Case Study: Hyper Acute Stroke Unit

Mrs Jones is an 86 year old lady who was admitted to a Hyper Acute Stroke Unit (HASU) from a medical ward. She was initially admitted with a fall at home and was alert on admission, however, a week later she had developed aphasia, with no limb weakness, visual field deficit or facial droop. Thrombolysis therapy, which involves dissolving the thrombus with an aim of re-opening the occluded artery was considered. However, although her initial CT Head confirmed she had not had a bleed (a contraindication to thrombolysis) she was not a suitable candidate as she woke up with the symptoms. Therefore, the precise time of symptom onset was unknown, and treatment must be started as early a possible and within 4.5 hours of symptom onset (Nice, 2008).
Given that the Broca’s area, located in the inferior frontal gyrus, is responsible for the construction of verbal language it is evident that the reduction in blood flow, caused by the LMCA occlusion, lead to damage in the Broca’s area. Williams et al (2010) point out that such damage to this area can lead to significant impairment to communication. However, there is another language centre in the brain: the Wernicke’s area, located in the superior posterior temporal lobe. Both the Wernicke’s and Broca’s area are connected by a large bundle of nerve fibres called the arcuate fasciculus, which play an instrumental role in connecting both language centres of the brain, allowing for the sequence of the interpretation and formation of language. Given that she had a substantial compromise in, both, her ability to understand language and form it the ischaemic stroke may have, also, compromised blood supply to the arcuate fasciculus where its ability to effectively perform its function was lost. Both this compromise of understanding as well as forming language is known as global
Initially the Nursing Staff from HASU had handed over that Mrs Jones was able to understand some verbal language, given that she was now responding ‘yes’ to questions and saying ‘jack’ (her sons name). However, on further study of the Speech and Language Therapist’s (SLT) notes it was stated that Mrs Jones was not engaging in written communication charts and gestures and was not following simple one stage commands. Whilst she was changing her pitch and making facial expressions, which may indicate that she had some understanding, there was in fact no constant means of communication. This meant that Nursing staff may have been asking her questions such as ‘would you like chicken for lunch?’ or ‘would you like your hair washed?’ and, of course, she had been saying ‘yes’ without understanding the question or even the answer. Evidently this suggests a gap in Stroke Nurse’s competence in language therapy and, whilst basic training in speech therapy is given to Nurses, alternative communication and assessment (gesturing, picture boards etc) are rarely used and considered to be beyond the role of nurses (Finke et al, 2008). However, given that Nurses are described as a natural and significant member of the rehabilitation team (Clarke, 2014) and spend 24/7 with patients they are vital in performing rehabilitation activities such as language assessment and