, T. N., & Williams, L. S. (2021). 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke, 52(7). https://doi.org/10.1161/STR.000000000000037

Korb, P. J., & Jones, W. (2017). Coding in Stroke and Other Cerebrovascular Diseases: CONTINUUM: Lifelong Learning in Neurology, 23(1), e1–e11. https://doi.org/10.1212/CON.0000000000000425

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International Journal of Molecular Sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609

Mahanes, D. (2020). Ethical Concerns Caring for the Stroke Patient. Critical Care Nursing Clinics of North America, 32(1), 121–133. https://doi.org/10.1016/j.cnc.2019.11.001

Morin, D., Rémillard, S., Salerno, A., & Michel, P. (2021). [Stroke patient education: Scientific evidence, practical application]. Therapeutische Umschau. Revue Therapeutique, 78(6), 249–258. https://doi.org/10.1024/0040-5930/a001269

Stubbe, D. E. (2018). Complementary and Alternative Medicine: If You Don’t Ask, They Won’t Tell. Focus (American Psychiatric Publishing), 16(1), 60–62. https://doi.org/10.1176/appi.focus.20170052

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Tadi, P., & Lui, F. (2022). Acute Stroke. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK535369/

Venketasubramanian, N. (2021). Complementary and alternative interventions for stroke recovery – a narrative overview of the published evidence. Journal of Complementary and Integrative Medicine, 18(3), 553–559. https://doi.org/10.1515/jcim-2020-0062 Primary Care Assignment Discussion