Mrs Soo Hui is a 46-year-old female (identifies as she, her) Case analysis

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Patient Case Study: Mrs. Soo Hui

Patient Details
Mrs Soo Hui is a 46-year-old female (identifies as she, her) admitted to your ward at St Elsewhere Hospital, following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. The next-door neighbour found her on the ground outside her front door unable to move or speak. She has been diagnosed as having a left sided ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.

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Family History

Born to Thai parents in Australia
Buddhist & speaks Thai & English
Lives with husband & 2 children, Ty (13 years old) & Grace (5 years old)
Also her father who is a frail 82-year-old.

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Medical History

• Hypertension

• Type 2 Diabetes

• Asthma

• Depression

• Hearing aid left ear

• Bi-focal glasses (broken in fall)

• Upper dental partial plate

• Medication: Amlodipine, Metformin, Salbutamol

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Admission Observations

• BP: 150/90

• PR: 85 regular

• RR: 24

• Temp: 36.9°C

• SpO₂: 96% on room air

• BGL: 8.4 mmol

• Weight: 69 kg

• Height: 162 cm

• GCS (Glasgow Coma Scale): 14

  • Eyes open to speech

  • Oriented to time, place, and person (speech slurred, but able to be understood)

  • Right hemiparesis

  • PERL (Pupils equal reactive to light)

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Issues/Impacts of the CVA

• Pain on movement, mainly right hip & shoulder stated as 7/10

• Large haematoma right hip

• 5 cm skin tear right elbow

• Dysphasia

• Dysphagia

• Right-sided facial droop

• Mild right-side hemiplegia

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Initial Doctor’s Orders and Interventions

• Rest in bed (RIB)

• 2nd hourly neurological observations

• Nil by mouth (NBM) until Speech Therapist review

• Physiotherapist review

• Full help with hygiene

• IDC in situ

• Intravenous therapy via cannula in left forearm

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Discharge Information

Mrs Soo Hui will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.

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Questions and Answers

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1. Explain how you would prepare the hospital room for Mrs Hui’s admission to the ward.

• Ensure the bed is properly made with clean linens.

• Arrange necessary equipment within reach (e.g., call bell, bedside table).

• Ensure adequate lighting and ventilation.

• Check and clean the bathroom facilities if applicable.

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2. List 4 pieces of equipment you would need to conduct an assessment on Mrs Hui when she is admitted to the ward.

• Sphygmomanometer (blood pressure cuff)

• Stethoscope

• Thermometer

• Glucometer

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3. Identify 4 components of correct nursing documentation (this also includes electronic documentation).

• Date and time of assessment or intervention

• Objective findings (vital signs, observations)

• Subjective information provided by the patient or caregiver

• Plan of care or interventions initiated

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4. Why is it important to measure and record a person’s weight and height on admission?

• To establish baseline data for monitoring changes in health status.

• To calculate medication dosages accurately.

• To assess nutritional status and plan appropriate dietary interventions.

• To monitor growth in pediatric or adolescent patients.

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5. Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui?

Identification: Mrs Soo Hui, 46-year-old female, admitted for left-sided ischemic CVA.
Situation: Admitted following symptoms of blurred vision, numbness, and sharp head pain. Currently on anti-coagulant therapy.
Background: Medical history includes hypertension, Type 2 diabetes, asthma, and depression. Lives with husband, 2 children, and elderly father.
Assessment: Presenting observations, neurological deficits, and any immediate concerns.
Recommendation: Orders for ongoing care, including neurological observations, nil by mouth status, and plans for rehabilitation.

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6. Explain the two types of CVA, including where it occurs and what causes it.

Ischemic Stroke:
Caused by a blockage (clot) in a blood vessel supplying blood to the brain. Can occur in various parts of the brain.

Hemorrhagic Stroke:
Caused by bleeding in the brain due to the rupture of a blood vessel. Can occur within the brain tissue (intracerebral) or between the brain and the skull (subarachnoid).

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7. Identify four (4) indications of a left sided CVA.

• Right-sided weakness or paralysis (hemiparesis/hemiplegia).

• Aphasia or dysphasia (difficulty speaking or understanding language).

• Visual disturbances.

• Impaired ability to perform tasks involving logic or analysis.

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8. Identify the other morbidities/co-morbidities that Mrs Hui has.

• Hypertension

• Type 2 Diabetes

• Asthma

• Depression

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9. Mrs Hui is 46 yrs of age, discuss how depression can affect a person in middle adulthood.

Depression can affect middle-aged individuals by impacting their ability to function at work, in relationships, and in daily activities.
It may manifest as fatigue, irritability, changes in appetite or sleep patterns, and loss of interest in previously enjoyed activities.
Middle-aged adults with depression may also be at increased risk for developing chronic health conditions like diabetes and cardiovascular disease.

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Care Plans

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Care Plan 1: Impaired Physical Mobility related to right-sided weakness secondary to CVA.

Nursing Implementations:

• Assist with range of motion exercises for affected limbs.

• Implement safety measures to prevent falls.

Rationale and Assessment:

• Rationale: Range of motion exercises prevent contractures and maintain joint function.

• Assessment: Evaluate the patient’s ability to perform exercises and document any improvement or deterioration in mobility.

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Care Plan 2: Risk for Aspiration related to dysphagia secondary to CVA.

Nursing Implementations:

• Assess swallowing function before allowing oral intake.

• Position the patient upright during meals and feedings.

Rationale and Assessment:

• Rationale: Assessing swallowing function prevents aspiration, which can lead to pneumonia.

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Answer Writing Guide – Exemplar;

Mrs. Soo Hui’s Admission to the Ward

Room Preparation Prior to Admission

Prior to Mrs. Hui’s admission, the hospital room should be prepared by ensuring a clean and safe environment.
The bed should be made with fresh linens, and necessary equipment, such as a bedside table, chair, and call bell, should be within reach.
Additionally, the room should be well-lit, with proper ventilation and temperature control.

Equipment for Mrs. Hui’s Assessment

• Sphygmomanometer (blood pressure cuff)

• Stethoscope

• Pulse oximeter

• Neurological assessment tools (e.g., Glasgow Coma Scale, stroke scale)

Nursing Documentation Components

• Patient identification (name, date of birth, medical record number)

• Date and time of entry

• Clear and concise documentation of assessments, interventions, and patient responses

• Legible handwriting or electronic entries

Importance of Measuring and Recording Weight and Height on Admission

Measuring and recording a person’s weight and height on admission is crucial for several reasons:

• Assists in calculating appropriate medication dosages

• Helps evaluate nutritional status and fluid balance

• Provides baseline data for monitoring changes over time

• Aids in determining equipment needs (e.g., wheelchair, walker)

ISBAR Handover for Mrs. Hui

I – Identification:
Mrs. Soo Hui, 46 years old, admitted with a left-sided ischemic cerebrovascular accident (CVA).

S – Situation:
Presented with blurred vision, right-sided numbness, and a sharp headache. Found on the ground outside her home, unable to move or speak.

B – Background:
Hypertension, Type 2 Diabetes, Asthma, Depression.
Medication – Amlodipine, Metformin, Salbutamol.
Husband and two children at home, also cares for an elderly father.

A – Assessment:
GCS 14, slurred speech, right hemiparesis, dysphagia, right facial droop, mild right-sided hemiplegia.
Vital signs stable.

R – Recommendation:
Continue neurological observations, physiotherapy review, speech therapy review, full assistance with hygiene, and intravenous therapy.
Discharge planning initiated.

Types of Cerebrovascular Accidents (CVA)

Ischemic Stroke:
Caused by a blockage in an artery supplying blood to the brain, leading to a lack of oxygen and nutrient supply.

Hemorrhagic Stroke:
Caused by a ruptured blood vessel in the brain, leading to bleeding and increased pressure on brain tissue.

Indications of a Left-Sided CVA

• Right-sided hemiparesis (weakness or paralysis)

• Right-sided hemineglect (lack of awareness of the right side of the body)

• Aphasia (difficulty with language and communication)

• Right-sided facial droop

Mrs. Hui’s Co-Morbidities

• Hypertension

• Type 2 Diabetes

• Asthma

• Depression

Depression in Middle Adulthood

Depression can significantly impact individuals in middle adulthood, affecting their overall well-being and quality of life.
It can lead to decreased productivity, strained personal relationships, and increased risk of developing other health issues.
Middle adulthood often brings unique challenges, such as career stress, caregiving responsibilities, and physical changes associated with aging, which can contribute to or exacerbate depressive symptoms.

Nursing Care Plans

1. Impaired Physical Mobility related to right-sided hemiparesis

Nursing Implementations:
a. Encourage active range-of-motion exercises and proper positioning to prevent contractures.
b. Provide assistive devices (e.g., walker, wheelchair) and ensure a safe environment for ambulation.

Rationale:
Promoting mobility and preventing complications associated with immobility.

Assessment:
Evaluate range of motion, strength, and ability to perform activities of daily living.

2. Risk for Impaired Skin Integrity related to immobility and incontinence

Nursing Implementations:
a. Perform regular skin assessments and implement pressure relief measures.
b. Provide incontinence care and maintain proper hygiene.

Rationale:
Preventing skin breakdown and promoting comfort.

Assessment:
Assess skin condition, identify areas of pressure or moisture, and monitor for signs of infection.

3. Dysphagia related to neurological impairment

Nursing Implementations:
a. Implement dietary modifications as recommended by the speech therapist.
b. Provide assistance with eating and drinking, ensuring proper positioning and monitoring for aspiration.

Rationale:
Preventing aspiration and ensuring adequate nutritional intake.

Assessment:
Observe for signs of difficulty swallowing, coughing, or choking during meals.

4. Risk for Injury related to cognitive impairment and physical limitations

Nursing Implementations:
a. Implement fall precautions and provide a safe environment.
b. Educate Mrs. Hui and her family on safety measures and techniques for safe transfers.

Rationale:
Preventing falls and promoting patient safety.

Assessment:
Evaluate cognitive function, balance, and mobility, and monitor for any unsafe behaviors.

References

Aiyagari, V. and Gorelick, P.B. (2018). Stroke Pathophysiology. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK531752/ [Accessed 25 Mar. 2024].

Breen, K.J. and Arvanitakis, Z. (2020). Depression in middle-aged and elderly adults. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327188/ [Accessed 25 Mar. 2024].

Hinkle, J.L. and Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 14th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Nursing Council of New Zealand (2020). Competencies for Registered Nurses. [online] Available at: https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursing-section/Standards_and_guidelines_for_nurses.aspx [Accessed 25 Mar. 2024].

Sacco, R.L. and Kasner, S.E. (2015). Treatment of Acute Ischemic Stroke. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434271/ [Accessed 25 Mar. 2024].

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 Sample Assessment Answer;

NURSING CARE PLAN FOR ACUTE ISCHAEMIC STROKE: CASE ANALYSIS OF MRS SOO HUI

Room Preparation and Admission Protocol

Preparation of the hospital room before patient arrival establishes safety parameters and facilitates immediate care delivery. The bed requires positioning at an appropriate height with side rails accessible for activation. Clean linen must be secured to prevent movement-related complications. The call bell requires placement within reach of the unaffected left hand, accounting for right-sided hemiparesis. Adequate lighting enables neurological assessment accuracy, whereas temperature regulation between 20-22°C maintains patient comfort without inducing vasoconstriction or vasodilation that could affect blood pressure readings.

Equipment arrangement follows functional accessibility principles. The bedside table positions on the left side to accommodate right-sided weakness. Oxygen delivery systems and suction equipment require immediate availability given aspiration risk from dysphagia. The bathroom undergoes cleaning with non-slip mats installed and grab rails verified for stability. Space allocation for monitoring equipment, intravenous poles, and wheelchair access determines furniture positioning (National Stroke Foundation, 2022).

Essential Assessment Equipment

Initial assessment requires a sphygmomanometer for blood pressure monitoring, as hypertensive episodes post-stroke indicate potential haemorrhagic transformation or inadequate blood pressure control. A stethoscope enables cardiac and respiratory auscultation to detect arrhythmias such as atrial fibrillation, a common ischaemic stroke precipitant, and aspiration-related adventitious breath sounds (Middleton et al., 2021).

A thermometer measures core temperature because fever within 48 hours post-stroke correlates with increased infarct size and poor outcomes. A glucometer provides blood glucose levels, as hyperglycaemia exacerbates ischaemic injury through oxidative stress mechanisms. Additional equipment includes a pulse oximeter for continuous oxygen saturation monitoring, neurological assessment tools incorporating the Glasgow Coma Scale for consciousness evaluation, and a penlight for pupillary response assessment (Cadilhac et al., 2020).

Documentation Standards

Accurate documentation requires patient identification through name, date of birth, and medical record number at each entry point. Date and time stamps in 24-hour format establish temporal relationships between interventions and patient responses. Objective data encompasses vital signs, neurological observations, and physical assessment findings documented using standardized terminology. Subjective information captures patient-reported symptoms, pain levels, and concerns expressed through verbal or non-verbal communication, accounting for dysphasia limitations.

Intervention documentation specifies actions taken, medications administered with dosages and routes, and patient responses. Electronic documentation systems require completion of mandatory fields without copy-forward functions that obscure temporal changes. Legibility and clarity prevent misinterpretation, whereas error correction follows institutional protocols involving single-line strikethrough with dated initials rather than deletion (Pollack et al., 2023).

Anthropometric Measurement Rationale

Weight and height measurement on admission establishes baseline parameters for multiple clinical calculations. Medication dosing, particularly anticoagulant therapy initiated for stroke management, requires accurate weight-based calculations to achieve therapeutic ranges without haemorrhagic complications. Body mass index calculation from height and weight identifies obesity as a modifiable stroke risk factor and informs nutritional intervention planning.

Fluid balance monitoring relies on weight trends to detect retention or deficit states. Weight changes signal disease progression, medication effects, or nutritional inadequacy. Height measurements determine appropriate equipment sizing for mobility aids, hospital beds, and pressure-relieving devices. Nutritional status assessment through weight-for-height comparisons guides dietary planning during the nil-by-mouth period and subsequent swallowing therapy progression (National Stroke Foundation, 2022).

ISBAR Clinical Handover

Identification introduces Mrs Soo Hui, a 46-year-old female admitted with left-sided ischaemic cerebrovascular accident. Location specifies the ward and bed number, whereas attending physician and admission date provide context.

Situation describes the presenting symptoms of blurred vision, right-sided numbness, and acute headache, with discovery circumstances noting the neighbour finding her immobile and non-verbal outside her residence. Current treatment includes anticoagulant therapy via intravenous cannula in the left forearm, neurological observations conducted two-hourly, and nil-by-mouth status pending speech therapy evaluation.

Background encompasses medical history of hypertension, type 2 diabetes, asthma, and depression. Medications prior to admission include amlodipine for blood pressure management, metformin for glycaemic control, and salbutamol for bronchodilation. Family composition includes her husband, two children aged 13 and 5 years, and an 82-year-old father requiring care, introducing caregiver burden considerations.

Assessment findings reveal Glasgow Coma Scale score of 14 with eyes opening to speech, person-place-time orientation maintained despite slurred speech, and right hemiparesis affecting mobility. Vital signs show blood pressure 150/90 mmHg, pulse 85 beats per minute regular, respiratory rate 24 breaths per minute, temperature 36.9°C, oxygen saturation 96% on room air, and blood glucose level 8.4 mmol/L. Physical examination identifies a 7/10 pain rating during movement concentrated in the right hip and shoulder, a large haematoma on the right hip, a 5cm skin tear on the right elbow, right-sided facial droop, and dysphagia requiring swallowing assessment.

Recommendation includes continuing two-hourly neurological observations to detect deterioration, maintaining nil-by-mouth status until speech therapist clearance, scheduling physiotherapist review for mobilization planning, providing full assistance with hygiene activities, monitoring the indwelling catheter for output and infection signs, and ensuring intravenous therapy patency. Discharge planning involves rehabilitation unit transfer after two weeks of acute care, with community services and discharge planning team engagement initiated (Middleton et al., 2021).

Cerebrovascular Accident Pathophysiology

Ischaemic stroke accounts for 87% of cerebrovascular accidents and results from arterial occlusion preventing blood flow to brain tissue. Thrombotic ischaemic strokes develop from atherosclerotic plaque formation in cerebral or carotid arteries, creating progressive stenosis until complete occlusion occurs. Embolic ischaemic strokes originate from cardiac sources, particularly atrial fibrillation, where thrombi dislodge and travel through the circulation to cerebral vessels. Occlusion duration determines infarct core formation within minutes, surrounded by penumbra tissue potentially salvageable through rapid intervention (National Stroke Foundation, 2022).

Haemorrhagic stroke represents 13% of cases and involves blood vessel rupture within brain parenchyma or subarachnoid space. Intracerebral haemorrhage results from chronic hypertension causing arterial wall weakening and rupture, typically affecting basal ganglia, thalamus, pons, or cerebellum. Subarachnoid haemorrhage frequently stems from aneurysm rupture at arterial bifurcations in the Circle of Willis. Blood accumulation creates mass effect, elevates intracranial pressure, and disrupts surrounding tissue through mechanical compression and toxic metabolite release (Cadilhac et al., 2020).

Left-Sided Cerebrovascular Accident Indicators

Left hemisphere stroke produces right-sided hemiparesis or hemiplegia due to corticospinal tract decussation at the medullary pyramids. Motor weakness affects the face, arm, and leg contralateral to the lesion, with upper extremity involvement typically more severe than lower extremity deficits.

Aphasia manifests when the stroke affects Broca’s area in the inferior frontal gyrus, producing expressive aphasia with intact comprehension but impaired speech production, or Wernicke’s area in the superior temporal gyrus, creating receptive aphasia with fluent but meaningless speech and comprehension deficits. Dysphasia represents milder language impairment along the aphasia spectrum.

Right-sided visual field deficits occur when the stroke damages the left occipital lobe or optic radiations, producing homonymous hemianopia where both eyes lose vision in the right visual field. Right-sided sensory loss accompanies parietal lobe involvement, impairing proprioception, touch, pain, and temperature sensation.

Left hemisphere dominance for analytical processing, sequential reasoning, and mathematical calculation creates deficits in these cognitive domains. Apraxia, the inability to execute learned motor tasks despite intact motor function, emerges from left parietal or frontal damage (Pollack et al., 2023).

Co-Morbidity Analysis

Hypertension constitutes the most significant modifiable stroke risk factor, with systolic blood pressure above 140 mmHg doubling stroke risk. Chronic hypertension accelerates atherosclerosis through endothelial damage, arterial stiffening, and lipid deposition. Mrs Hui’s admission blood pressure of 150/90 mmHg indicates inadequate control despite amlodipine therapy, necessitating medication adjustment post-acute phase.

Type 2 diabetes increases stroke risk through multiple mechanisms including hyperglycaemia-induced endothelial dysfunction, increased thrombogenicity, and accelerated atherosclerosis. Insulin resistance promotes inflammatory cytokine production and oxidative stress. Blood glucose level of 8.4 mmol/L requires monitoring because post-stroke hyperglycaemia worsens neurological outcomes through lactate accumulation in ischaemic tissue and blood-brain barrier disruption.

Asthma management with salbutamol presents minimal direct stroke correlation but requires consideration during respiratory assessment. Beta-agonist therapy can increase heart rate and blood pressure, complicating cardiovascular monitoring. Aspiration pneumonia risk from dysphagia necessitates vigilant respiratory assessment for bronchospasm or infection.

Depression affects 30-40% of stroke survivors, but Mrs Hui’s pre-existing depression suggests chronic course potentially exacerbated by stroke-related disability. Depression impairs rehabilitation participation, medication adherence, and functional recovery (Middleton et al., 2021).

Depression in Middle Adulthood

Middle adulthood, spanning ages 40-65 years, involves multiple psychosocial stressors that depression magnifies. Occupational demands peak during these years, whereas depression impairs concentration, decision-making, and productivity, jeopardizing employment stability. Mrs Hui’s inability to work during recovery compounds financial stress, particularly with dependent children and an elderly parent requiring care.

Relationship strain emerges as depression diminishes emotional availability and communication quality. Spousal relationships experience tension when the affected partner withdraws, exhibits irritability, or cannot fulfill previous role expectations. Parenting capacity diminishes when depression interferes with emotional responsiveness, patience, and engagement in children’s activities.

Physical health deteriorates through depression’s bidirectional relationship with chronic disease. Depression worsens glycaemic control in diabetes through cortisol-mediated insulin resistance and poor self-care behaviours including medication non-adherence and dietary indiscretion. Cardiovascular disease risk increases through inflammatory pathway activation, autonomic dysfunction, and health behaviour deterioration.

Sleep architecture disruption in depression creates early morning awakening, frequent nocturnal awakenings, and non-restorative sleep, exacerbating fatigue and cognitive impairment. Appetite changes produce weight fluctuations affecting diabetes management and cardiovascular risk. Anhedonia eliminates previously enjoyable activities, constricting social support networks precisely when stroke recovery demands maximum support (Pollack et al., 2023).

Impaired Physical Mobility Care Plan

Right-sided hemiparesis following left hemisphere stroke creates mobility limitations requiring structured intervention. Nursing implementations incorporate passive and active-assisted range-of-motion exercises performed every two hours during waking hours to prevent contracture development. Positioning protocols alternate between supine, left lateral, and semi-recumbent positions every two hours to prevent pressure injury while maintaining affected limb alignment through pillows and positioning devices.

Fall prevention measures include bed rails raised on the right side, non-slip footwear, adequate lighting, and assistance for all transfers. Mobility assessment occurs before each movement attempt, evaluating strength, balance, and cognition. Assistive devices such as walking frames or wheelchairs require fitting by physiotherapy, with nursing staff trained in transfer techniques using slide sheets and appropriate body mechanics.

Rationale stems from immobility complications including muscle atrophy, joint contractures, pressure injuries, venous thromboembolism, and pneumonia. Range-of-motion exercises maintain joint flexibility, prevent contracture formation, and stimulate proprioceptive pathways potentially facilitating neuroplasticity. Positioning prevents dependent oedema, maintains skin integrity, and optimizes respiratory function.

Assessment parameters include range of motion measurement using goniometry, muscle strength grading on the 0-5 Oxford scale, pain levels during movement, and activities of daily living independence using the Barthel Index. Skin condition requires inspection during repositioning for redness, blanching, or breakdown. Documentation captures exercise completion, positioning schedules, patient tolerance, and progress toward mobility goals (National Stroke Foundation, 2022).

Aspiration Risk Management

Dysphagia affects 50-70% of acute stroke patients, creating aspiration pneumonia risk when oral secretions, food, or liquid enter the airway. Nursing implementations maintain nil-by-mouth status until speech therapist swallowing assessment using videofluoroscopy or fibreoptic endoscopic evaluation identifies safe swallowing strategies. Positioning maintains head-of-bed elevation at 30-45 degrees continuously, increasing to 90 degrees during oral care and swallowing trials.

Oral hygiene protocols include mouth cleansing every four hours using foam swabs moistened with water or alcohol-free mouthwash, removing debris and reducing bacterial colonization. Suction equipment remains at bedside for immediate secretion clearance. Swallowing assessment incorporates water swallow tests, diet texture modifications from puree to regular consistency as tolerance improves, and liquid thickness adjustments from honey to nectar to thin consistency.

Rationale addresses aspiration pneumonia’s 20% incidence in dysphagic stroke patients, occurring when aspirated material introduces bacteria into bronchial passages. Silent aspiration, occurring without cough reflex activation, complicates detection and increases pneumonia risk. Upright positioning uses gravity to facilitate bolus movement toward the oesophagus rather than the trachea.

Assessment includes respiratory rate, oxygen saturation, auscultation for adventitious sounds such as crackles or wheezing, and temperature monitoring for infection indicators. Swallowing observation notes coughing, choking, wet vocal quality, or facial drooling during trials. Nutritional status requires monitoring through weight trends, albumin levels, and caloric intake documentation once oral feeding commences (Cadilhac et al., 2020).

Impaired Skin Integrity Prevention

Immobility, incontinence from indwelling catheter placement, and right-sided sensory loss create pressure injury risk. Nursing implementations incorporate comprehensive skin assessment every four hours using the Braden Scale to quantify risk through sensory perception, moisture, activity, mobility, nutrition, and friction-shear parameters. Pressure redistribution uses alternating pressure mattresses or high-specification foam mattresses for patients scoring below 18 on the Braden Scale.

Repositioning schedules maintain two-hourly position changes documented on turning charts. Skin protection involves moisture barrier creams for incontinence management, prophylactic dressings on the sacrum and heels, and prompt cleanup after episodes of incontinence. Nutritional optimization includes protein intake of 1.25-1.5 grams per kilogram body weight daily and adequate hydration to maintain skin turgor.

Rationale recognizes pressure injuries’ development from capillary occlusion when external pressure exceeds 32 mmHg, the normal capillary closing pressure. Tissue ischaemia progresses from Stage 1 non-blanchable erythema to Stage 4 full-thickness tissue loss with exposed bone, tendon, or muscle. Mrs Hui’s existing right hip haematoma and elbow skin tear require specific wound care protocols.

Assessment documents skin condition using stage classification for any breakdown, measuring wound dimensions, assessing wound bed tissue type as granulation, slough, or necrotic, and noting exudate amount and characteristics. Pain assessment at dressing changes guides analgesic administration timing. Photography creates visual documentation for wound progression monitoring (Pollack et al., 2023).

Injury Prevention Strategies

Cognitive impairment from stroke, right-sided weakness, and visual disturbances create multifactorial fall risk. Nursing implementations establish fall precaution protocols including yellow identification bands, bedside signage, and care plan alerts. Environmental modification removes clutter, secures electrical cords, and ensures adequate lighting during nighttime bathroom trips. Bed height remains in the lowest position when unattended, with brakes engaged and call bell accessible.

Toileting schedules every two hours prevent urgency-related rushed transfers despite indwelling catheter presence, as catheter removal typically occurs within 48 hours to prevent infection. Footwear provides non-slip soles and ankle support. Eyeglasses require replacement to correct visual deficits, whereas hearing aid functionality ensures instruction comprehension.

Rationale acknowledges that 30-40% of stroke patients experience falls during hospitalization, with 10% resulting in serious injury including fractures or intracranial haemorrhage. Right-sided neglect creates unawareness of the affected body side, whereas impaired proprioception disrupts balance mechanisms. Cognitive impairment affects judgment and safety awareness.

Assessment utilizes fall risk screening tools such as the Morse Fall Scale, evaluating fall history, secondary diagnosis, ambulatory aids, intravenous therapy, gait, and mental status. Balance testing through sit-to-stand maneuvers, Romberg test, and gait observation identifies specific deficits requiring targeted intervention. Cognitive screening using the Montreal Cognitive Assessment detects impairment affecting safety judgment (Middleton et al., 2021).

Rehabilitation Planning and Discharge Coordination

Acute care stabilization precedes intensive rehabilitation addressing physical, cognitive, and psychosocial recovery domains. Interdisciplinary team involvement begins during acute hospitalization, with physiotherapy assessing mobility potential, occupational therapy evaluating activities of daily living capacity, speech therapy managing communication and swallowing deficits, and social work addressing discharge barriers.

Rehabilitation unit transfer after two weeks enables intensive therapy provision, typically consisting of three hours daily across multiple disciplines. Goals emphasize functional independence maximization, adaptive strategy development for persistent deficits, and caregiver training for home management. Mrs Hui’s family structure, including two school-aged children and a frail elderly father, necessitates comprehensive discharge planning addressing home modifications, equipment needs, community service coordination, and caregiver support.

Community services potentially required include home nursing for wound management and medication supervision, home care assistance for personal care and household tasks, physiotherapy and occupational therapy home visits, respite care for caregiver burden reduction, and psychological services for depression management. Equipment needs may encompass hospital bed, shower chair, toilet frame, walking frame, and wheelchair depending on recovery trajectory (National Stroke Foundation, 2022).

References

Cadilhac, D.A., Kim, J., Lannin, N.A., Sundararajan, V. & Thrift, A.G. (2020). Understanding hospital and patient variation in acute stroke care and outcomes in Australia. International Journal of Stroke, 15(5), 508–517. https://doi.org/10.1177/1747493019889319

Middleton, S., Lannin, N.A., Anderson, C.S., Levi, C.R. & Donnan, G.A. (2021). Implementation of evidence-based stroke care: The Australian Stroke Clinical Registry perspective. BMC Health Services Research, 21(1), 421. https://doi.org/10.1186/s12913-021-06412-7

National Stroke Foundation (2022). Clinical Guidelines for Stroke Management 2022. Melbourne: Stroke Foundation. Available at: https://informme.org.au/guidelines/clinical-guidelines-for-stroke-management [Accessed 10 Oct. 2025].

Pollack, M., Lalor, E., Khan, F. & Middleton, S. (2023). Rehabilitation nursing in stroke: Advancing person-centred care in Australia. Collegian: Journal of the Royal College of Nursing Australia, 30(2), 185–192. https://doi.org/10.1016/j.colegn.2022.05.004