One of Gretas close friends from the Latvian club has a daughter who is a second year student nurse.

Greta has asked if you can explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system to her friends daughter as she doesnt understand and has an exam approaching. Greta has given her permission for you to use her as an example. Please explain the pathophysiology of a Cerebro Vascular Accident (stroke) and how it affects the central nervous system using the correct medical and nursing terminology.
INTRODUCTION
Mrs Greta Balodis is a 75 year-old widow who until recently lived alone in her single-storey house. She has recently returned home from rehabilitation post a R) CVA. Her daughter Anne has relocated to the city with her family to become Gretas full-time live-in carer. However Annes family have psychosocial and psychological complexities that impact on the wider family dynamics. Greta is regularly subjected to her grandson and son-in-laws problematic alcohol and drug use. Also because of Anne and Johns relationship issues and Dylans erratic behaviour Greta no longer feels safe in her own home. For some time Anne manages to care for her mother in the home; however after Greta trips over the cat she deteriorates post-fall and eventually needs to be placed in high level care.
Meet Greta
Patient
information MRN:
78012499 Surname:
BALODIS Given names:
Greta Ainija DOB:
22/4/1938 Gender:
F

Personal details
Patient: Greta Ainija Balodis
DOB: 22/4/1938
Age: 75
Address: 36 Main Street Elizabeth North SA 5113
Weight: 84 kg
Height: 155 cm
MRN: 78012499
Migrated: Latvia to UK (age 20) and UK to Australia (age 35) under the Skilled Workforce program
Family/Significant others
Daughter: Anne 42yrs old
Son-in-law: John 45yrs old
Grandchildren: Dylan 11yrs old Jessica 5yrs old
No other family living in Australia
Background
Greta has been living independently for 38 years in a single-storey house with a garden in the northern suburbs of Adelaide. Over the past two years Gretas health has declined making it harder for her to carry out her activities of daily living as independently as she would like. She has been paying for Domiciliary Care to visit once per week and assist her with cleaning and shopping. Gretas daughter Anne and her family have decided to move back to Adelaide and share Gretas home in order to assist caring for her. Socially Greta enjoys attending her local Latvian club for their monthly activities.
Past medical history
? Trans-ischemic attack (TIA) 2/12 ago (refer year 1 lecturer notes 1)
Hypertension (refer year 1 lecturer notes 2)
3 falls in last 6/12
Past surgical history
Appendectomy 40 years ago
Current medication
Atenolol PO 50mg daily
Panadol PO 500mg prn
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Physiotherapy notes (Jill Garner PT): Day 2 Admission post CVA
Patient is in ICU check with nursing staff and medical staff re status and read medical notes. Subjective assessment: diagnosis noting area of stroke and interventions until this date PMH SH: living arrangements steps inside and access to her home services provided falls history note 3 falls in last 6 months previous level of mobility including use of aids. Some of this information may be in the notes and some may not be able to be gained from the patient due to her state of alertness/orientation so the assessment may continue over the next few days until a fuller picture of the patients SH is uncovered.
Objective assessment:
state of alertness
orientation
ability to communicate
Body awareness and awareness of midline
Chest assessment auscultation regarding flow of air in the lungs and any added sounds such as creps or atelectasis.
Assessment will be limited with communication issues due to dysphasia.
All limbs: ROM motor control and sensation JPS tone special note re left shoulder possible pain and risk of subluxation.
Treatment at this stage:
positioning of Gretas limbs in normal alignment especially left side
active exercises on right side and active assisted exercises on left
chest care
In consultation with medical staff bring Greta up against gravity into sitting with Greta trying to manage as much of the task as possible with help of therapist and nursing staff as needed. Sitting assists orientation head and eye control and use of trunk muscles
Physiotherapy notes (Jill Garner PT): Day 3 Admission post CVA
Treatment:
Continue to monitor shoulder. If low tone and inactivity persists possible use of supportive device to protect left shoulder from subluxation and pain.
encouraging correct alignment of left side
active exercises especially left side.
Functional activities of lying to sit
sitting balance including reaching out of her base of support.
orientation to her environment
sit to stand practice standing balance and stepping practice with 1-2 assist.
discussion and advice to nursing staff re: manual handling of Greta sitting and how to transfer her on the ward.
Physiotherapy notes (Jill Garner PT): Day 4 Admission post CVA
Day 4 transferred to Inpatient rehabilitation:
Initial physiotherapy assessment focuses on functional abilities to assist with Gretas management on the ward. This will be documented in the medical notes and clearly discussed with the nursing staff.
There is further assessment by the treating physiotherapist as per Day 2. Review and check for vestibular symptoms that may have led to previous falls at home.
Rehabilitation outcome measure is the FIM (Functional Independence measure).This measures level of dependence and is completed by the team. It is completed on admission and discharge. All FIM information is collated by AROC (Australian Rehabilitation Outcome Centre).
Physiotherapy outcome measures include Ritchie articular index to measure shoulder pain 6 min walk test and standing balance. These are assessed on admission and discharge.
Assessment for hydrotherapy: check list for contraindications and risks especially continence post stroke/ seizure and cognitive/behavioural problems.
If Greta is continent she will have daily hydrotherapy as well as Individual therapy. There may be group interaction as her condition improves.
Patient centred goals identified on admission for first week: Lie to sit independently. Sit to stand with standby stand transfer to the right with x 1 assist.
Whilst on rehabilitation the rehabilitation team (medical nursing physiotherapy occupational therapy speech pathology social worker possible: dietician and psychologist) will have weekly case conferences to review goals made and achieved and discuss discharge plans.
Many of the goals will involve a few team members ie. Stand transfer to the right will involve nursing/physiotherapy and maybe occupational therapy.
Physiotherapy notes (Jill Garner PT): Day 3 Triage nurses
Triage Nurses
Assess for rehabilitation in consultation with doctors nurses and therapists. When medically stable triage nurses discuss with patient and family:
patient centred goals
discharge destination
Proposed length of stay.
Physiotherapy notes (Jill Garner PT): Weeks 2-3 of rehabilitation
Weeks 2-3 of rehabilitation
As Greta becomes more mobile her falls risk on the ward increases. Often patients have decreased insight into their abilities and feel they can perform functional activities by themselves when they are not safe to do so.
Patient centred goals identified for week 3: get in and out of her bed independently. Walk to bathroom with rollator frame and 1 assist.
Greta attends physiotherapy as per her timetable: 9am hydrotherapy1pm land based physiotherapy in the gym including: functional exercises exercises in standing stepping walking exercises to encourage active use of her left without right side being over active. Greta is now walking with a rollator frame with x 1 assist to the bathroom.
Physiotherapy notes (Jill Garner PT): Week 4 of rehabilitation
Week 4
Goals for week 4: walk to bathroom and dining room independently with rollator frame car transfers with one assist on and off the floor with use of furniture falls prevention strategies
Treatment: balance exercise in standing and walking walking in therapy with nil aids on and off the floor car transfers stair practice. Outside mobility with rollator frame.
Pre discharge: family meeting to give an overview of Gretas patient journey and discuss discharge plans
On discharge: Falls risk assessment discharge summary/ equipment/RITHOM referral.
RITHOM physiotherapy assessment: patient centred goals full assessment in the home. Rehabilitation outcome measure used in RITHOM setting: Lawtons outcome measure
RITHOM physiotherapy goals:
Independent mobility inside her home and in the garden without walking aid.
Increase strength in left upper and lower limb
increase co-ordination left side and accuracy of task.
There is a weekly case conference where greats progress is discussed

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