Background. Stroke is a major cause of mortality in the United Kingdom; it is the third biggest killer in the UK (National audit office 2005) around 53,000 people die every year from this long term condition. (Scarborough et al 2009) In people under the age of 75 it is a main cause of premature mortality with 1 in 20 dying because of an acute stroke and the complications that arise. In socially deprived areas a person is 3 times more likely to suffer from a stroke than in the least deprived areas of the UK. Dehydration is preventable but is unfortunately very common; there is a method of early identification that could stop a patient becoming increasingly unwell in a short space of time. What is the best and safest method for the patient when replacing lost fluids? Dysphagia, a person who has problems with swallowing, is another common concern with people who have suffered a stroke. Most issues resolve themselves within a few weeks after the stoke, but for an unfortunate few problems persist and more complications arise in up to 19% of patients (Rowat 2011) including dehydration, nutritional problems because of a poor dietary intake and depression perhaps due to embarrassment of the effects of the stroke Search Terms. The keywords used in this literature review were, ‘stroke’, ‘dehydration’, ‘nursing’ ‘dysphagia’ and ‘literature review’.
The keywords were used in a variety of ways to see as many different articles of interest. The databases used were Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scorpus and Google Scholar. The search has included worldwide journals and papers with the date limitations of 2001 to 2012 to ensure that all evidence and information is current. Only those articles published in English and available through the University of Dundee library were considered for inclusion. Findings. Morris (2008) states a stroke has a far greater effect on a person’s ability to function in a way that would be deemed normal in society; it has a larger impact on a person than any other medical condition. (Morris 2008) Dehydration after a stroke is very common (Rowat 2012) between 50% and 60% of patients display some degree of dehydration during their hospital stay. A Rowat (2011) paper states that there is no gold standard of assessment to measure the estimation or the frequency of this problem.
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Rowat (2011) in addition states that dehydration after a stroke has been associated with an increase in blood viscosity or the measure of the bloods thickness as it flows through the body and an increase in stroke mortality. In addition Morris (2008) adds that the fatality rate among patients who have had a stroke and the added complication of problems with dysphagia, have increased the chances of death significantly. Earlier identification of dehydration may allow the nurse to prevent significant development of any complications and improve patient outcomes. Forster’s review (2011) states that orophrangeal dysphagia is often underestimated, this type of dysphasia is characterised as an alteration in the swallowing dynamics which may lead to associated swallowing issues. This may significantly impair the patient and cause malnutrition and dehydration. Patients’ symptoms are seldom mentioned due to embarrassment or lack of awareness. Forster (2011) feels a bedside screening test would select the patients in need of more investigations, these tests could be individualised to suit each patient as they require.
However, due to staffing levels and time constraints this rarely appears to happen during the first 72 hours of admission. (Forster 2011) Rowat (2011) states that 50% of patients have some degree of dysphagia after the onset of stroke and that most problems do resolve themselves, but 19% of patients problems do persist. Rowat (2011) in addition states that dehydration is common and is caused by a lack of fluid intake that can be caused by patient drowsiness, infection, communication issues or weak limbs. In an investigation of 128 patients with different degrees of swallowing complications, issues relating to dysphagia were detected in 64% of patients. (Morris 2008) Another study found that 42% of stroke survivors have choked when attempting to swallow or have shown signs of difficulty when eating or drinking. (Morris 2008) Claros (2011) similarly accounts that dehydration is increased with patients that are taking 4 or more medications. As a person ages the total body water in a person decreases alongside the thirst perception. Claros (2011) also states that patients with altered mobility are at a higher risk of dehydration because they may not be able to independently access fluids.
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Dehydration is possible to stop in its tracks if staff are given the time to check upon patients to see if they are managing to take water when required. But do nurses have the time, are they are able to manage, a nurse needs to place best practice and take a few moments to assist the person in their care. Hypodermoclysis, which is a subcutaneous method of fluid infusion, this is a method of fluid replacement in older adults. Scales (2011) states that older people are more difficult to manage due to the physical effects of ageing, it is easier to manage by a subcutaneous method of fluid replacement than by an intravenous infusion method. However Slesak (2003) in his trial of ninety six patients with mild to moderate dehydration, when placed into two separate groups of forty eight with each group receiving either an infusion intravenously or by the subcutaneous method it was noted it did not make any difference as to which way the patient received the fluids the same outcome was achieved. It was noted however that in the patients who were confused the subcutaneous method was safer and fairer method of delivery. Nurses, it was noted often preferred to use the subcutaneous method of delivery (Slesak 2003) also for fluids as they felt it was better for their patient and the care delivery they were trying to provide.
Residential homes and hospitals have consistently struggled to deliver good hydration to their patients Campbell (2012) and The Patients Association (2011) note that evidence still suggests that nurses are still failing to provide the most basic level of care to the frailest and most vulnerable patients. Evidence suggests that staffing levels are directly related to the substandard care being delivered. The Health Service Ombudsman (2011) and the Care Quality Commission (2011) both reported that the most vulnerable in the community were still in receipt of substandard care in the most basic standards of living. Shipman (2007) also queried if care homes are adequately staffed. Some elderly residents it was reported had capacity and were mainly independent but feared reaching the toilet on time so would only take tiny sips of water. If staffing levels were higher Shipman (2007) argues then these basic needs could be addressed easily with the nurse having an informal conversation with the resident and by making sure the resident understands that they will make the toilet on time and in fact will need to use the toilet less if they drink more.
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These facts lead a simple question, would staff whether they be qualified nurses or health care assistants provide better and safer care if they had the time to consider their daily actions before moving onto the next task? Are residential care homes really that understaffed? Residents’ needs could and would be met simply and quickly if more staff were available. Rowat’s (2012) study to discover the frequency of dehydration and its associated issues. This was a large and broad study, the amount of patients requested to take part in this study were 2591 people. This case study lacked any real investigation. The test consisted of a single blood sample, if the results of the urea-to-creatinine ratio came back as over 80 the patient was defined as being dehydrated. The conclusion to this was that further investigation was required to establish if the outcomes could be improved on. Another of Rowat’s studies (2011) examined whether “urine specific gravity and urine colour could provide an early warning of dehydration” (p1976) this study only recruited 20 patients but required testing their urine every day over a 10 day period.
However this study also concluded that further research was required as this was not a practical tool for early detection. Sign Guidelines (2008) state that having dysphagia can lead to many consequences, a lack of hydration, nutrition and pneumonia all of which impact on a person’s lifestyle. Gillespie (2004) and Morris (2008) in addition also agree that dysphagia impacts hugely on life choices as having just one of these issues can leave a patient weak and tired. Schrock’s (2012) study’s whether an elevated blood urea-creatinine ratio does associate with a worse outcome after a stroke. In this study 324 patients were tested during their hospital stay, 33% had a bad outcome, 6% of those patients died and 27% had a diagnosis of dehydration. The conclusion in this study was that further investigation was required to discover if a patients hydration levels were assessed upon arrival at hospital could the outcome of the patients’ stroke be improved in the long run. All studies that used the blood sampling of urea/creatinine levels have so far arrived at the same conclusions, at this moment in time there is not a best practice standard for dehydration or any firm conclusions about the outcomes.
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Dehydration and nutritional difficulties with patients admitted with an acute stroke can become worse during hospitalisation. The FOOD (Feed or ordinary diet) trial was an 8 yearlong study conducted in 18 countries and involved 131 hospitals, over 5000 patients were asked to participate over three separate trials. (Dennis 2006) This was dependent on the level of stroke and the level of dysphagia that needed to be addressed. The three trials were early enteral feeding verses non early enteral feeding, PEG (percutaneous endoscopic gastrostomy) feeding verses NG (nasogastric) tube feeding and normal hospital diet verses normal hospital diet with added supplements. (Dennis 2006) The outcomes of the first trial, the patients on the supplemented diet showed a reduction in the chance of death by 0.7%. In the second trial the early intervention of enteral feeding proved to reduce the risk of death for patients by 5.2%. The third trial in which the most severe stroke patients were placed showed an absolute increased risk of death if treated with the PEG feeding method over the NG tube by 7.8%. This outcome was not expected and could not be easily explained.
The conclusions from this trial showed the benefits of early enteral tube feeding which seemed to promote the best physical outcome for the patient. (Dennis 2006) Dependent of the level of disability, patients can be treated with any one of these methods of treatment, however it is now unlikely that a patient would be fed with a PEG tube due to these conclusions as best practice now shows the safer and less invasive technique of the NG tube provides a better long term outcome. Li-Chan’s 2002 study concentrated more on training the patient in a swallowing technique rather than the dietary intake of the patient. By improving the swallowing technique of a stroke patient the Li-Chan (2002) study concludes that you can eliminate or reduce the risks of developing complications that come with having problems with dysphagia. The results of this study proved that there was a significant increase in body weight and fewer problems with choking incidents. (Li-Chan 2002) Strategies in the changes of the swallowing technique included the Mendelsohn manoeuvre, which is a technique designed to lessen laryngeal movement and increase tongue coordination while swallowing. (Li-Chan 2002)
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Patient confidentiality is a fundamental practice in healthcare and it is integral part of healthcare ethical standards (Purtilo & Dougherty, 2010). According to the American Nurses Association (ANA) code of ethics “the nurse has a duty to maintain confidentiality of all patient information” (Nursing world, p.6). Also, when a patient confidentiality is violated the nurse may risk their safety ...
Treatment sessions lasted for 8 weeks and consisted of 6 sessions a week for 30 minutes the outcomes and conclusions of this course of re-training was that if the patient can regain the ability to cough correctly and at the appropriate times it can increase food intake and decrease incidents of choking. Nazarko (2010) in her review of managing dysphagia also talks about improving swallowing and how it can deteriorate quickly. Nazarko’s (2010) report focusing more on tongue movement, making vowel sounds as these stimulate tone and movement and excercises with straws as this strengthens the soft palate andmakes swallowing easier Campbell-Taylor (2008) states that the treatment of oropharyngeal dysphagia lacks an evidence base, an established treatment is not available and due to lack of appropriate training most clinicians get treatment wrong. Campbell-Taylor (2008) feels doctors need training with regards to assessment and management of a patient’s dysphagia issue.
The Essay on Swallowing and Prediction of Dysphagia Severity
Introduction: Daniels, McAdam, Brailey, and Foundas (1997) reviewed literature from Linden, Kuhlemeier, and Patterson (1993) and examined signs of aspiration, but specifically six risk factors, including dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, voice change after swallow, and cough after swallow. They then designed their study in an attempt to link the six signs of ...
However, Scottish Intercollegiate Guidelines Network (SIGN) state in there guideline on the management of dysphagia (SIGN guideline 119) that all patients should have the water swallow test as part of screening process. (Forster 2011, Lin 2002, Campbell 2012, Rowat 2011, 2012 and Westergren 2006) all agree that a swallow test should be used as part of initial screening of a stroke patient. Best practice from the SIGN guidelines also recommend a clinical bedside assessment by a speech and language therapist to measure need of the patient. This is the best practice treatment that is available at this present time. The Dewsbury feeding and swallowing screening is used in the United Kingdom after two research papers found evidence (NICE 2008) that formal screening was required in order to reduce risk to stroke patients and improve outcomes of occurrences of malnutrition and dehydration. The Heart and Stroke Foundation of Ontario (HSFO) in 2002 developed the best practice for managing dysphagia these guidelines dictate that all stroke patients should be assessed for swallowing as soon as patient is awake and aware. (McNicoll-Whiteman 2008)
Speech and Language therapists state that wherever possible (SIGN 2010) trained staff should conduct the assessment. Cichero (2009) states that a study of the swallowing screening tool was conducted and was rolled out to 442 patients. By assessing everybody and not just victims of stroke, conclusions suggest that the swallowing screening assessment (SSA) is a smart and quick tool at discovering patients that are suffering from dehydration. Screening tools are an essential part of nursing practice; evidence base suggests that assessment must take place as soon as the patient is able. (SIGN 2010) By assessing quickly the outcome for the patient can only be improved by better practice and better care. (Rowat 2011) The Standardised Swallowing assessment tool when used correctly can have an effect on the outcome for the patient (Perry 2001) this helps nurse’s show clinical judgement when assessing patients with swallowing difficulties. Studies have been attempted and efforts have been made to roll out a swallowing assessment tool for all patients (Cichero 2009) when in an admission to hospital. In one particular study 442 patients were screened and conclusions suggest it is a strong tool for picking out dysphagia patients.
However training must be delivered to staff correctly (Perry 2001) or outcomes will be less successful for patients suffering with dysphagia and its associated problems. The water swallow test should be conducted by a trained member of staff before any food or drink is allowed. (Perry 2001) A patient should start with a few teaspoons of water and should be monitored closely by a nurse and be assessed continually. If no signs of distress are noted than the patient should be given a glass to drink from. (SIGN 2010, Perry 2001, Rowat 2011) Evidence based practice suggests that a bedside screening test is the best possible option for staff to monitor swallowing mechanism (Perry 2001) and patients to be under no duress or stress during the evaluation. (SIGN 2010) Conclusions The search that was conducted was quite broad and the literature that was available covered many of the topics in relation to Stroke and the side effects that can occur in varying degrees to every stroke patient. The studies that have been investigated are thorough and cover most issues regarding how to deal with dehydration and dysphagia. There are areas where further research requires to be carried out.
Further research into the subcutaneous method of fluid delivery as this appears to be a kinder and a more effective way of delivering fluids to a confused stroke patient quickly and efficiently. As evidence appears to suggest that it does help to assess every patient for swallowing problems this could be considered for roll out in other accident and emergency departments and admission wards in more hospitals. Training of a stroke patient in the art of a new swallowing technique can, it appears, prevent choking incidents and the outcomes of Li-Chan’s 2002 study should be addressed further, some of the techniques used could be placed in with the Speech and Language therapists techniques for delivering best practice. Unfortunately not all the information returned by the search could be accessed due to database access arrangements and many interesting articles had to be dismissed.
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