Cerebrovascular problems and the role of registered nurses
Cerebrovascular problems are chronic illnesses that necessitate the participation of all health care providers in order to improve the patients' quality of life. The Nursing and Midwifery Board of Australia (NMBA) has established seven requirements for registered nurses to follow when providing these services. According to the second requirement, registered nurses should engage in therapeutic and professional relationships. Effective communication and consistent assistance are required for these individuals throughout their rehabilitation process. It is critical that the RN comprehends the significance of the patient's history and religious views. This context protects patient autonomy and ensures compliance and optimal rehabilitation.
The administration of thrombolytic agents for cerebrovascular accidents
Cerebrovascular accidents are becoming more common. There is a possibility that thrombolytic agents administered within a specified period when a person has an attack might limit the damaging effects of hypoxia on the brain. In this Cochrane review, this possibility is further explored. As much as there are benefits to be gained from this therapy, there is a risk of cerebral hemorrhage. Different countries have different directives on how to administer these agents. Countries like the USA and Canada suggest up to 3 hours administering while some European nations recommend 4.5 hours.
Reducing dependency rate and the risk of mortality
This review explains that the dependency rate post a cerebrovascular accident is reduced significantly. The down side, however, is the possibility of earlier mortality due to the cerebral hemorrhage. The authors argue that once the risk of the early bleeding episode has elapsed, the benefits long-term are higher and improve the prognosis and the quality of life of the patient approximately 3-6 month after the CVA. Other factors such as brain imaging and differences in the administration of the agents are also discussed.
Establishing the benefits and risks of thrombolytic agents
This review aims at establishing whether administering thrombolytic agents post CVA improves the prognosis and quality of life in patients who have suffered cerebrovascular accidents. It also wants to establish whether the benefits of thrombolysis outweigh the adverse effects, i.e. cerebral bleeding. The review also focuses on the kind of patient who will benefit from this therapy as opposed to those to whom it will prove fatal. In the review, the benefits and contribution of brain imaging are also discussed.
Trials and outcomes
In this review several trials were studied. The studies had to be truly randomized. The bias had to be reduced significantly. An intention-to-treat analysis was also performed. The kinds of participants used were those who had a definitive diagnosis of an acute ischemic stroke. The kind of thrombolytic agents administered either intravenously or intra-arterially was used. Examples of the agents included urokinase, streptokinase, desmoteplase and recombinant plasminogen activator.
The measures of outcomes used were death or dependency. The dependency is as described by the modified Rankin score. The outcomes expected could be the death of complications due to intracerebral hemorrhage or cerebral edema caused by infarcts. The patient may also deteriorate further in neurological functioning or die 7-10 days after initiation of treatment. Apart from these, any other outcome was considered secondary.
Searching for trials and resources
The Cochrane Stroke Group module was used to search for all trials in all languages dating from 1966 to November 2013. The searches were in Medline and Embase. Other resources were hand searched from different journals and conference proceedings.
References
from papers on thrombolysis were also utilized. Direct contact and correspondence with investigators of different trials in different continents and companies that manufacture thrombolytic agents were also made during this review.
The general outcome of this review shows a long term benefit in using thrombolytic agents in patients with cerebrovascular strokes though the risk of succumbing due to intracerebral hemorrhage is high. From 13 of the trials studied, early deaths with thrombolysis were significant. These studies had a total of 7458 participants. Compared to the 11.5% patients on thrombolytic therapy, the control was at 7.4% which means that 40 participants out of 1000 died 7-10 days after thrombolytic therapy.
The results from 17 of the trials studied showed that there was a six times higher chance of intracerebral hemorrhage with thrombolytic therapy. To note however is that some of the participants who succumbed did not have brain imaging or postmortem studies so it might underestimate the incidence of intracranial hemorrhage. In the trials in which recombinant plasminogen was used, there were 30 extra cases of bleeding in every 1000 participants in the trials. However, there was no significant difference seen as compared to the other trials. The time limit to which the thrombolytic agents may be administered to achieve the benefits was not clear from the trials studied. However, it is noted in the review that patients who received the treatment approximately 3-6 hours of the attack had fewer mortality rates due to the complications of the drugs.
The evidence of lower rates of dependency is reported with patients who do not succumb to intracranial bleeding post therapy. A reduction of 60 out of 1000 participants in the 22 trials studied was noted regarding dependency rates if they were treated with thrombolytic agents, unlike the control. From all the trials studied, it was difficult to establish the relationship between the concomitant use of thrombolytic agents and antithrombin therapy.
All these studies are very relevant to nurses in the universal care of cerebrovascular patients. Nurses can then weigh the benefits of giving thrombolytic therapy to patients against the high possibility of mortality due to the intracranial bleeding. During the care of such patients, the nurse will also take care to note early signs of neurological deterioration and act accordingly. This is in line with the stipulations in the NMBA of acting with knowledge of current findings in the medical field and collaboration with other health care givers.
As a health care workers who are constantly being with the patients, observing and providing support to them, nurses provide a significant contribution to the prognosis of these patients. Knowledge of the kinds of patients to consider while administering thrombolytic agents is fundamental. The consideration of age versus doses to be given changes the way a patient is handled. With patients having a higher likelihood to succumb in the first ten days, it is critical that they are thoroughly monitored. There is however limited information as to whether one thrombolytic agent is better than another. This review provides a kind of criteria which may be used while strategizing an intervention of patients with acute cerebral stroke. It also gives a new perspective to health care givers particularly nurses on how to deal with these patients, specifically the long term benefits they are to receive if given these thrombolytic agents. In the long run, the patient’s quality of life will be improved (Wardlaw, 2014).
Reference
Wardlaw, J. M. (2014). Thrombolysis for acute ischemic stroke. The Cochrane Library.
