The aim of this paper is to look at the pathophysiological changes resulting from trauma and alterations in the cerebrovascular blood flow. It discusses the effects of these two to the cognitive abilities of the patient, and how the patient operates in the social, emotional and physical capacity, after suffering such misfortune. It takes into perspective recent research into better healthcare delivery, on the part of the nurse, in relation to prognosis, discharge and home based care and hoe these relate for better patient management. Lastly, it delves into the strategies employed to rehabilitate a person who has suffered trauma or has cerebrovascular disturbance in blood flow.
Neuroscience is a vast field of neurology that encompasses the dynamics and mechanisms of the brain. In life, there are situations where misfortune befalls us e.g. a car accident or a stroke and our brain suffers a terrible blow. This causes pathophysiological changes in our brain function occurs as a result of trauma or disturbances in the blood flow in the brain. This is an exploration of this subject of trauma and cerebrovascular functions, its effect on the patient and the society, and the relevance to nursing world as well as the rehabilitation efforts towards this cause.
Cognition is a “term referring to the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging and problem solving. These are higher-level functions of the brain and encompass language, imagination, perception and planning” (Cherry, 2010). It involves processes such as abstraction and executive functions.
This paper will discuss how brain trauma resulting from stroke will affect the cognitive functions of executive functions and the abstraction.
Executive functions are referred to as “a set of cognitive abilities that control and regulate other abilities and behaviors” (Encyclopedia of Mental Disorders, n.d.). It encompasses the ability to initiate and stop behavior, to monitor and change our behaviors and to plan functions based on future goals. It allows for successful functioning in the work –place due to an increased ability to adapt to changes in the environment, which arbitrarily spring up. They help us to avoid stress these functions seek solutions to these unexpected occurrences. They are important for someone to fit in well in society, as it inhibits inappropriate behavior. In the case of a stroke (sometimes called a cerebrovascular accident[CA]), the patient usually lacks oxygen supply to the brain because of a blockage in the jugular artery. This may be due to a clot or thrombosis or a rupture in the artery. This leads to death of the brain cells that are mostly in the frontal lobe. In the case of non –fluent aphasia,(which is also an effect of a stroke) the patient’s temporal lobe is the one that is affected. It is a disturbance of the cerebrovascular in that the blood flow is interrupted. Other pathophysiological processes such as bleeding in the brain due to an aneurysm, or a hematoma can lead to a stroke that again leads to deficient or defective executive functions.
The effects of trauma on executive functions like motor skills, speech and memory include loss of short-term memory, trouble walking, paralysis and other speech disorders such as dysarthia or weakness of the oral muscles, as well as lack of self-control in social situations.
CA in the right hemisphere of the brain causes an inverse manifestation of the result of trauma through paralysis in the left side of the body. It may lead to different types of aphasia that retard one’s speech and language abilities. Aphasia is defined by Salter et al. “as a reduction of the patient’s ability to communicate by language expression and comprehension and can affect all aspects of communication performance, such as speaking, reading (alexia) or writing (agraphia)” (Nys et al., 2005). A person who has suffered a stroke may struggle to comprehend when being spoken to, or may struggle to communicate with him or herself. In social situations, they may not feel any restrictions to saying what they feel even if it is hurtful since they do not realize that it is in appropriate. They may also struggle with remembering some words or objects even though they know what it is e.g. they may see a ball, know that it is a ball but cannot annunciate to others that whatever is before them is in fact a ball. This creates feelings of frustration, anxiety and in extreme cases, it may result in depression in patients who struggle to communicate their wishes to others in cases of aphasia, apraxia and dysarthia (Nys et al., 2005,p.205). Erratic mood changes also characterize stoke recovery patients.
With respect to abstraction, a stroke acts in the same way as it would act with memory or attentiveness. Abstraction is defined as “absent-mindedness, inattention or mental absorption” (Abstraction, n.d.). It works such that the cerebrovascular disturbance to the right hemisphere causes the patient to struggle with keeping his/ her attention fixed to one thing for a prolonged period of time. the patient becomes preoccupied in their own thought and cannot concentrate on the task they are doing. They have difficulty discerning which task deserves their attention and which does not.
Psychosocially, it leads to reduced self-esteem, inefficiency in performing tasks and in relating with others. It may also lead to feelings of frustration and hopelessness. Physically, it has no blatant effects apart from preoccupation.
Recent research into the cases of stroke , stroke recovery and rehabilitation in strokes, patients have produced the following results. The probability of occurrence of aphasia in stroke patients is 20-40%(Hoffman, 2001 Salter et al., 2005). According to the National Aphasia Association 80, 000 people acquire aphasia annually in the US with one million being reported to be suffering from it (Aphasia, n.d.).
Research has also shown that most patients (40%) who have suffered a stroke and consequently acquired aphasia, recover within a year through spontaneous recovery but those who persisted post one year were found to be chronic aphasia sufferers and they constituted about 18- 27% (Paolucci et al., 2005).
In relation to nursing, the research addresses the things that nurses can do so as to identify the probability the patient may develop aphasia by using screening tests done by nurses since they are in close contact with the patients and know their communication patterns. In addition, the speech therapists may help in training the nurse in order for them to gain the expertise in speech therapy to enhance the rehabilitation process. “A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes” (McCloskey & Bulechek, 2000, p. 19).
The studies have shown that nurses can help in the diagnosis by the definition of what aphasia is and it can employ the major intervention of Communication Enhancement: Speech Deficit’ (Johnson et al. 2006, p. 98). It also employs the therapeutic intervention of Speech Language Therapy(SLT). This is a continuous process of speech therapy with increased complexity of speech intervention procedures.
Below are a selection of these studies based on screening, rehabilitation, treatment and nursing interventions:
According to the Quasi Experimental Screening cited by (Edwards et al., 1006), the unscreened patients who went on with undetected aphasia were 79% with another 97% constituting those who went with undetected anomia. This research used the Frenchay Aphasia Screening Test (FAST) screening instrument for aphasia and the Boston Naming Test for anomia. The brevity of the screening tests also improved the identification of aphasia by a large margin was also a conclusion drawn by Edwards and his colleagues.
Another Study authored by (Enderson &Crow, 1996) inferred the significance of the Functional Communication Profile(FCP) and Minnesota test for the differential diagnosis of aphasia(MTTDA) SLT tests as well as FAST screening instrument in not only identifying but also in research for recovery purposes.
Thommessen et al., (1999) also gives another research report that contained details of a screening done by group of nurses in Norway who used the Ullevaal Aphasia Screening (UAS) instead of the gold standard screens given by speech pathologists. It gave the following screens in language expression, comprehension, repetition, reading, reproduction of a string of words and free communication. 86% of the researchers agreed it was a valid screen in that it gave a good prediction of probability of aphasia in the acute stage of post-stroke with a predictive value of a positive test =0.67.
On the effectiveness of the SLT, the following research studies were included:
(Bakheit et al., 2007) inferred that t intensive SLT had no significant effect in improving aphasic symptoms.
(Bartolo et al., 2003) did research in to the chronic phase of aphasia where spontaneous recovery has not taken effect. The conclusion was that the different routes were responsible for different types of gestures. If the imitation of pantomimes was not being done, it was because of the deficiency in the efficiency of the working memory.
(Paolucci et al., 2000) did research on first time stroke patients who were in the acute stage and received early SLT screening within 20 days post -stroke. His results showed that if SLT was administered, early the effectiveness of the treatment was greatly increased.
(Salter et al., 2006) found that the FAST screen was the most widely used in evaluations and the UAS, which was used among nurses, was more specific but there was need for further research into evaluation of screening tools.
To summarize the effectiveness of nursing interventions to treating aphasia, nurses can apply three speech interventions: task-specific interventions, augmentative alternative communication and computer-based therapy.
- Task specific calls for targeting specific forms of impairment such as alexia and focuses on reading and comprehension (Cherney 2004, Beeson et al. 2005).
- Augmentative Alternative Communication (AAC) includes non-verbal communication through gestures, cards and pantomimes. The evidence showing their effectiveness was inconclusive in most cases since the research group was small (O’ Rourke & Walsh, 2010).
- (Salter et al., 2005) provided evidence of the effectiveness of computers in improving speech language skills especially in auditory discrimination exercises for patients with difficulty distinguishing the difference between phonemes or how the words sound.
Short-term effects of trauma on the patient have been discussed above about the physical, emotional and social adjustment for the person. Long-term, the patient will have to exert him or herself into rehabilitation efforts to get over the pain, the likelihood of aphasia, problems with memory, impulsivity and inappropriateness so as to become a member of the social world again and to work effectively in working environments and other environments.
Short-term effects on the society will be of shock at the inappropriateness and bluntness of the patient as well as sympathy. Long –term, the society especially the family will work to help the patient overcome problems in the cognitive processes of the trauma patient.
Strategies and approaches used in treating a trauma patient include speech therapy, physical therapy, computer-based speech therapy, brain exercises to jog one’s memory, screening patients to anticipate the aphasic effects so as to treat it more effectively.
In conclusion, this paper has discussed the details of a traumatic event on the brain. It looks at CA in particular and how it affects the cognitive functions of abstraction and executive functions. In addition, the short-term and long-term effects of these trauma and cerebrovascular disturbances were discussed in reference to the patient and to the society. Research studies into the input of nursing in the discipline of neuroscience and how nurses can be of help o speech pathologists was also reviewed in the number of nursing interventions available that is SLT and FAST. It explores the future of computers in treating aphasic patients and its impediments. It discusses the importance of a nurse in treating aphasic patients as they are usually in close contact with the patient and can observe the communication patterns of the patient in the acute post-stroke stage. This therefore summarizes the paper with the realization that further research needs to be done in this area and it is important for nurses to be included in this process. They need to be trained in the delivery of speech therapy so as to work in collaboration with the therapists and the doctors in this field.
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