Download 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 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:
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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:
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Impaired physical mobility related to hemiparesis, loss of balance and
coordination, spasticity, and brain injury
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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:
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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 threeor 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.