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Stroke Nursing Rehab

Stroke Nursing Rehab. Presented by: Leah Garey Becky Clarkson. Stroke Rehabilitation. Nursing implications. Learning objectives. At the end of this presentation the learner will: Understand the pattern of deficits for hemispheric, brain stem, and cerebellar CVAs.

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Stroke Nursing Rehab

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  1. Stroke Nursing Rehab Presented by: Leah Garey Becky Clarkson

  2. Stroke Rehabilitation • Nursing implications

  3. Learning objectives • At the end of this presentation the learner will: • Understand the pattern of deficits for hemispheric, brain stem, and cerebellar CVAs. • Understand the key nursing implications of care for a left and right hemiplegia. • Understand the nursing care implications for common CVA deficits, aphasia, neglect, impaired sensory processing, motor, and visual field deficits. • Identify Common Medical Complications associated with CVA

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

  5. The cortex

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

  7. Ischemic Stroke

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

  9. HemorrhagicStroke

  10. Hemispheric Expression of the stroke • Motor and sensory deficits are found on the side OPPOSITE to the affected side of the brain • Visual field deficits are also found on the side OPPOSITE to the affected side of the brain • Horizontal gaze is also affected in the direction OPPOSITE to the affected side of the brain • Because the eye can’t move to the opposite side, it actually appears to be looking AT the affected side of the brain in hemispheric strokes

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

  12. Left CVA • MOTOR • Right sided paralysis • Hemiparesia/hemiparalysis • Communication/Cognition deficits • Aphasia- expressive, receptive & Global aphasia • Apraxia • Dysarthria • Loss of problem solving skills • Emotional Lability • Decreased organizational skills and initiation • Disoriented to time & place • Perseverative movements & phrases

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

  14. Communication Deficits with Left CVA • Aphasia • Apraxia • Dysarthria

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

  16. Expressive aphasia (motor or Broca’s) • difficulty in selecting, organizing and initiating speech • speech is slow, hesitant and labored- short phrases or single words; affects speaking and writing • Receptive aphasia (sensory or Wernicke’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 aphasia • nonfluent speech with poor comprehension and limited ability to name objects or repeat words

  17. Apraxia • A movement planning problem involving disruption in sequencing of voluntary muscle movements • A transmission problem between the brain and the muscle

  18. Dysarthria • A group of speech disorders resulting from disturbed muscular control of the speech mechanism • Speech may be alterred in: • Speed • Strength • Range • Coordination • Affects breathing, voicing, articulation, resonation and rhythm

  19. Language Areas

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

  21. Right CVA • Left sided Paralysis • Hemiparesia/hemiparalysis • Left visual field deficits • Agnosia – inability to recognize familiar objects (keys, pen, persons)

  22. Right CVA • Visual spatial deficits • Neglect in left visual field, loss of depth perception • Cognitive Deficits

  23. Right CVA • Vision-Neglect or inattention to Right side • Behavior-quick, euphoric, disorganized • Emotional Lability • Safety Issues

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

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

  26. Do you think you will have difficulty? “None”Task is performed Did you have any difficulty? “None”

  27. Failure to recognize side of body contralateral to injury • May not bathe contralateral side of body or shave contralateral side of face • Deny own limbs • Objects in contralateral visual field ignored

  28. Judgment/Insight • Poor insight into Deficits • Denial of Deficits • Confabulates • Over estimated abilities • Impulsivity: Act without thinking first • Disorientation: Difficulty with ability to remember different aspects of personal info, time, place, or current situation

  29. Attention/Memory • Easily Distracted • Poor Memory • Long Term Memory usually intact • Impaired short term recall and new learning • Attention • Inability to distinguish stimuli

  30. Brainstem Typical Signs: Bilateral Abnormalities Crossed Signs (1 side of face and contralateral body) Quadriparesis Sensory Loss in All 4 Limbs Hemiparesis Hemisensory Loss

  31. Cranial nerve signs suggest localization to (and within) the brainstem

  32. Brainstem Typical Signs: Cranial Nerve and Other Deficits Vertigo, Tinnitus Dizziness Decreased LOC Nausea, Vomiting Hiccups, Abnormal Respirations Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Palsy (horizontal gaze deficit or gaze preference) Nystagmus Oropharyngeal Weakness: Dysarthria (speaking), Dysphagia (swallowing)

  33. Cerebellum Typical Signs: Lack of Coordination Dysarthria Dysphagia Nystagmus Ipsilateral (same side) Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance) Tremors, or Limb Ataxia, result from lack of coordination of opposing muscle groups (flexors vs. extensors), causing the muscle groups to fight each other

  34. Cerebellar Stroke • Ataxia: Gross lack of coordination of muscle movement • Decreased Proprioception • Wallenburg’s Syndrome

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

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

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

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

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

  40. “Patients reporting high level of emotional support showed dramatic improvement despite having the lowest baseline functional status.”

  41. Cardinal Principles of Rehab • E: Early Treatment • A: Activity Strengthens • S: Stress Abilities, NOT disabilities • T: Treat total patient • Treat adults as adults!

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

  43. Impaired Mobility—Therapy Tx • Interventions include: Exercises/Activities to address: Balance/midline Gait Transfers Safety Strength Coordination Endurance

  44. Impaired Mobility—Nursing Tx • Interventions include: ROM exercises for the involved extremities Protection of involved side Change of patient’s position frequently Prevention of deep vein thrombosis Use transfer/gait techniques as outlined by therapy Reinforce specific techniques learned in therapy

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