Stroke: Diagnostics and Treatment

Introduction

One of the most critical characteristics of stroke is its classification as a neurological disorder and a cardiovascular disease. Because of poor blood supply, the brain is damaged, provoking certain disabilities. Donkor (2018) explains this condition as an issue of immense public health importance with a variety of economic and social outcomes. According to Stroke Association (2017; 2020), stroke strikes about every five minutes and influences the lives of more than 100,000 people annually. In the UK, stroke remains the fourth leading cause of death and the leading cause of disability because 2/3 of stroke survivors have severe complications, and dysphagia is one of them (Stroke Association, 2017).

The neural swallowing network undergoes considerable changes as soon as blood and oxygen do not reach the brain in the necessary amount. Therefore, the National Health Service (NHS) recommends identifying the signs of stroke immediately to provide patients with the necessary medical help and care. In this paper, stroke as the cause of dysphagia and malnutrition will be analysed in terms of assessment, diagnostics, and the NHS policies to treat this neurological condition either in clinical settings or at home.

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Stroke

Being frequently studied by many professional organisations and medical facilities, stroke is not always easy to prevent and predict. It happens quickly as a result of blood vessel obstruction. In some cases, brain cells die when no nutrients and oxygen are obtained, and it is impossible to continue proper functioning (National Institute of Neurological Disorders and Stroke and National Institutes of Health, 2020).

Sometimes, cells become too damaged because of extensive bleeding within the brain. Modern scientists, researchers, and doctors use the definition given by the World Health Organisation (WHO) several decades ago. Stroke is characterised by “rapidly developed clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 h or leading to death, with no apparent cause other than of vascular origin” (as cited in Abbot et al., 2017, para. 2). In other words, time becomes a crucial factor in treating patients and preventing stroke-related complications.

The help that a medical team may be offered to people with damaged brain cells depends on the type of stroke. Compared to other cardiovascular problems like myocardial infarction or heart failure, stroke is not always easy to identify its risk factors because of the existing variety of forms (Boehme, Esenwa and Elkind, 2017). Ischaemic and haemorrhagic strokes are the two common types of this condition that also have their specific classifications. The cause of ischaemic is a blockage that cuts off the brain from the blood supply, and haemorrhagic stroke happens when a blood vessel bursts in the brain due to abnormal vascular structure (Stroke Association, 2017).

The former type is observed in 80% of cases, and the latter type is diagnosed in 20% of patients, depending on the population (Boehme, Esenwa and Elkind, 2017). In addition, haemorrhagic stroke is defined as a severer and more dangerous type because about 10-15% of people are not able to reach a hospital and die because of brain surface bleeding (Stroke Association, 2017). Computer tomography (CT) or magnetic resonance imaging (MRI) is used to determine the type of stroke.

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In their turn, more subtypes are revealed for this neurological-cardiovascular disorder. For example, ischaemic strokes are classified as per the cause of damage (thrombotic, cardiogenic embolic, or cryptogenic) (Abbott et al., 2017; Donkor, 2018). Haemorrhagic stroke can be intracerebral (hypertension provokes small vessels’ rupture) or subarachnoid (aneurysm and arteriovenous malformations emerge) (Donkor, 2018; Stroke, 2020). These differences have to be identified to choose a treatment method and help an individual within allowable time limitations.

Stoke is a medical emergency, and its symptoms are thoroughly studied by doctors and nurses. There are four aspects that have to be examined, and they are known as FAST (National Health Service, 2019). First, attention is paid to face that may be dropped on one side. Second, arms are assessed because a person cannot lift them due to weakness (National Health Service, 2019). A person demonstrates slurred speech or is not able to talk at all, and no time is left but to call emergency and ask for help.

Dysphagia

In addition to common FAST symptoms of stroke, such consequences as dysphagia is observed in some patients. This condition follows acute stroke and is explained as a loss of functional connectivity; thus, a person has difficulties with swallowing (Duncan et al., 2020). A patient has a sensation that solids (mechanical obstruction) or liquids (motor disorder) do not pass from the mouth to the stomach (Carretero et al., 2016).

Sometimes, people cannot swallow certain substances, and such reactions as coughing and choking are noticed while eating or drinking. There are also situations when no food or water at all can pass, provoking vomiting or nose bleeding. If dysphagia remains poorly recognised, undiagnosed, and untreated, new digestive or neurological disorders may be developed, including aspiration pneumonia. Therefore, physiotherapists should check the patient’s ability to swallow regularly within the next 24 hours after admission, and the Gugging Swallowing Screen is frequently used (Arnold et al., 2016). Other methods to assess patients with dysphagia include radiological esophagogram, endoscopic evaluation, manometry, and electromyography (Carretero et al., 2016). However, each patient has unique characteristics, and they should be taken into consideration during interventions.

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Challenges of Stroke and Dysphagia

When a person has difficulties in swallowing because of stroke, there is a risk for malnutrition being developed with time. According to Saito et al. (2017), malnutrition and dysphagia are associated, and videofluorography is a common standard for the care providers to evaluate and manage this complication of stroke. When it is hard or even impossible for a person to swallow food or water, nutrition processes become affected, provoking new dysfunctions in different body systems. As Saito et al. (2017) mention, when patients are diagnosed with and treated for particular acute illnesses, not enough attention is usually paid to their nutritional statuses. As a result, nutritional disorders like malnutrition continue to grow along with swallowing dysfunction.

The connection between stroke, dysphagia, and malnutrition is frequently addressed in many current studies. When stroke patients need feeding assistance because of dysphagia, nurses use nasogastric tubes or percutaneous endoscopic gastrostomy for enteral nutrition after the first signs of stabilisation are observed (Sabbouh and Torbey, 2018).

Malnutrition and pneumonia disturb about 30-50% of patients after stroke as no proteins or other food-related vitamins are obtained, and improvements are predicted for the next 7-14 days in most cases (Sabbouh and Torbey, 2018). Food intake plays a significant role in patient healing processes. People are not always able to recognise their problems and threats, and it is expected from nurses to help their patients deal with dysphagia. When feeding turns out to be a challenge along with other stroke comorbidities, healthcare management is required.

Healthcare Management

Dysphagia is a complication that requires attention in terms of its assessment, diagnosis, and treatment. According to the policies by the National Health Service (2018), if a person has the signs of dysphagia like coughing, bringing food back up, and drooling, it is time to visit a hospital and seek medical advice. The main diagnostic steps are learning the patient’s history (the duration of health changes and analysis of symptoms), therapist’s, gastroenterologist’s, and neurologist’s assessment, and taking a swallow test (National Health Service, 2018). Screening and assessment of swallowing are two different interventions to examine the likelihood of dysphagia and oral intake safety (screening) and to evaluate sensory and motor functions and cognitive abilities (assessment) (Jiang et al., 2016). When the cause and type of dysphagia are established, a treatment plan has to be developed.

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Malnutrition affects a general condition of a patient or even provokes stroke-associated pneumonia; thus, specialists assess swallowing abilities regularly. The main intervention includes alternative feeding, along with oral care and articulation exercises to stimulate pharynx cooling (Eltringham et al., 2018). According to Molina et al. (2017), these interventions may be performed at primary, special, and socio-health care levels. Nutritional intake is determined by the patient’s eating and drinking abilities that are decreased because of associated discomfort (Krekeler et al., 2017). Therefore, dysphagia may be improved by means of careful management that consists of speech and language therapy (to show new swallowing techniques) and different forms of feeding (National Health Service, 2018).

Physiotherapeutic approaches are implemented by nurses to strengthen patient’s swallowing musculature and restore movement and coordination (Diéguez-Pérez and Leirós-Rodríguez 2020). This help usually results in rapidly progressive outcomes, and Audag et al. (2019) underline the importance of regular follow-up assessments, non-instrumental examinations, and self-administration. Speech and occupational therapists share simple recommendations with their patients to rain them and participate in a dysphagia treatment plan.

Pharmacological treatment is another part of after-stroke dysphagia management and self-care. Patients are usually prescribed to lipid-lowering agents, euglycemic drugs, and inhibitors to improve symptoms (Diéguez-Pérez and Leirós-Rodríguez 2020). Antihypertensive medications should be regularly taken not to provoke new stroke-related complications. Molina et al. (2017) state that there is no specific pharmacological treatment for oropharyngeal dysphagia, and all the offered medication focus on facilitating the conditions that provoke difficulty swallowing. More attention should be paid to alternative therapies and lifestyle changes.

Regarding the connection between dysphagia and malnutrition, dietary changes become a crucial element in a post-stroke patients’ healing process. For example, to minimise risks, patients should apply some texture modifications in their food and fluid habits (Audag et al., 2019; Molina et al., 2017). Thickened liquids and pureed or semi-solid foods are offered. However, some people demonstrate their dissatisfaction with the changed quality of products and taste (Krekeler et al. 2018).

They are depressed and anxious about their inabilities, and psychological assistance and emotional support are expected to motivate and remind about the importance of regular tasks either at home or in hospitals. Adherence with a therapy (physical and emotional conditions) plays a serious role, and patients, as well as their families, should be properly educated. Communication, illustrative examples, statistical reports, and simple language are the major facilitators in managing care for stroke and dysphasia patients. Living with a degenerative neurological condition is never easy, and dietary modifications cannot be ignored to cover energy, vitamin, and protein needs.

In some cases, therapeutic interventions and dietary changes are not enough to stabilise patients and avoid malnutrition risks. Therefore, surgical improvements or electrical stimulation may be required. Surgeons aim at widening the oesophagus by inserting a plastic stent or applying endoscopic dilatation (National Health Service, 2018). Electrical stimulation is based on the implementation of small electrical impulses to throat muscles (Arnold et al., 2016; Diéguez-Pérez and Leirós-Rodríguez 2020).

There are several modalities for this method: transcranial (brain stimulation with weak currents), invasive (pharyngeal stimulation to promote plasticity), and surface (neuromuscular stimulation to increase muscle performance and regular contractions) (Diéguez-Pérez and Leirós-Rodríguez 2020). Post-stroke patients question the safety and harmfulness of this method because of their physical weakness, but many professional organisations admit fewer or no adverse effects of neuromuscular electrical stimulation. No medication or cognitive therapy promises a 100% recovery, and the outcomes of the chosen approach are not always possible to predict due to specific characteristics of patients, their medical histories, and stroke complications.

Conclusion

Regarding the offered information and the analysis of NHS policies and peer-reviewed studies, complications of stroke are proved different and critical for patients. Although it is necessary to remember about the FAST warning signs of stroke and address the nearest hospital for help, this step is not enough to deal with all possible outcomes and conditions. Stroke treatment depends on the complications experienced by a patient, and this essay focuses on dysphagia and malnutrition.

Dietary modifications, speech and language therapy, electrical stimulations, and education play an important role in managing the chosen neurological condition and its potential consequence. Self-care, self-management, and cooperation with the medical staff cannot be neglected. Despite the possibility of dissatisfaction with changes or extensive recovery, stroke and dysphagia may be treated and predicted, minimising the risk for malnutrition.

Reference List

Abbott, A. L. et al. (2017) ‘Optimizing the definitions of stroke, transient ischemic attack, and infarction for research and application in clinical practice’, Frontiers in Neurology. Web.

Arnold, M. et al. (2016) ‘Dysphagia in acute stroke: incidence, burden and impact on clinical outcome’, PLoS One, 11(2). Web.

Audag, N. et al. (2019) ‘Screening and evaluation tools of dysphagia in adults with neuromuscular diseases: a systematic review’, Therapeutic Advances in Chronic Disease, 10, pp. 1-15. Web.

Boehme, A. K., Esenwa, C. and Elkind, M. S.V. (2017) ‘Stroke risk factors, genetics, and prevention’, Circulation Research, 120(3), pp. 472-495. Web.

Carretero, R. G. et al. (2016) ‘Dysphagia and aspiration as the only manifestations of a stroke’, BMJ Case Reports, 2016. Web.

Diéguez-Pérez, I. and Leirós-Rodríguez, R. (2020) ‘Effectiveness of different application parameters of neuromuscular electrical stimulation for the treatment of dysphagia after a stroke: a systematic review’, Journal of Clinical Medicine, 9(8). Web.

Donkor, E. S. (2018) ‘Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life’, Stroke Research and Treatment. Web.

Duncan, S. et al. (2020) ‘Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysis’, Intensive Care Medicine, 46(7), pp. 1326-1338. Web.

Eltringham, S.A. et al. (2018) ‘Impact of dysphagia assessment and management on risk of stroke-associated pneumonia: a systematic review’, Cerebrovascular Diseases, 46(3-4), pp.97-105. Web.

Jiang, J. L. et al. (2016) ‘Validity and reliability of swallowing screening tools used by nurses for dysphagia: a systematic review’, Tzu Chi Medical Journal, 28(2), pp. 41–48. Web.

Krekeler, B. N. et al. (2018) ‘Patient adherence to dysphagia recommendations: a systematic review’, Dysphagia, 33(2), pp.173-184. Web.

Molina, L. et al. (2017) ‘Nursing interventions in adult patients with oropharyngeal dysphagia: a systematic review’, European Geriatric Medicine, 9(1), pp. 5–21. Web.

National Health Service (2018) Dysphagia. Web.

National Health Service (2019) Stroke. Web.

National Institute of Neurological Disorders and Stroke and National Institutes of Health (2020) Stroke: hope through research. Web.

Sabbouh, T. and Torbey, M. T. (2018) ‘Malnutrition in stroke patients: risk factors, assessment, and management’, Journal of Neurocritical Care, 29(3), pp. 374-384. Web.

Saito, T. et al. (2017) ‘A significant association of malnutrition with dysphagia in acute patients’, Dysphagia, 33(2), pp. 258-265. Web.

Stroke (2020). Web.

Stroke Association (2017) State of nation. Web.

Stroke Association (2020) Stroke statistics. Web.

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