stroke rehabilitation

Stroke RehabilitationStroke Rehabilitation• Nursing Nursing

implicationsimplications

Learning objectivesLearning objectives

• At the end of this presentation the learner will:At the end of this presentation the learner will:

• Understand the pattern of deficits for Understand the pattern of deficits for hemispheric, brain stem, and cerebellar CVAs.hemispheric, brain stem, and cerebellar CVAs.

• Understand the key nursing implications of Understand the key nursing implications of care for a left and right hemiplegia.care for a left and right hemiplegia.

• Understand the nursing care implications for Understand the nursing care implications for common CVA deficits, aphasia, neglect, common CVA deficits, aphasia, neglect, impaired sensory processing, motor, and visual impaired sensory processing, motor, and visual field deficits.field deficits.

Stroke: DefinitionStroke: Definition

Stroke is clinically defined as a Stroke is clinically defined as a neurologic syndrome characterized neurologic syndrome characterized by acute disruption of blood flow to by acute disruption of blood flow to an area of the brain, and an area of the brain, and corresponding onset of corresponding onset of neurologic neurologic deficits related to the concerned deficits related to the concerned area of the brainarea of the brain Nurs Clin N Am 2002;37:35-57

The cortexThe cortex

Stroke: ClassificationStroke: Classification

Ischemic strokeIschemic stroke: Account for 80%. Results : Account for 80%. Results from occlusion in a blood vessel from occlusion in a blood vessel supplying the brainsupplying 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)

Ischemic Ischemic StrokeStroke

ClassificationClassification

Hemorrhagic strokeHemorrhagic stroke: Account for 20%. Results : Account for 20%. Results from rupture of blood vessels leading to from rupture of blood vessels leading to bleeding in brainbleeding 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

HemorrhagicHemorrhagicStrokeStroke

Hemispheric Hemispheric Expression of the Expression of the strokestroke

• Motor and sensory deficits are found on the side Motor and sensory deficits are found on the side OPPOSITE to the affected side of the brainOPPOSITE to the affected side of the brain

• Visual field deficits are also found on the side OPPOSITE Visual field deficits are also found on the side OPPOSITE to the affected side of the brainto the affected side of the brain

• Horizontal gaze is also affected in the direction OPPOSITE Horizontal gaze is also affected in the direction OPPOSITE to the affected side of the brainto the affected side of the brain– Because the eye can’t move to the opposite side, it actually

appears to be looking AT the affected side of the brain in hemispheric strokes

LeftLeft (Dominant)(Dominant) Hemisphere Typical Hemisphere Typical Signs: Signs: RightRight Side Weakness and Side Weakness and AphasiaAphasia

AphasiaAphasia

Left Gaze Left Gaze Preference Preference

(in hemispheric (in hemispheric stroke, looks stroke, looks

TOWARD the side TOWARD the side of the injury)of the injury)

Right Right HemiparesisHemiparesis

Right Right Hemisensory Hemisensory LossLoss

Right Visual Right Visual Field DeficitField Deficit

Hemiparesis: weakness or partial

paralysis

Hemiplegia: paralysis

AphasiaAphasia• In right hand dominant people, the In right hand dominant people, the

speech center of the brain is found in the speech center of the brain is found in the left hemisphereleft hemisphere– So So left hemispheric strokeleft hemispheric stroke is the most likely is the most likely

cause of aphasia in most peoplecause of aphasia in most people

– HOWEVER, some left hand dominant people HOWEVER, some left hand dominant people have their speech centers on the right side of have their speech centers on the right side of the brain, so they may present with right the brain, so they may present with right hemispheric stroke symptoms and aphasiahemispheric stroke symptoms and aphasia

• Expressive aphasia (motor or Expressive aphasia (motor or Broca’sBroca’s))– difficulty in selecting, organizing and initiating speech– speech is slow, hesitant and labored- short phrases or

single words

• Receptive aphasia (sensory or Receptive aphasia (sensory or Wernicke’sWernicke’s))– 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 aphasiaGlobal aphasia– nonfluent speech with poor comprehension and limited

ability to name objects or repeat words

Language AreasLanguage Areas

RightRight (Nondominant)(Nondominant) Hemisphere Typical Hemisphere Typical Signs: Signs: LeftLeft Side Weakness Side Weakness

Right Gaze Right Gaze PreferencePreference

(in hemispheric (in hemispheric stroke, looks stroke, looks TOWARD the side TOWARD the side of the injury)of the injury)

Left HemiparesisLeft Hemiparesis

Left Left Hemisensory Hemisensory

LossLoss

Left Hemi-Left Hemi-inattention inattention

(Neglect)(Neglect)Left Visual Left Visual

Field DeficitField Deficit

Hemi-inattention or Hemi-inattention or “Neglect”“Neglect”• Patients with neglect tend not to acknowledge Patients with neglect tend not to acknowledge

anything about the affected side of their bodyanything 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)

Hemi-inattention or Hemi-inattention or “Neglect”“Neglect”

• The most common form of neglect is neglect of The most common form of neglect is neglect of the left side of the body due to a right the left side of the body due to a right hemispheric lesionhemispheric lesion

• If a patient appears not to acknowledge your If a patient appears not to acknowledge your presence from one side of the body, try presence from one side of the body, try changing sides to rule out hemi-neglectchanging sides to rule out hemi-neglect

• Patients can often eventually totally recover Patients can often eventually totally recover from hemi-inattention deficitsfrom hemi-inattention deficits

Do you think you will have difficulty? “None”

Task is performed Did you have any difficulty? “None”

• Failure to recognize Failure to recognize side of body side of body contralateral to injurycontralateral to injury

• May not bathe May not bathe contralateral side of contralateral side of body or shave body or shave contralateral side of contralateral side of faceface

• Deny own limbsDeny own limbs

• Objects in Objects in contralateral visual contralateral visual field ignoredfield ignored

Left CVALeft CVA

• Right sided paralysisRight sided paralysis• Communication deficitsCommunication deficits• Aphasia- expressive, Aphasia- expressive,

receptive & Global aphasiareceptive & Global aphasia• Loss of problem solving Loss of problem solving

skillsskills• Right visual field deficitRight visual field deficit• Emotional LabilityEmotional Lability• Decreased organizational Decreased organizational

skills and initiationskills and initiation• Disoriented to time & placeDisoriented to time & place• Perseverative movements Perseverative movements

& phrases& phrases

Left CVALeft CVA

• Vision-Unable to Vision-Unable to discriminate words & discriminate words & letters or read. Deficits in letters or read. Deficits in right visual fieldright visual field

• Behavior-slow, cautious, Behavior-slow, cautious, anxious when attempting anxious when attempting new tasknew task

• Depression or catastrophic Depression or catastrophic response to illness, sense of response to illness, sense of guilt, Emotional Labilityguilt, Emotional Lability

• Feeling of worthlessness, Feeling of worthlessness, worries over future, is worries over future, is quick to anger & becomes quick to anger & becomes frustrated easily.frustrated easily.

Right CVARight CVA

• Left sided ParalysisLeft sided Paralysis• Left visual field deficitsLeft visual field deficits• Agnosia – inability to recognize familiar Agnosia – inability to recognize familiar

objects (keys, pen, persons)objects (keys, pen, persons)• Poor JudgementPoor Judgement• Impulsive behaviorImpulsive behavior• Denial of deficitDenial of deficit• Easily distractedEasily distracted• Unilateral neglectUnilateral neglect

Right CVARight CVA

• Visual spatial deficitsVisual spatial deficits

• Neglect in left visual field, loss of depth Neglect in left visual field, loss of depth perceptionperception

• Impulsive behavior – unaware of deficitsImpulsive behavior – unaware of deficits

• Confabulates –EuphoricConfabulates –Euphoric

• Constant SmileConstant Smile

• Poor judgementPoor judgement

• Over estimates abilitiesOver estimates abilities

BrainstemBrainstem Typical Signs: Typical Signs: BilateralBilateral Abnormalities Abnormalities

Quadriparesis

Sensory Loss

in All 4 Limbs

Crossed Signs (1 side of face and contralateral body)Hemiparesis

Hemisensory

Loss

Cranial nerve signs suggest localization to

(and within) the brainstem

BrainstemBrainstem Typical Signs: Typical Signs: Cranial NerveCranial Nerve and Other Deficits and Other Deficits

Oropharyngeal Oropharyngeal Weakness:Weakness:

Dysarthria Dysarthria (speaking), (speaking), Dysphagia Dysphagia (swallowing)(swallowing)

Eye Movement Eye Movement Abnormalities:Abnormalities:

DiplopiaDiplopia

Dysconjugate GazeDysconjugate Gaze

Gaze Palsy Gaze Palsy (horizontal gaze (horizontal gaze

deficit or gaze deficit or gaze preference)preference)

NystagmusNystagmus

Decreased LOCDecreased LOC

Nausea, Nausea, VomitingVomiting

Hiccups, Hiccups, Abnormal Abnormal RespirationsRespirations

Vertigo, Vertigo, TinnitusTinnitus

DizzinessDizziness

CerebellumCerebellum Typical Signs: Typical Signs: Lack of CoordinationLack of Coordination

Ipsilateral (same Ipsilateral (same side) Limb side) Limb Ataxia Ataxia (dyscoordination(dyscoordination)) Truncal or GaitTruncal or Gait

Ataxia (imbalance)Ataxia (imbalance)Tremors, or Limb Tremors, or Limb Ataxia, result from Ataxia, result from lack of coordination lack of coordination of opposing muscle of opposing muscle groups (flexors vs. groups (flexors vs. extensors), causing extensors), causing the muscle groups the muscle groups to fight each otherto fight each other

REHABILITATIONREHABILITATION

Restoration of a disabled person Restoration of a disabled person to maximum independence by to maximum independence by

developing his/her residual developing his/her residual capacities.capacities.

””Spontaneous” recoverySpontaneous” recovery

• ””Spontaneous” recovery from, e.g., strokeSpontaneous” recovery from, e.g., stroke

• Quick recovery of functions during the Quick recovery of functions during the first three months after injuryfirst three months after injury

• Slower recovery thereafter, but can Slower recovery thereafter, but can improve over years if they keep working improve over years if they keep working on iton it

Theories of RecoveryTheories of Recovery• Resolution of harmful factorsResolution of harmful factors

– Reduced edema, resorption of toxins, increased circulation

• NeuroplasticityNeuroplasticity– 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

Figure 5.25 Collateral sproutingA surviving axon grows a new branch to replace the synapses left

vacant by a damaged axon.

Adult Plasticity and RegenerationAdult Plasticity and RegenerationThe brain has an amazing ability to reorganize The brain has an amazing ability to reorganize

itself rapidly through new pathways and itself rapidly through new pathways and connections .connections .

• Through Practice: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

Cardinal Principles of RehabCardinal Principles of Rehab• EE: Early Treatment: Early Treatment• AA: Activity Strengthens: Activity Strengthens• SS: Stress Abilities, NOT disabilities: Stress Abilities, NOT disabilities• TT: Treat total patient: Treat total patient

• Treat adults as adults!Treat adults as adults!

Essential nursing competenciesEssential nursing competencies

Protect, maintain, restoreProtect, maintain, restore and and promotepromote

the health of individuals and the the health of individuals and the

command of their vital physical and command of their vital physical and

mental functions taking into account mental functions taking into account

the personality of each the personality of each

person and his psychological, social, person and his psychological, social,

economic and cultural characteristics.economic and cultural characteristics.

Unilateral NeglectUnilateral Neglect• This syndrome is most commonly seen This syndrome is most commonly seen

with right cerebral stroke.with right cerebral stroke.

• Teach client toTeach client to::

– Observe safety measures.Observe safety measures.

– Touch and use both sides of the body.Touch and use both sides of the body.

– Use scanning technique of turning the head Use scanning technique of turning the head

from side to side to expand the visual fieldfrom side to side to expand the visual field

Nursing Intervention for Stroke Deficits

Motor

Hemiparesis or Hemiparesis or hemiplegiahemiplegia

DysarthriaDysarthria

DysphagiaDysphagia

Positioning, alignment, ROM

Provide alternative communication

Test reflexes before offering nourishment; elevate headSpeech consultation

Sensory Deficits

Teach patient to check body parts visually

ProtectProtect involved area; accept pt.'s perception; position involved area; accept pt.'s perception; position

pt. to face involved areapt. to face involved area

ControlControl amt. of change in schedule; reorient amt. of change in schedule; reorient

CorrectCorrect misuse of object; demonstrate misuse of object; demonstrate

correct usecorrect use

CorrectCorrect misinformation misinformation

PlacePlace equipment where pt. can see it equipment where pt. can see it

ReduceReduce distraction distraction

PhrasePhrase requests without R/L designationrequests without R/L designation

Expressive Aphasia Speak clearly, use tactilecues & gestures.

Receptive Aphasia Patience!!!!Global Aphasia Mime techniques

Memory lossShort attention spanDistractibilityPoor judgmentInability to transfer learningInability to calculate, reason, or think abstractly

Provide informationDivide activities in small segmentsControl distractionsProtect pt. from injuryRepeat, Repeat, RepeatKeep expectations realistic & keep it simple

Language and Cognitive Deficits

Impaired Mobility and Self-CareImpaired Mobility and Self-Care• Interventions include:Interventions include:

ROM exercises for the involved ROM exercises for the involved extremitiesextremities

Change of client’s position frequentlyChange of client’s position frequently

Prevention of deep vein thrombosisPrevention of deep vein thrombosis

Therapy focused on ADLsTherapy focused on ADLs

Reinforce specific techniques learned in Reinforce specific techniques learned in therapytherapy

Urinary & Bowel IncontinenceUrinary & Bowel Incontinence

• Altered level of consciousness may Altered level of consciousness may

cause incontinence or impaired cause incontinence or impaired

innervation, or an inability to innervation, or an inability to

communicate.communicate.

• Develop a bladder and bowel training Develop a bladder and bowel training

program.program.

Bladder RetrainingBladder Retraining

• DiagnosisDiagnosis– Rule out reversible causes-UTI’s, BPH , Meds

– Post-void residuals-Retention

– Urodynamic studies

• TreatmentTreatment– 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

Bowel RetrainingBowel Retraining

• Bowel Dysfunction 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 >4 weeks usually poor Persistent bowel incontinence >4 weeks usually poor functional predictorfunctional predictor

Medical ComplicationsMedical Complications

• Pressure Sores Pressure Sores – Preventive Strategies

• Nutrition

• Hydration

• Incontinence care

• Specialty Mattresses

• Heel protector boots

• Positioning and turning

• Pressure relief


• Deep Venous Thrombosis (DVT) Deep Venous Thrombosis (DVT) – Incidence

• Up to 20% to 75% of stroke survivors

– Preventive • Stockings

– Thigh-high TED’s

– Pneumatic compression/SCD’s

• Subcutaneous heparin or Lovenox,

– Treatment• Heparin, Lovenox

• Warfarin


• Shoulder Pain 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


• CRPS Type I Treatment for shoulder pain CRPS Type I Treatment for shoulder pain – Aggressive range of motion (ROM) – Pharmacologic agents

• Nonsteroidal agents

• Antidepressants

• Local injections

• Corticosteroids

• Gabapentin

• Sympathetic blocks

– eTENS


• Shoulder Subluxation Shoulder Subluxation – Pathogenesis not well understood– Supraspinatus weakness implicated

• TreatmentsTreatments– Shoulder supports – Functional electrical stimulation (FES)– Arm boards – Overhead slings– Never lift under hemiparetic arm during transfers

or bed mobility


• Spasticity Spasticity – Treatment

• Goals– Prevention of deformities – Tone inhibition

• Modalities– Orthoses – Static activities– Inhibitory– Dynamic activities

• Surgery– Muscle release – Tendon lengthening


• Spasticity Treatment Medications Spasticity Treatment Medications – Systemic

• Dantrolene • Clonidine • Tizanidine• Oral Baclofen

– Neurolytic Agents• Phenol or denatured alcohol blocks• Botulinum toxin

– Intrathecal• Baclofen pump


• DysphagiaDysphagia– Occurrence

• Up to one·third 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

DysphagiaDysphagia

• Interventions includeInterventions include::

– Assessment of client’s ability to swallow via Speech Therapy Assessment of client’s ability to swallow via Speech Therapy evaluation, video fluoroscopy, fiberoptic laryngoscopyevaluation, video fluoroscopy, fiberoptic laryngoscopy

– Client head positioning to facilitate the process of Client head positioning to facilitate the process of swallowing before feedingswallowing before feeding

– Appropriate diet for the client, including modified textures Appropriate diet for the client, including modified textures of foods and fluidsof foods and fluids

– Utilization of compensatory strategies during feeding Utilization of compensatory strategies during feeding (double swallow, chin tuck, use of straws etc.)(double swallow, chin tuck, use of straws etc.)


• Depression Depression – Incidence

• 25% to 79% of survivors • <5% receive intervention • More prevalence 6 months to 2 years post stroke

– Causes• Reactive or situational• Organic chemical imbalance

– Treatment• Psychotherapy • Medications

Efficacy of Stroke RehabilitationEfficacy of Stroke Rehabilitation

• Europe Europe Integrated Programs Integrated Programs – Increased functional gains – Increased discharge rate to home – Decreased 1-year mortality – Increased quality of life

• United States United States Multidisciplinary Rehab UnitsMultidisciplinary Rehab Units– Decreased dependency – Decreased institutionalization – Decreased 1-year mortality

Elks Stroke Program 2009Elks Stroke Program 2009

• Number of Patients in Sample:Number of Patients in Sample: 154 154

• Average Number of Treatment Hours:Average Number of Treatment Hours: 3 3

• Men Served:Men Served: 68 68

• Women Served:Women Served: 86 86

• Average Age:Average Age: 73 73

• 75% of our patients were able to discharge to the 75% of our patients were able to discharge to the communitycommunity– 9% over the national average of

2009 Elks Stroke Program2009 Elks Stroke Program

Community Discharges

75%

66%

50%55%60%65%70%75%80%

IERH Nation


Discharge Destinations

Home59%

Other9%

Assisted Living13%

Long Term Care16%

Board & Care, etc.

3%


Functional Improvement

22.1720.21

0

5

10

15

20

25

IERH National

Stroke Patient Satisfaction @ ElksStroke Patient Satisfaction @ Elks

Patient Satisfaction

Satisfied97%

Neutral2%

Dissatisfied1%


Patient Satisfaction (5 highest score)

4

4.84

1

2

3

4

5

IERH Goal

Pool TherapyPool Therapy

Thank you for your attentionThank you for your attention

• Are there any questions????Are there any questions????

stroke rehabilitation

Documents

hemispheric stroke symptoms

sensory deficits

brain stem

classificationischemic

rupture of blood vessels

brain commonest cause

pattern of deficits

brainvisual field deficits