Stroke Rehabilitation

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Stroke Rehabilitation

• Nursing implications

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Learning objectives

• At the end of this presentation the learner will
• Understand the pattern of deficits for
  hemispheric, brain stem, and cerebellar CVAs.
• Understand the key nursing implications of care
  for a left and right hemiplegia.
• Understand the nursing care implications for
  common CVA deficits, aphasia, neglect, impaired
  sensory processing, motor, and visual field
  deficits.

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Stroke Definition

• Stroke is clinically defined as a neurologic
  syndrome characterized by acute disruption of
  blood flow to an area of the brain, and
  corresponding onset of neurologic deficits
  related to the concerned area of the brain

Nurs Clin N Am 20023735-57
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The cortex
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Stroke Classification

• Ischemic stroke Account for 80. Results from
  occlusion in a blood vessel supplying the brain
• Thrombotic Occlusion due to atherothrombosis of
  small/large vessels supplying the brain with
  blood
• Embolic Occlusion due to embolus arising either
  from heart (e.g. atrial fibrillation, valvular
  disease, PFO) or another blood vessel (DVT)

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Ischemic Stroke
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Classification

• Hemorrhagic stroke Account for 20. Results from
  rupture of blood vessels leading to bleeding in
  brain
• Intracerebral Bleeding within the brain due to
  rupture of small blood vessels. Occurs mainly due
  to high blood pressure
• Subarachnoid Bleeding around the brain
  commonest cause is rupture of aneurysm.Other
  causes Head injury secondary to trauma or fall

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HemorrhagicStroke
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Hemispheric Expression of the stroke

• Motor and sensory deficits are found on the side
  OPPOSITE to the affected side of the brain
• Visual field deficits are also found on the side
  OPPOSITE to the affected side of the brain
• Horizontal gaze is also affected in the direction
  OPPOSITE to the affected side of the brain
• Because the eye cant move to the opposite side,
  it actually appears to be looking AT the affected
  side of the brain in hemispheric strokes

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Left (Dominant) Hemisphere Typical Signs Right
Side Weakness and Aphasia
Aphasia
Right Visual Field Deficit
Left Gaze Preference (in hemispheric stroke,
looks TOWARD the side of the injury)
Right Hemiparesis Right Hemisensory Loss
Hemiparesis weakness or partial
paralysis Hemiplegia paralysis
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Aphasia

• In right hand dominant people, the speech center
  of the brain is found in the left hemisphere
• So left hemispheric stroke is the most likely
  cause of aphasia in most people
• HOWEVER, some left hand dominant people have
  their speech centers on the right side of the
  brain, so they may present with right hemispheric
  stroke symptoms and aphasia

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• Expressive aphasia (motor or Brocas)
• difficulty in selecting, organizing and
  initiating speech
• speech is slow, hesitant and labored- short
  phrases or single words
• Receptive aphasia (sensory or Wernickes)
• impaired auditory comprehension and feedback,
  unable to monitor and correct speech
• Speech may be of normal rate and grammar intact,
  however unaware of and unable to correct
  mistakes may substitute a group of sounds, words
  or syllables
• Global aphasia
• nonfluent speech with poor comprehension and
  limited ability to name objects or repeat words

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Language Areas
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Right (Nondominant) Hemisphere Typical Signs
Left Side Weakness
Left Hemi-inattention (Neglect)
Left Visual Field Deficit
Right Gaze Preference (in hemispheric stroke,
looks TOWARD the side of the injury)
Left Hemiparesis Left Hemisensory Loss
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Hemi-inattention or Neglect

• Patients with neglect tend not to acknowledge
  anything about the affected side of their body
• People who experience damage to the right
  parietal lobe sometimes show a fascinating
  condition called hemi-inattention. When this
  occurs, the person is unable to attend to the
  left side of the body and the world. A person
  with hemi-inattention may shave or apply makeup
  only to the right side of the face. While
  dressing, he or she may put a shirt on the right
  arm but leave the left side of the shirt hanging
  behind the body. The person may eat from only the
  right side of the plate, not noticing the food on
  the left side. This condition is not due to
  visual problems or the loss of sensation on the
  left side of the body, but is a deficit in the
  ability to direct attention to the left side of
  the body and the world. (Psychobiology, Salem
  Press)

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Hemi-inattention or Neglect

• The most common form of neglect is neglect of the
  left side of the body due to a right hemispheric
  lesion
• If a patient appears not to acknowledge your
  presence from one side of the body, try changing
  sides to rule out hemi-neglect
• Patients can often eventually totally recover
  from hemi-inattention deficits

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Do you think you will have difficulty? None
Task is performed
Did you have any difficulty?
None
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• Failure to recognize side of body contralateral
  to injury
• May not bathe contralateral side of body or shave
  contralateral side of face
• Deny own limbs
• Objects in contralateral visual field ignored

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Left CVA

• Right sided paralysis
• Communication deficits
• Aphasia- expressive, receptive Global aphasia
• Loss of problem solving skills
• Right visual field deficit
• Emotional Lability
• Decreased organizational skills and initiation
• Disoriented to time place
• Perseverative movements phrases

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Left CVA

• Vision-Unable to discriminate words letters or
  read. Deficits in right visual field
• Behavior-slow, cautious, anxious when attempting
  new task
• Depression or catastrophic response to illness,
  sense of guilt, Emotional Lability
• Feeling of worthlessness, worries over future, is
  quick to anger becomes frustrated easily.

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Right CVA

• Left sided Paralysis
• Left visual field deficits
• Agnosia inability to recognize familiar objects
  (keys, pen, persons)
• Poor Judgement
• Impulsive behavior
• Denial of deficit
• Easily distracted
• Unilateral neglect

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Right CVA

• Visual spatial deficits
• Neglect in left visual field, loss of depth
  perception
• Impulsive behavior unaware of deficits
• Confabulates Euphoric
• Constant Smile
• Poor judgement
• Over estimates abilities

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Brainstem Typical Signs Bilateral Abnormalities
Crossed Signs (1 side of face and
contralateral body)
Quadriparesis Sensory Loss in All 4 Limbs
Hemiparesis Hemisensory Loss
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Brainstem Typical Signs Cranial Nerve and
Other Deficits
Vertigo, Tinnitus Dizziness
Decreased LOC Nausea, Vomiting Hiccups, Abnormal
Respirations
Eye Movement Abnormalities Diplopia Dysconjugate
Gaze Gaze Palsy (horizontal gaze deficit or gaze
preference) Nystagmus
Oropharyngeal Weakness Dysarthria (speaking),
Dysphagia (swallowing)
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Cerebellum Typical Signs Lack of Coordination
Ipsilateral (same side) Limb Ataxia
(dyscoordination)
Truncal or Gait Ataxia (imbalance)
Tremors, or Limb Ataxia, result from lack of
coordination of opposing muscle groups (flexors
vs. extensors), causing the muscle groups to
fight each other
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REHABILITATION

• Restoration of a disabled person to maximum
  independence by developing his/her residual
  capacities.

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Spontaneous recovery

• Spontaneous recovery from, e.g., stroke
• Quick recovery of functions during the first
  three months after injury
• Slower recovery thereafter, but can improve over
  years if they keep working on it

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Theories of Recovery

• Resolution of harmful factors
• Reduced edema, resorption of toxins, increased
  circulation
• Neuroplasticity
• Collateral sprouting - From intact cells to
  denervated region after some or all input has
  been destroyed
• Unmasking of neural pathways and synapses not
  normally used
• Can be altered by drugs, environmental
  conditions, electrical stimulation

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Figure 5.25  Collateral sprouting A surviving
axon grows a new branch to replace the synapses
left vacant by a damaged axon.
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Adult Plasticity and Regeneration

• The brain has an amazing ability to reorganize
  itself rapidly through new pathways and
  connections .
• Through Practice
• Motor regions
• After damage or injury
• Undamaged neurons make new connections and take
  over functionality or establish new functions
• But requires stimulation
• Stimulation is a standard technique for stroke
  survivor in rehabilitation

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Cardinal Principles of Rehab

• E Early Treatment
• A Activity Strengthens
• S Stress Abilities, NOT disabilities
• T Treat total patient
• Treat adults as adults!

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• Essential nursing competencies
• Protect, maintain, restore and promote the
  health of individuals and the command of their
  vital physical and mental functions taking into
  account the
  personality of each person and his
  psychological, social, economic and cultural
  characteristics.

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Unilateral Neglect

• This syndrome is most commonly seen with right
  cerebral stroke.
• Teach client to
• Observe safety measures.
• Touch and use both sides of the body.
• Use scanning technique of turning the head from
  side to side to expand the visual field

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Nursing Intervention for Stroke Deficits
Motor
Positioning, alignment, ROM Provide alternative
communication Test reflexes before offering
nourishment elevate head Speech consultation
Hemiparesis or hemiplegia Dysarthria Dysphagia

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Sensory Deficits
Teach patient to check body parts visually

• Protect involved area accept pt.'s perception
  position pt. to face involved area
• Control amt. of change in schedule reorient
• Correct misuse of object demonstrate
• correct use
• Correct misinformation
• Place equipment where pt. can see it
• Reduce distraction
• Phrase requests without R/L designation

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Language and Cognitive Deficits
Expressive Aphasia Speak clearly, use
tactile cues gestures. Receptive
Aphasia Patience!!!! Global Aphasia
Mime techniques
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Impaired Mobility and Self-Care

• Interventions include
• ROM exercises for the involved extremities
• Change of clients position frequently
• Prevention of deep vein thrombosis
• Therapy focused on ADLs
• Reinforce specific techniques learned in therapy

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Urinary Bowel Incontinence

• Altered level of consciousness may cause
  incontinence or impaired innervation, or an
  inability to communicate.
• Develop a bladder and bowel training program.

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Bladder Retraining

• Diagnosis
• Rule out reversible causes-UTIs, BPH , Meds
• Post-void residuals-Retention
• Urodynamic studies
• Treatment
• Timed toileting use toilet or commode to
  promote optimal emptying of bladder, men should
  stand to void if able
• Fluid restriction after dinner
• External catheters
• Intermittent or indwelling catheterization
• Medications

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Bowel Retraining

• Bowel Dysfunction
• Causes
• Disinhibition of reflex emptying mechanisms,
  sensation or cognitive impairments
• Prevention Treatment
• Diet adequate fluids, fiber
• Toileting after meals (gastrocolic reflex)
• Medications stool softeners, bowel stimulants,
  suppositories, enemas
• Use toilet or commode chair for best results if
  possible
• Persistent bowel incontinence gt4 weeks usually
  poor functional predictor

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Medical Complications

• Pressure Sores
• Preventive Strategies
• Nutrition
• Hydration
• Incontinence care
• Specialty Mattresses
• Heel protector boots
• Positioning and turning
• Pressure relief

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Medical Complications

• Deep Venous Thrombosis (DVT)
• Incidence
• Up to 20 to 75 of stroke survivors
• Preventive
• Stockings
• Thigh-high TEDs
• Pneumatic compression/SCDs
• Subcutaneous heparin or Lovenox,
• Treatment
• Heparin, Lovenox
• Warfarin

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Medical Complications

• Shoulder Pain
• Causes
• Impaired passive range of motion
• Adhesive capsulitis
• Neuropathy
• Chronic regional pain syndrome (CRPS), RSD
  (Reflexive Sympathetic Dystrophy) or Shoulder
  Hand Syndrome
• Shoulder trauma
• Bursitis Tendinitis
• Rotator cuff tear
• Heterotropic ossification

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Medical Complications

• CRPS Type I Treatment for shoulder pain
• Aggressive range of motion (ROM)
• Pharmacologic agents
• Nonsteroidal agents
• Antidepressants
• Local injections
• Corticosteroids
• Gabapentin
• Sympathetic blocks
• eTENS

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Medical Complications

• Shoulder Subluxation
• Pathogenesis not well understood
• Supraspinatus weakness implicated
• Treatments
• Shoulder supports
• Functional electrical stimulation (FES)
• Arm boards
• Overhead slings
• Never lift under hemiparetic arm during transfers
  or bed mobility

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Medical Complications

• Spasticity
• Treatment
• Goals
• Prevention of deformities
• Tone inhibition
• Modalities
• Orthoses
• Static activities
• Inhibitory
• Dynamic activities
• Surgery
• Muscle release
• Tendon lengthening

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Medical Complications

• Spasticity Treatment Medications
• Systemic
• Dantrolene
• Clonidine
• Tizanidine
• Oral Baclofen
• Neurolytic Agents
• Phenol or denatured alcohol blocks
• Botulinum toxin
• Intrathecal
• Baclofen pump

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Medical Complications

• Dysphagia
• Occurrence
• Up to onethird of stroke survivors
• Complications
• Malnutrition /Dehydration
• Aspiration Pneumonia
• Aspiration Symptoms
• Dysphonia, wet voice quality
• Decreased gag reflex
• Decreased cough reflex
• Elevated temp, abnormal lung sounds

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Dysphagia

• Interventions include
• Assessment of clients ability to swallow via
  Speech Therapy evaluation, video fluoroscopy,
  fiberoptic laryngoscopy
• Client head positioning to facilitate the process
  of swallowing before feeding
• Appropriate diet for the client, including
  modified textures of foods and fluids
• Utilization of compensatory strategies during
  feeding (double swallow, chin tuck, use of straws
  etc.)

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Medical Complications

• Depression
• Incidence
• 25 to 79 of survivors
• lt5 receive intervention
• More prevalence 6 months to 2 years post stroke
• Causes
• Reactive or situational
• Organic chemical imbalance
• Treatment
• Psychotherapy
• Medications

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Efficacy of Stroke Rehabilitation

• Europe Integrated Programs
• Increased functional gains
• Increased discharge rate to home
• Decreased 1-year mortality
• Increased quality of life
• United States Multidisciplinary Rehab Units
• Decreased dependency
• Decreased institutionalization
• Decreased 1-year mortality

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Elks Stroke Program 2009

• Number of Patients in Sample 154
• Average Number of Treatment Hours 3
• Men Served 68
• Women Served 86
• Average Age 73
• 75 of our patients were able to discharge to the
  community
• 9 over the national average of

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2009 Elks Stroke Program
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2009 Elks Stroke Program
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2009 Elks Stroke Program
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Stroke Patient Satisfaction _at_ Elks
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2009 Elks Stroke Program
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Pool Therapy
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Thank you for your attention

• Are there any questions????