Part B: Scholarly Written Paper

Part B: Scholarly Written Paper

Janna Enikeeva
Student ID: N01026810
Date Submitted: March 15, 2016
Complex Issues and Patient Safety
Humber College

Introduction
The life of a nurse is a tough one. Nurses hold the lives of their patients in the palms of
their hands. Any mistake they make could lead to disaster and sometimes death, so they need to
be certain in their judgements. Unfortunately, theyre only human and humans make mistakes.

Part B: Scholarly Written Paper

This paper is an attempt to peer behind the mind of a nurse and understand the rationale that goes
into these critical, life-changing decisions.
The particular case in question is of a 92 year old male resident who has been in long
term care. He has Type 2 Diabetes Mellitus and coronary artery disease, which forced him to get
a coronary artery bypass graft approximately 4 years ago. He also has hypertension, depression,
and atrial fibrillation. Its been noted that he has a new onset of confusion and disorientation,
which has caused displays of agitation and yelling out.
Pathophysiological/Psychosocial Priority
The first step in deducing the appropriate course of action is to determine which
pathophysiological/psychosocial threat takes priority. Here we are faced with a choice between
delirium and the risk for stroke. Before we can make choice however, we need to understand the
definitions and consequences of each. Delirium is, a state of acute medical confusion (Lewis,
Dirksen, Heitkemper, Bucher & Camera, 2014, p. 1737). The American Psychiatric Association
describes the core features of delirium as follows:
(A) Disturbance of consciousness (i.e., reduced clarity of awareness of the environment)
with reduced ability to focus, sustain or shift attention; (B) a change in cognition (such as
memory deficit, disorientation, language disturbance) or the development of a perceptual
disturbance that is not better accounted for by a pre-existing, established or evolving
dementia; (C) the disturbance develops over a short period of time (usually hours to days)
and tends to fluctuate during the course of the day (as cited in Lewis et al., 2014, p. 1737)
As we can see, this patient has already started to demonstrate symptoms of delirium. Now
lets move on to risk of stroke. Lewis et al. (2014) says:
Stroke occurs when there is ischemia (inadequate blood flow) to a part of the brain or
hemorrhage into the brain that results in the death of brain cells. Functions such as
movement, sensation, or emotions that were controlled by the affected area of the brain
are lost or impaired (p. 1673)

Part B: Scholarly Written Paper

The second part of that statement sheds a light on why stroke should be the
pathophysiological/psychosocial threat that takes priority. It indicates that stroke can in fact
contribute to delirium by augmenting, in particular, the emotional, motor, and sensory perception
parts of the brain. Lewis et al. (2014) add to that fact by saying:
Patients who have had a stroke may have difficulty controlling their emotions. Emotional
responses may be exaggerated or unpredictable. Depression and feelings associated with
changes in body image and loss of function can make this worse (Christensen, Mayer,
Ferran, & Kissela, 2009). Patients may also be frustrated by mobility and communication
problems. Depression is common in the first year following a stroke (p. 1679)
This particular patient has already showed signs of depression and agitation and a stroke
would only magnify that. Apart from this, there have been studies done that demonstrate just
how deadly strokes can be. In this study, Yang et al. (2006) attempted to show the correlation
between folic acid fortification in grain products and stroke mortality. They did this by first
gathering data in the US, Canada, and the UK regarding mortality rates. Yang et al. (2006) write,
We restricted our analysis to the period from 1990 through 2002 and to people 40 years of age,
a group that experienced >95% of deaths associated with stroke (Methods section, Mortality
Data, para. 1). That is a startling statistic. The study goes on to conclude that the mandated folic
acid fortification that the US and Canada implemented helped to significantly decrease the
mortality rate for strokes. However, we can see how dangerous and lethal strokes were back
when we didnt understand them as well as we do now. A publication by Statistics Canada on
January 18th, 2014 showcased how deadly strokes are even in more recent years. The data shows
that strokes are the 3rd leading causes of death ranging from 2000 2011. With this rationale and
evidence to back our decision, it only makes sense to select risk of stroke as the
pathophysiological/psychosocial threat that takes priority.
Clinical Manifestation or Complication

Part B: Scholarly Written Paper

With risk of stroke selected as our pathophysiological/psychosocial priority, we now have

the task of selecting the clinical manifestation/complication associated with it. By looking at our
patients report, we can deduce the three clinical manifestations/complications that can attribute
to the risk of stroke. These are hypertension (with blood pressure being 150/60), atrial
fibrillation, and Diabetes Mellitus. Well be taking a look at atrial fibrillation first.
Atrial fibrillation is, characterized by a total disorganization of atrial electrical activity
caused by multiple ectopic foci, resulting in loss of effective atrial contraction (Lewis et al.,
2014, p. 961). What does this mean for someone at the risk of a stroke? Woods et al. (2005)
address this by stating, Overall risk of stroke increases five-fold with atrial fibrillation. Risk of
stroke is even higher in patients with structural heart disease, those with hypertension, and those
older than 65 years (as cited in Lewis et al., 2014, p. 961). As we see from our report, our
patient is well over the age of 65 and suffers from hypertension and coronary artery disease. This
puts him at serious risk for a stroke.
Hypertension is defined as, sustained elevation of systemic arterial blood pressure and
cause for visits to primary care physicians (Lewis et al., 2014, p. 667). Atrial fibrillation puts
our patient at 5 times the risk for stroke while hypertension only puts the patient at 3 times the
risk (and thats assuming statistics between men and women are fairly equal). Therefore, in this
case, we have to look at atrial fibrillation first.
Diabetes Mellitus is a multisystem disease related to abnormal insulin production,
impaired insulin utilization, or both (Lewis et al., 2014, p. 1429). A study in the UK done by
Kothari et al. attempted to find the correlation between Type 2 Diabetes and the risk of stroke.
Their opening statement in their full report says, In people with type 2 diabetes, there is a 2- to
5-fold increased risk for stroke compared with those without diabetes (Kothari et al., 2002).
They follow this by saying, Risk factors for increased risk of stroke in the type 2 diabetic
population include elevated blood pressure, smoking, age, male sex, atrial fibrillation (AF), and

Part B: Scholarly Written Paper

hyperglycemia (Kothari et al., 2002). This again puts us in an unfortunate position where we
have to look at numbers and compare. Type 2 Diabetes puts our patient at risk at a rate of 2 to 5
times, whereas atrial fibrillation is a flat 5 times.
The fact of the matter is hypertension, Diabetes Mellitus, and atrial fibrillation all put our
patient at risk for a stroke and they unfortunately all complement each other. However, atrial
fibrillation stands out as the most pressing issue at the moment and in trying to minimize the
impact it has on our patient, we can hopefully reduce the severity hypertension and Type 2
Diabetes as well.
Nursing Interventions
Now that we have our clinical manifestations/complication, we can make an attempt at
implementing nursing interventions. The first step is administering medication. A study done by
the American Heart Association (1991) attempted a trial to demonstrate how effective medication
was in stroke prevention. The double-blind test that administered either warfarin/aspirin or a
placebo found that primary events and deaths were reduced by 58% when on warfarin and 32%
when on aspirin (compared 6.3% on placebo) (American Heart and Stroke Foundation, 1991).
We then monitor and evaluate the patients ECG and vitals to be able to catch any abnormalities
as you should in any situation. We then encourage the patient to reduce the intake of caffeine and
alcohol and promote stress management techniques, because as noted earlier in this paper, stress
and alcohol in particular attribute to things like HTN.
Conclusion
By using our rationale and finding evidence to back our claims, we can be confident in
our decision-making in how to help our patient in the best way possible. We can implement this
procedure in the future to facilitate a higher proficiency in assessing and saving our patients.

Part B: Scholarly Written Paper

References
American Heart Association. (1991). Stroke prevention in atrial fibrillation
study. Final results. Circulation, 84, 527-539. doi:10.1161/01.CIR.84.2.527

Kothari, V., Stevens, R. J., Adler, A. I., Stratton, I. M., Manley, S. E., Neil, A. H., Holman, R. R.
(2002). Risk of stroke in Type 2 Diabetes estimated by the UK Prospective Diabetes Study Risk
Engine. Stroke, 33, 1776-1781. doi:10.1161/01.STR.0000020091.07144.C7
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2014). Medicalsurgical nursing in Canada: Assessment and management of clinical problems (3rd Canadian
ed.). M. A. Barry, S. Goldsworthy & D. Goodridge (Eds.). Toronto, ON: Elsevier Canada
Psaty, B. M., Manolio, T. A., Kuller, L. H., Kronmal, R. A., Cushman, M., Fried, L.
P., White, R., Furberg, C. D., Rautaharju, P. M. (1997). Incidence of risk factors
for atrial fibrillation in older adults. Circulation, 96, 2455-2461.
doi:10.1161/01.CIR.96.7.2455
Statistics Canada. (2014). [Table illustration in column-comparative form].
Ranking, number and percentage of deaths for the 10 leading causes,
Canada, 2001, 2010 and 2011. Retrieved from
http://www.statcan.gc.ca/daily-quotidien/140128/t140128b001-eng.htm
Yang, Q., Botto, L. D., Erickson, D. J., Berry, R. J., Sambell, C., Johansen, H.,
Friedman, J. M. (2006). Improvement in stroke mortality in Canada and the
United States, 1990 to 2002. Circulation, 113, 1335-1343.
doi:10.1161/CIRCULATIONAHA.105.570846

Part B: Scholarly Written Paper