The Patient Recovering from an Ischemic Stroke

Nursing Process

The Patient Recovering From an Ischemic Stroke

The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care. The patient who has had a stroke is at risk for multiple complications, including deconditioning and other musculoskeletal problems, swallowing difficulties, bowel and bladder dysfunction, inability to perform self-care, and skin breakdown. After the stroke is complete, management focuses on the prompt initiation of rehabilitation for any deficits.

Assessment

During the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient's clinical status:

• Change in level of consciousness or responsiveness as evidenced by movement, resistance to changes of position, and response to stimulation; orientation to time, place, and person
• Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body posture; and position of the head
• Stiffness or flaccidity of the neck
• Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
• Color of the face and extremities; temperature and moisture of the skin
• Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure
• Ability to speak
• Volume of fluids ingested or administered; volume of urine excreted each 24 hours
• Presence of bleeding
• Maintenance of blood pressure within the desired parameters

After the acute phase, the nurse assesses mental status (memory, attention span, perception, orientation, affect, speech/language), sensation/perception (usually the patient has decreased awareness of pain and temperature), motor control (upper and lower extremity movement), swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function. Ongoing nursing assessment continues to focus on any impairment of function in the patient's daily activities, because the quality of life after stroke is closely related to the patient's functional status.

Diagnosis

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses for a patient with a stroke may include the following:

• Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
• Acute pain (painful shoulder) related to hemiplegia and disuse
• Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
• Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
• Impaired swallowing
• Total urinary incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
• Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
• Impaired verbal communication related to brain damage
• Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility
• Interrupted family processes related to catastrophic illness and caregiving burdens
• Sexual dysfunction related to neurologic deficits or fear of failure

Collaborative Problems/Potential Complications

Potential complications include:

• Decreased cerebral blood flow due to increased ICP
• Inadequate oxygen delivery to the brain
• Pneumonia

Planning and Goals

Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort. It is helpful for the team to know what the patient was like before the stroke: his or her illnesses, abilities, mental and emotional state, behavioral characteristics, and activities of daily living (ADLs). It is also helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and level of consciousness at time of admission) in order to provide stroke survivors and their families with realistic goals (Adams et al., 2003; Cucchiara, Kasner, Wolk, et al., 2004).

The major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of self-care, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications.

Nursing Interventions

Nursing care has a significant impact on the patient's recovery. Often, many body systems are impaired as a result of the stroke, and conscientious care and timely interventions can prevent debilitating complications. During and after the acute phase, nursing interventions focus on the whole person. In addition to providing physical care, the nurse encourages and fosters recovery by listening to the patient and asking questions to elicit the meaning of the stroke experience.

Improving Mobility and Preventing Joint Deformities

A patient with hemiplegia has unilateral paralysis (paralysis on one side). When control of the voluntary muscles is lost, the strong flexor muscles exert control over the extensors. The arm tends to adduct (adductor muscles are stronger than abductors) and to rotate internally. The elbow and the wrist tend to flex, the affected leg tends to rotate externally at the hip joint and flex at the knee, and the foot at the ankle joint supinates and tends toward plantar flexion.

Correct positioning is important to prevent contractures; measures are used to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies, especially of the ulnar and peroneal nerves. Because flexor muscles are stronger than extensor muscles, a posterior splint applied at night to the affected extremity may prevent flexion and maintain correct positioning during sleep. (See Chapter 11 for additional information.)

Preventing Shoulder Adduction

To prevent adduction of the affected shoulder while the patient is in bed, a pillow is placed in the axilla when there is limited external rotation; this keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than the more proximal joints (ie, the elbow is positioned higher than the shoulder and the wrist higher than the elbow). This helps to prevent edema and the resultant joint fibrosis that will limit range of motion if the patient regains control of the arm (Fig. 62-3).

Positioning the Hand and Fingers

The fingers are positioned so that they are barely flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position. If the upper extremity is flaccid, a volar resting splint can be used to support the wrist and hand in a functional position. If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. In this instance a dorsal wrist splint is useful in allowing the palm to be free of pressure. Every effort is made to prevent hand edema.

Spasticity, particularly in the hand, can be a disabling complication after stroke. Researchers reported that repeated intramuscular injections of botulinum toxin A into wrist and finger muscles reduced upper limb spasticity after stroke, resulting in significant and sustained improvements in muscle tone (Gordon, Brashear, Elovic, et al., 2004).

Changing Positions

The patient's position should be changed every 2 hours. To place a patient in a lateral (side-lying) position, a pillow is placed between the legs before the patient is turned. To promote venous return and prevent edema, the upper thigh should not be acutely flexed. The patient may be turned from side to side, but if sensation is impaired, the amount of time spent on the affected side should be limited.

If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh (Fig. 62-4). This position helps to promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures. The prone position also helps to drain bronchial secretions and prevents contractural deformities of the shoulders and knees. During positioning, it is important to reduce pressure and change position frequently to prevent pressure ulcers.

Establishing an Exercise Program

The affected extremities are exercised passively and put through a full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.

Repetition of an activity forms new pathways in the CNS and therefore encourages new patterns of motion. At first, the extremities are usually flaccid. If tightness occurs in any area, the range-of-motion exercises should be performed more frequently (see Chapter 11).

The patient is observed for signs and symptoms that may indicate pulmonary embolus or excessive cardiac workload during exercise; these include shortness of breath, chest pain, cyanosis, and increasing pulse rate with exercise. Frequent short periods of exercise always are preferable to longer periods at infrequent intervals. Regularity in exercise is most important. Improvement in muscle strength and maintenance of range of motion can be achieved only through daily exercise.

The patient is encouraged and reminded to exercise the unaffected side at intervals throughout the day. It is helpful to develop a written schedule to remind the patient of the exercise activities. The nurse supervises and supports the patient during these activities. The patient can be taught to put the unaffected leg under the affected one to assist in moving it when turning and exercising. Flexibility, strengthening, coordination, endurance, and balancing exercises prepare the patient for ambulation. Quadriceps muscle setting and gluteal setting exercises are started early to improve the muscle strength needed for walking; these are performed at least five times daily for 10 minutes at a time.

Preparing for Ambulation

As soon as possible, the patient is assisted out of bed. Usually an active rehabilitation program is started as soon as the patient regains consciousness. The patient is first taught to maintain balance while sitting and then to learn to balance while standing. If the patient has difficulty in achieving standing balance, a tilt table, which slowly brings the patient to an upright position, can be used. Tilt tables are especially helpful for patients who have been on bed rest for prolonged periods and have orthostatic blood pressure changes.

If the patient needs a wheelchair, the folding type with hand brakes is the most practical because it allows the patient to manipulate the chair. The chair should be low enough to allow the patient to propel it with the uninvolved foot and narrow enough to permit it to be used in the home. When the patient is transferred from the wheelchair, the brakes must be applied and locked on both sides of the chair.

The patient is usually ready to walk as soon as standing balance is achieved. Parallel bars are useful in these first efforts. A chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy.

The training periods for ambulation should be short and frequent. As the patient gains strength and confidence, an adjustable cane can be used for support. Generally, a three- or four-pronged cane provides a stable support in the early phases of rehabilitation.

Preventing Shoulder Pain

As many as 70% of stroke patients suffer severe pain in the shoulder that prevents them from learning new skills. Shoulder function is essential in achieving balance and performing transfers and self-care activities. Three problems can occur: painful shoulder, subluxation of the shoulder, and shoulder–hand syndrome.

A flaccid shoulder joint may be overstretched by the use of excessive force in turning the patient or from overstrenuous arm and shoulder movement. To prevent shoulder pain, the nurse should never lift the patient by the flaccid shoulder or pull on the affected arm or shoulder. If the arm is paralyzed, subluxation (incomplete dislocation) at the shoulder can occur as a result of overstretching of the joint capsule and musculature by the force of gravity when the patient sits or stands in the early stages after a stroke. This results in severe pain. Shoulder–hand syndrome (painful shoulder and generalized swelling of the hand) can cause a frozen shoulder and ultimately atrophy of subcutaneous tissues. When a shoulder becomes stiff, it is usually painful.

Many shoulder problems can be prevented by proper patient movement and positioning. The flaccid arm is positioned on a table or with pillows while the patient is seated. Some clinicians advocate the use of a properly worn sling when the patient first becomes ambulatory, to prevent the paralyzed upper extremity from dangling without support. Range-of-motion exercises are important in preventing painful shoulder. Overstrenuous arm movements are avoided. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The patient is instructed to flex the affected wrist at intervals and move all the joints of the affected fingers. He or she is encouraged to touch, stroke, rub, and look at both hands. Pushing the heel of the hand firmly down on a surface is useful. Elevation of the arm and hand is also important in preventing dependent edema of the hand. Patients with continuing pain after attempted movement and positioning may require the addition of analgesia to their treatment program.

Medications are helpful in the management of poststroke pain. Amitriptyline hydrochloride (Elavil) has been used, but it can cause cognitive problems, has a sedating effect, and is not effective in all patients. The antiseizure medication lamotrigine (Lamictal) has been found to be effective for poststroke pain, and it may serve as an alternative for patients who cannot tolerate amitriptyline (Nicholson, 2004).

Enhancing Self-Care

As soon as the patient can sit up, personal hygiene activities are encouraged. The patient is helped to set realistic goals; if feasible, a new task is added daily. The first step is to carry out all self-care activities on the unaffected side. Such activities as combing the hair, brushing the teeth, shaving with an electric razor, bathing, and eating can be carried out with one hand and are suitable for self-care. Although the patient may feel awkward at first, the various motor skills can be learned by repetition, and the unaffected side will become stronger with use. The nurse must be sure that the patient does not neglect the affected side. Assistive devices will help make up for some of the patient's deficits (Chart 62-3). A small towel is easier to control while drying after bathing, and boxed paper tissues are easier to use than a roll of toilet tissue.

Return of functional ability is important to the patient recovering after a stroke. An early baseline assessment of functional ability with an instrument such as the Functional Independence Measure (FIMTM) is important in team planning and goal setting for the patient. The FIMTM is a widely used instrument in stroke rehabilitation and provides valuable information about motor, social, and cognitive function (Kelly-Hayes, 2004). The patient's morale will improve if ambulatory activities are carried out in street clothes. The family is instructed to bring in clothing that is preferably a size larger than that normally worn. Clothing fitted with front or side fasteners or Velcro closures is the most suitable. The patient has better balance if most of the dressing activities are carried out while seated.