Nursing Process: 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 blad-der dysfunction, inability to perform self-care, and skin break-down. 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 the level of consciousness or responsiveness as ev-idenced 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 reac-tions 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 param-eters

After the acute phase, the nurse assesses mental status (memory, attention span, perception, orientation, affect, speech/language), sensation/perception (usually the patient has decreased aware-ness of pain and temperature), motor control (upper and lower extremity movement), swallowing ability, nutritional and hydra-tion status, skin integrity, activity tolerance, and bowel and blad-der 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:

·      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 (hygiene, toileting, grooming, and feeding) related to stroke sequelae

·      Disturbed sensory perception related to altered sensory re-ception, transmission, and/or integration

·      Impaired swallowing

·      Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating

·      Disturbed thought processes related to brain damage, con-fusion, 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 whatthe patient was like before the stroke: his or her illnesses, abilities, mental and emotional state, behavioral characteristics, and activ-ities of daily living. It is also helpful for clinicians to be knowl-edgeable about the relative importance of predictors of stroke outcome (age, gender, NIHSS score at time of admission, to name a few) in order to provide stroke survivors and their families with realistic goals (Demchuk & Buchan, 2000).

The major goals for the patient (and family) may include im-proved 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 de-bilitating complications. During and after the acute phase, nurs-ing interventions focus on the whole person. In addition to providing physical care, nurses can encourage and foster recovery by listening to patients and asking questions to elicit the mean-ing of the stroke experience (Eaves, 2000; Pilkington, 1999).

IMPROVING MOBILITY AND PREVENTING JOINT DEFORMITIES

A hemiplegic patient 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 ro-tate 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 plan-tar 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 po-sitioning during sleep.

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 ex-ternal 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. Thus, the elbow is positoned 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 func-tional 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 pres-sure. Every effort is made to prevent hand edema.

Spasticity, particularly in the hand, can be a disabling com-plication after stroke. Researchers have recently reported that in-tramuscular injections of botulinum toxin A decreased spasticity in the wrist and fingers and increased functional ability in dress-ing, washing, and other activities of daily living (Brashear et al., 2002).

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 be-tween 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 the amount of time spent on the affected side should be limited if sensation is impaired.

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 umbili-cus to the upper third of the thigh (Fig. 62-4). This helps to pro-mote 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 para-lyzed extremity, prevent further deterioration of the neuro-muscular 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 ex-tremities are usually flaccid. If tightness occurs in any area, the range-of-motion exercises should be performed more frequently.

The patient is observed for signs and symptoms that may in-dicate 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 in-tervals. 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 un-affected side at intervals throughout the day. It is helpful to de-velop 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 move it when turning and exercis-ing. Flexibility, strengthening, coordination, endurance, and bal-ancing exercises prepare the patient for ambulation. Quadriceps muscle setting and gluteal setting exercises are started early to im-prove the muscle strength needed for walking; these are per-formed 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, when hemiplegia has resulted from a thrombosis, an active reha-bilitation program is started as soon as the patient regains con-sciousness; a patient who has had a cerebral hemorrhage cannot participate actively until all evidence of bleeding is gone.

The patient is first taught to maintain balance while sitting and then to learn to balance while standing. If the patient has dif-ficulty 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 are having 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 ma-nipulate 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 trans-ferred 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 bal-ance 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 fre-quent. 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

Up to 70% of stroke patients suffer severe pain in the shoulder that prevents them from learning new skills, because 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 ex-cessive 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 from over-stretching the joint capsule and musculature by the force of grav-ity 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.

Medications are helpful in the management of post-stroke pain. Amitriptyline hydrochloride (Elavil) has been used but it can cause cognitive problems, has a sedating effect, and is not effective in all patients. A recent study showed the efficacy of an antiseizure medication lamotrigine (Lamictal) in treating post-stroke pain (Jensen et al., 2001).

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 movement and positioning have been attempted may require the addition of analgesia to their treatment program.

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 var-ious 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 62-4). 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 recov-ering after a stroke. An early baseline assessment of functional ability with an instrument such as the Functional Independence Measure (FIM) is important in team planning and goal setting for the patient. The FIM is a widely used instrument in stroke re-habilitation and also provides valuable functional information during the acute phase of care (Hinkle, 2000, 2001).

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 done in a seated position.

Perceptual problems may make it difficult for the patient to dress without assistance because of an inability to match the clothing to the body parts. To assist the patient, the nurse can take steps to keep the environment organized and uncluttered, because the patient with a perceptual problem is easily distracted. The clothing is placed on the affected side in the order in which the garments are to be put on. Using a large mirror while dress-ing promotes the patient’s awareness of what he or she is putting on the affected side. Each garment is put on the affected side first. The patient has to make many compensatory movements when dressing; these can produce fatigue and painful twisting of the in-tercostal muscles. Support and encouragement are provided to prevent the patient from becoming overly fatigued and discour-aged. Even with intensive training, not all patients can achieve independence in dressing.

MANAGING SENSORY-PERCEPTUAL DIFFICULTIES

Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The pa-tient can be taught to turn the head in the direction of the defec-tive visual field to compensate for this loss. The nurse should make eye contact with the patient and draw his or her attention to the affected side by encouraging the patient to move the head. The nurse may also want to stand at a position that encourages the patient to move or turn to visualize who is in the room. Increasing the natural or artificial lighting in the room and pro-viding eyeglasses are important in increasing vision.The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is im-portant for the nurse to constantly remind the patient of the other side of the body, to maintain alignment of the extremities, and, if possible, to place the extremities where the patient can see them.

MANAGING DYSPHAGIA

Stroke can result in swallowing problems (dysphagia) due to im-paired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal re-gurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition.

A speech therapist will evaluate the patient’s gag reflexes and ability to swallow. Even if partially impaired, swallowing func-tion may return in some patients over time, or the patient may be taught alternative swallowing techniques, advised to take smaller boluses of food, and taught about which foods are easier to swal-low. The patient may initially be started on a thick liquid or puréed diet because these foods are easier to swallow than thin liquids. Having the patient sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest as he or she swallows, will help prevent aspiration. The diet may be advanced as the patient becomes more proficient at swal-lowing. If the patient cannot resume oral intake, a gastrointesti-nal feeding tube will be placed for ongoing tube feedings.

Managing Tube Feedings

Enteral tubes can be either nasogastric (placed in the stomach) or nasoenteral (placed in the duodenum) to reduce the risk of aspi-ration. Nursing responsibilities in feeding include elevating the head of the bed at least 30 degrees to prevent aspiration, check-ing the position of the tube before feeding, ensuring that the cuff of the tracheostomy tube (if in place) is inflated, and giving the tube feeding slowly. The feeding tube is aspirated periodically to ensure that the feedings are passing through the gastrointestinal tract. Retained or residual feedings increase the risk for aspiration. Patients with retained feedings may benefit from the placement of a gastrostomy tube or a percutaneous endoscopic gastrostomy tube. In a patient with a nasogastric tube, the feeding tube should be placed in the duodenum to reduce the risk of aspiration. For long-term feedings, a gastrostomy tube is preferred.

ATTAINING BOWEL AND BLADDER CONTROL

After a stroke, the patient may have transient urinary inconti-nence due to confusion, inability to communicate needs, and in-ability to use the urinal or bedpan because of impaired motor and postural control. Occasionally after a stroke, the bladder becomes atonic, with impaired sensation in response to bladder filling. Sometimes control of the external urinary sphincter is lost or di-minished. During this period, intermittent catheterization with sterile technique is carried out. When muscle tone increases and deep tendon reflexes return, bladder tone increases and spasticity of the bladder may develop. Because the patient’s sense of aware-ness is clouded, persistent urinary incontinence or urinary reten-tion may be symptomatic of bilateral brain damage. The voiding pattern is analyzed and the urinal or bedpan offered on this pat-tern or schedule. The upright posture and standing position are helpful for male patients during this aspect of rehabilitation.

Patients may also have problems with bowel control or con-stipation, with constipation being more common. Unless con-traindicated, a high-fiber diet and adequate fluid intake (2 to 3 L per day) should be provided and a regular time established (usu-ally after breakfast) for toileting.

IMPROVING THOUGHT PROCESSES

After a stroke, the patient may have problems with cognitive, be-havioral, and emotional deficits related to brain damage. In many instances, however, a considerable degree of function can be re-covered because not all areas of the brain are equally damaged; some remain more intact and functional than others.

After assessment that delineates the patient’s deficits, the neu-ropsychologist, in collaboration with the primary care physician, psychiatrist, nurse, and other professionals, structures a training program using cognitive-perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.

The role of the nurse is supportive. The nurse reviews the results of neuropsychological testing, observes the patient’s per-formance and progress, gives positive feedback, and, most impor-tantly, conveys an attitude of confidence and hope. Interventions capitalize on the patient’s strengths and remaining abilities while attempting to improve performance of affected functions. Other interventions are similar to those for improving cognitive func-tioning after a head injury.

IMPROVING COMMUNICATION

Aphasia, which impairs the patient’s ability to understand what is being said and to express himself or herself, may become ap-parent in various ways. The cortical area responsible for integrat-ing the myriad of pathways required for the comprehension and formulation of language is called Broca’s area. It is located in a convolution adjoining the middle cerebral artery. This area is re-sponsible for control of the combinations of muscular move-ments needed to speak each word. Broca’s area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances.

The speech pathologist assesses the communication needs of the stroke patient, describes the precise deficit, and suggests the best overall method of communication. With many language in-tervention strategies for the aphasic adult, the program can be in-dividually tailored. The patient is expected to take an active part in establishing goals.

A person with aphasia may become depressed because of the inability to talk. The inability to talk on the telephone, answer a question, or participate in conversation causes anger, frustration, fear of the future, and hopelessness. Nursing interventions in-clude doing everything possible to make the atmosphere con-ducive to communication. This includes being sensitive to the patient’s reactions and needs and responding to them in an ap-propriate manner, always treating the patient as an adult. The nurse provides strong moral support and understanding to allay anxiety.

A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient.This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter ef-forts to practice putting thoughts together and completing the sentence. A consistent schedule, routines, and repetitions help the patient to function despite significant deficits. A written copy of the daily schedule, a folder of personal information (birth date, address, names of relatives), checklists, and an audiotaped list help improve the patient’s memory and concentration. The pa-tient may also benefit from a communication board, which has pictures of common needs and phrases. The board may be trans-lated into several languages.

When talking with the patient, it is important to have the pa-tient’s attention, speak slowly, and keep the language of instruc-tion consistent. One instruction is given at a time, and time is allowed for the patient to process what has been said. The use of gestures may enhance comprehension. Speaking is thinking out loud, and the emphasis is on thinking. The patient must sort out incoming messages and formulate a response. Listening requires mental effort; the patient must struggle against mental inertia and needs time to organize an answer.

In working with the aphasic patient, the nurse must remem-ber to talk to the patient during care activities. This provides so-cial contact for the patient. Chart 62-5 describes points to keep in mind when communicating with the aphasic patient.

MAINTAINING SKIN INTEGRITY

The stroke patient may be at risk for skin and tissue breakdown because of altered sensation and inability to respond to pressure and discomfort by turning and moving. Therefore, preventing skin and tissue breakdown requires frequent assessment of the skin, with emphasis on bony areas and dependent parts of the body. During the acute phase, a specialty bed (eg, low-air-loss bed) may be used until the patient can move independently or as-sist in moving.

A regular turning and positioning schedule must be followed to minimize pressure and prevent skin breakdown. Pressure-relieving devices may be employed but do not replace regular turn-ing and positioning. The turning schedule (at least every 2 hours) must be adhered to even if pressure-relieving devices are used to prevent tissue and skin breakdown. When the patient is posi-tioned or turned, care must be used to minimize shear and friction forces, which cause damage to tissues and predispose the skin to breakdown.

The patient’s skin must be kept clean and dry; gentle massage of healthy (nonreddened) skin and adequate nutrition are other factors that help to maintain normal skin and tissue integrity.

IMPROVING FAMILY COPING

Family members play an important role in the patient’s recovery. Some type of counseling and support system should be available to them to prevent the care of the patient from taking a signifi-cant toll on their health and interfering too radically with their lives. Involving others in the patient’s care and teaching stress management techniques and methods for maintaining personal health also facilitate family coping.

The family may have difficulty accepting the patient’s disabil-ity and may be unrealistic in their expectations. They are given information about the expected outcomes and are counseled to avoid doing for the patient those things that he or she can do. They are assured that their love and interest are part of the pa-tient’s therapy.

The family needs to be informed that the rehabilitation of the hemiplegic patient requires many months; progress may be slow. The gains made by the patient in the hospital or rehabilitation unit must be maintained. All should approach the patient with a supportive and optimistic attitude, focusing on the abilities that remain. The rehabilitation team, the medical and nursing team, the patient, and the family all must be involved in developing at-tainable goals for the patient at home.

Most relatives of stroke patients handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The patient may laugh or cry easily and may be irritable and de-manding or depressed and confused. The nurse can explain to the family that the patient’s laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional la-bility usually improves with time.

HELPING THE PATIENT COPE WITH SEXUAL DYSFUNCTION

Sexual functioning can be profoundly altered by stroke. Often stroke is such a catastrophic illness that the patient experiences loss of self-esteem and value as a sexual being. Although research in this area of stroke management is limited, it appears that stroke patients consider sexual function to be important, but most have sexual dysfunction. The combined effects of age and stroke cause a marked decline in many aspects of sexuality (Lipski & Alexan-der, 1997). In-depth assessments to determine sexual history be-fore and after the stroke should be followed by appropriate interventions. Interventions for the patient and partner focus on providing relevant information, education, reassurance, adjust-ment of medications, counseling regarding coping skills, sugges-tions for alternative positions, and a means of sexual expression and satisfaction (Lipski & Alexander, 1997).

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Patient and family education is a fundamental component of re-habilitation, and ample opportunity for learning about stroke, its causes and prevention, and the rehabilitation process should be provided (Mumma, 2001). In both acute care and rehabilitation facilities, the focus is on teaching patients to resume as much self-care as possible. This may entail using assistive devices or modifying the home environment to help the patient live with a disability.

An occupational therapist may be helpful in assessing the home environment and recommending modifications to help the patient become more independent. For example, a shower is more convenient than a tub for the hemiplegic patient because most patients do not gain sufficient strength to get up and down from a tub. Sitting on a stool of medium height with rubber suc-tion tips permits the patient to wash with greater ease. A long-handled bath brush with a soap container is helpful to the patient who has only one functional hand. If a shower is not available, a stool may be placed in the tub and a portable shower hose at-tached to the faucet. Handrails may be attached beside the bath-tub and the toilet. Other assistive devices include special utensils for eating, grooming, and dressing (see Chart 62-3).

Continuing Care

The recovery and rehabilitation process after stroke may be pro-longed, requiring patience and perseverance on the part of the pa-tient and family. Depending on the specific neurologic deficits resulting from the stroke, the patient at home may require the ser-vices of a number of health care professionals. The nurse often coordinates the care of the patient at home. The family (often the spouse) will require assistance in planning and providing care. The caregiver often requires reminders to attend to his or her health problems and well-being.

The family is advised that the patient may tire easily, become irritable and upset by small events, and is likely to show less in-terest in things. Because a stroke frequently occurs in the later stages of life, there is the possibility of intellectual decline related to dementia.

Emotional problems associated with stroke are often related to speech dysfunction and frustrations about being unable to communicate. A speech therapist who visits the home allows the family to be involved and gives the family practical instructions to help the patient between therapy sessions.

Depression is a common and serious problem in the stroke pa-tient. Antidepressant therapy may help if depression dominates the patient’s life. As progress is made in the rehabilitation program, some problems will diminish. The family can help by continuing to support the patient and by giving positive reinforcement for the progress that is being made.

Community-based stroke support groups allow the patient and family to learn from others with similar problems and to share their experiences (Olson, 2001). The patient is encouraged to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation. All nurses com-ing in contact with the patient should encourage the patient to keep active, adhere to the exercise program, and remain as self-sufficient as possible.

The nurse should recognize the potential effects of caregiving on the family (Teel et al., 2001). Not all families have the adap-tive coping skills and psychological functioning necessary for the long-term care of another. The patient’s spouse may be elderly, with his or her own health problems; in some instances the stroke patient may have been the provider of care to the spouse. Even healthy caregivers may find it difficult to maintain a schedule that includes being available around the clock. Some effects of sus-tained caregiving include increased risk for depression and sub-stance abuse, and increased use of health care services by the caregiver (King et al., 2001). Depressed caregivers are more likely to resort to physical or emotional abuse of the patient and are more likely to place the patient in a nursing home. Respite care(planned short-term care to relieve the family from having to pro-vide continuous 24-hour care) may be available from an adult day care center. Some hospitals also offer weekend respite care that can provide caregivers with needed time to themselves. Nurses should encourage families to arrange for such services and should provide information to assist them.

The nurse involved in home and continuing care also needs to remind patients and family members of the need for continuing health promotion and screening practices. Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care providers, if indicated.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Achieves improved mobility

a)     Avoids deformities (contractures and footdrop)

b)    Participates in prescribed exercise program

c)     Achieves sitting balance

d)    Uses unaffected side to compensate for loss of function of hemiplegic side

2)    Reports absence of shoulder pain

a)     Demonstrates shoulder mobility; exercises shoulder

b)    Elevates arm and hand at intervals

3)    Achieves self-care; performs hygiene care; uses adaptive equipment

4)    Turns head to see people or objects

5)    Demonstrates improved swallowing ability

6)    Achieves normal bowel and bladder elimination

7)    Participates in cognitive improvement program

8)    Demonstrates improved communication

9)    Maintains intact skin without breakdown

a)     Demonstrates normal skin turgor

b)    Participates in turning and positioning activities

10)       Family members demonstrate a positive attitude and cop-ing mechanisms

a)     Encourage patient in exercise program

b)    Take an active part in rehabilitation process

c)     Contact respite care programs or arrange for other fam-ily members to assume some responsibilities for care

11)       Has positive attitude regarding alternative approaches to sexual expression