During her shift, Jennifer, a rehabilitation therapist, cares for two patients in their early 60s who have survived the acute stage of a stroke. Mr. Donovan is paralyzed on his left side. He talks clearly and coherently and tells Jennifer how much he wants to return to his job as head of a large sales department. He insists that he could walk if he tried, but he won’t be allowed out of his wheelchair. He wheels his chair into the wall, rolls back, and repeats the action again and again.

Mr. Slater is paralyzed on his right side. His speech is hesitant and unintelligible, and he seems to be frightened and depressed. The therapists report he cries all the time when he’s not cursing loudly and clearly, and are having difficulty identifying his needs.

These patients share the same diagnosis, but their behaviors vary markedly. And these differences determine their plan of care.

Therapists care for stroke patients during every phase of the illness from acute onset to reentry into the community. Because therapists plan, coordinate, and implement care, they need to understand the underlying cause of each patient’s stroke; the areas of the brain that have been damaged; the physical, mental, and emotional effects; the long-term outcomes; and the expected behaviors.

Diverse Risks and Common Causes

Stroke, the third ranking cause of death and a leading cause of disability in the U.S., is the country’s primary neurological problem. Each year about 780,000 people have a new or recurrent stroke. About 600,000 are first strokes, and 180,000 are recurrent strokes.¹ The term stroke refers to damage to the brain caused by disruption of the cerebral blood supply. Major predisposing risk factors are:

Nonmodifiable —

• Advanced age
• Male gender
• Ethnicity, with a higher incidence of strokes in black Americans and Hispanic Americans
• Genetic factors/family history of stroke

Modifiable —

• Hypertension
• Cardiac disease (particularly atrial fibrillation and valvular heart disease)
• Carotid artery stenosis
• Diabetes mellitus
• Obesity, body fat distribution, and poor diet
• Cigarette smoking
• Limited physical activity
• Dyslipidemia
• Sickle cell disease
• Postmenopausal hormone therapy

Other risk factors are less well-documented and may be potentially modifiable. These are: metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, hypercoagulability, and migraine headache. Other less well-documented risk factors are associated with mechanisms that may cause endothelial injury, such as elevated homocysteinemia, elevated lipoprotein (a), elevated lipoprotein-associated phospholipase, inflammation, and infection.²

The pathological processes that cause the injury are either ischemic (diminished blood flow to the brain) or hemorrhagic (bleeding that results in localized or generalized pressure on brain tissue). Ischemic injury, comprising 85% of all strokes, can be thrombotic or embolic.³ Thrombosis, the most prevalent occurrence in stroke, is usually a localized, gradual, occlusive process, which most often accompanies advanced atherosclerosis. Emboli, clots that commonly originate in the heart or major arteries, cause a sudden onset of symptoms. Tissue plasminogen activator (t-PA), a clot-dissolving medication, can be effective in combating acute ischemic strokes when administered within three hours of the onset of symptoms.^{3 (Level A)} Hemorrhagic strokes can be subarachnoid, from ruptured aneurysms or arterio-venous malformations, or intracerebral, from a ruptured intracerebral artery that bleeds directly into the brain tissue. Uncontrolled hypertension (high systolic blood pressure) is the most common risk factor associated with hemorrhagic strokes.⁴ Hemorrhagic stroke is the cause in 10% to 15 % of all first strokes and has significant mortality.⁵ Current evidence-based guidelines for ischemic and hemorrhagic stroke can be found at the websites of The American Stroke Association at www.strokeassociation.org, The National Stroke Association at www.stroke.org, The Internet Stroke Center at www.strokecenter.org, and The Brain Attack Coalition at www.stroke-site.org.

Because nerve fibers cross over in the brain stem (i.e. the right hemisphere controls the left side of the body, and the left hemisphere controls the right side), perception of sensation and motor function will be impaired on the side of the body opposite the damaged brain tissue. Each area of the brain controls specialized functions. In most people, the left hemisphere is highly analytical and logical and controls speech and language. The right hemisphere is responsible for spatial and perceptual relationships.⁶

Damage to the Right Brain

Mr. Donovan is a patient with right-sided brain damage. He talks incessantly, confabulates and makes up stories without regard to facts, and reads aloud without comprehension. Mr. Donovan displays poor judgment, makes frequent errors, and overestimates his ability to perform simple tasks. His attention span is short and he has difficulty with the concept of time. His behavior is often impulsive and impatient.

Patients with right-sided brain damage may also have severe spatial/perceptual deficits, misjudging distances or the relationship of their body to the environment. They may confuse up and down, inside and outside, or right and left. They frequently bump into things and easily injure themselves, posing special considerations for nursing care.^6,7

Cognitive testing should be done as early as possible to identify and document deficits, which can be incorporated into the nursing care plan. Patients like Mr. Donovan may deny that a paralyzed area of the body belongs to them, a behavior called anasognosia. When Mr. Donovan discovers his left arm or leg in his bed, he may call and report that another person is in bed with him. Since he cannot feel that part of his body, he denies ownership.^6,7

Mr. Donovan may need constant reminding that his left side is still part of his body. Remind him to slow down and reinforce the necessity of assistance with transfers. Fall prevention may become a nursing priority because of impulsiveness and denial of impairments. Assess the patient’s need for safety belts and side rails. Finally, include family members in monitoring the patient’s behavior to maintain a safe environment during recovery.

Comparing Left- and Right-Sided Strokes
Damage to the Left Brain	Damage to the Right Brain
Paralysis or weakness on right side of body Right visual field deficit Aphasia (expressive, receptive, or global) Slow, cautious behavior Difficulties with memory Chewing or swallowing problems	Paralysis or weakness on left side of body Left visual field deficit Spatial-perceptual deficits Neglect of affected side Easily distracted Impulsive behavior and poor judgment Lack of awareness of deficits

Damage to the Left Brain

Mr. Slater is a classic example of the patient with left hemisphere damage. He is anxious, fearful, and easily frustrated. He needs cuing and feedback for every step of any task he is expected to perform. Sometimes a list taped to the bedside or to the arm of the wheelchair is a helpful reminder. All personnel working with Mr. Slater need to follow the same daily sequence of activities.

When Mr. Slater is asked by the therapist to copy a simple drawing of a house, he copies only the left half. When he is served his meals, he eats only the food on the left side of his tray. He keeps his head turned to the left, and responds only when approached from that side.

Although vision can be damaged by injuries to either side of the brain, Mr. Slater has lost his right visual field in both eyes, a condition called homonymous hemianopsia. Some patients with hemianopsia learn to automatically turn their heads to compensate, while others need frequent reminders.

The nursing care plan suggests specific nursing interventions for Mr. Slater’s visual problem. A sign placed at the head of his bed reminds the staff to approach him from the left side and to arrange all his food on the left side of his tray. The nursing staff ensures Mr. Slater’s bedside table, tray, telephone, urinal, and call light are all placed on his left side. They also position his bed so that his left side faces the doorway. These strategies may help to alleviate some of the feelings of isolation that frequently accompany such sensory losses.⁸

Communication, the process of exchanging thoughts, is accomplished through speech and language. Speech refers to a motor act, vocalization, which is produced by phonation, articulation, and respiration. Language refers to word symbols and ideas, both written and spoken.

Because the centers for speech and language are located in the left hemisphere of the brain in 95% of the population, the patient with a left-sided stroke may experience speech disorders or dysarthria that result from damage to motor neurons that produce the sound itself. Speech may be slurred or sluggish and nasal in tone. Frequently these patients have chewing or swallowing problems and are at risk for aspiration, dehydration, and malnutrition. Muscle weakness is a major concern and treatment consists of muscular strengthening exercises to help develop control. Nursing personnel need to work closely with the speech therapist to develop an effective and safe plan of care.^6,7

Patients with a left-sided stroke may experience aphasias. These language disorders are classified according to the areas of the brain affected by the stroke. Two common categories are Broca’s and Wernicke’s aphasias, named for the physicians who first identified the areas of the brain.

Broca’s area is located in the left frontal lobe and is responsible for the muscular movements required for speech. With Broca’s aphasia, also called motor or expressive aphasia, speech loses fluency and often becomes telegraphic. These patients are aware of the problem, but are unable to express their thoughts and ideas verbally or in writing. They frequently become frustrated and depressed. Automatic speech, such as counting, recitation, and cursing may be unaffected.⁶ Mr. Slater sustained this type of language disorder.

Wernicke’s area, located in the left temporal lobe, analyzes sensory input. In Wernicke’s aphasia, also called receptive or sensory aphasia, speech may be fluent but without meaning. The patient is unable to comprehend spoken or written words and may ramble.

Global aphasia, which is both receptive and expressive, is usually accompanied by severe neurological damage that can affect both sides of the body. This condition is characterized by a lack of auditory and reading comprehension and an absence of speech.

Patients may recover speech and language with early intervention, although the extent may be limited by age, health, severity of stroke, and concurrent medical problems. The most accurate predictor of the functional outcome is the extent of the neurological deficit. Other stroke-related or preexisting sensory deficits may impair a patient’s ability to communicate. For example, the hearing deficit of a hemiplegic patient with facial paralysis may be due to a collapsed Eustachian tube, or a patient may have used glasses or a hearing aid prior to the stroke. Because the therapists knew that Mr. Slater was hard of hearing before his stroke, they ensured that he had his hearing aid when going to therapy sessions.

The Language of Strokes7,8
Symptom	What it means	Treatment
Homonymous hemianopsia	Loss of half of visual field resulting in neglect of affected side	Place all objects in patient’s field of vision. Instruct patient to turn head to unaffected side.
Diplopia	Double vision	Place objects in same location. Alternately cover one eye at a time with patch and keep environment free from safety hazards.
Paresthesia	Numbness and tingling on side opposite brain damage	Encourage range of motion and strengthening. Provide appropriate therapy in conjunction with physical therapists.
Hemiparesis	Weakness on side opposite brain damage	Place objects on unaffected side. Observe safety precautions. Use supportive devices as indicated and work closely with rehab specialists.
Hemiplegia	Paralysis on side opposite brain damage	Position frequently used items on the functional side. Encourage patient to accept paralyzed part of his body.
Ataxia	Unsteady gait, or inability to coordinate movements	Use supportive devices, such as a quad cane, during ambulation. Use the expertise of physical therapists.
Dysphagia	Difficulty swallowing	Modify diet to prevent aspiration, starting with soft, moist foods. Confer with dieticians and speech therapists for a swallowing evaluation.
Dysarthria	Inability to form words, usually resulting from damage to left hemisphere	Identify alternate methods of communication. Speech therapists can help to devise a plan.

Thrombolytic Therapy for Ischemic Stroke

Currently the only FDA-approved medication to treat acute stroke is recombinant tissue plasminogen activator (t-PA). This medication works by dissolving the blood clot blocking blood flow to the part of the brain that is affected by the stroke. It binds to fibrin and converts plasminogen to plasmin, which stimulates fibrinolysis of the clot.

Thrombolytic therapy must be administered within three hours of stroke symptom onset. This rapid treatment was proven to improve the overall long-term functional improvement after stroke.³ Determining when the patient was last normal and when his or her symptoms began is of utmost importance when a therapist first assesses a patient with possible ischemic stroke. This urgent assessment in addition to a CT Scan to rule out an intracerebral hemorrhage will help make the initial determination of whether or not the patient is eligible to receive this important medication.

Some of the contraindications for thrombolytic therapy include symptom onset greater than three hours prior to admission, intracerebral hemorrhage, a patient who is anticoagulated and has an international normalized ratio [INR] greater than 1.7, a patient who has recently had a stroke or head injury (within the last three months), and a systolic BP > 185 mm Hg or diastolic BP > 110 mm Hg.³

Dosing: If found to be eligible the patient will receive IV t-PA, 0.9 mg/kg (maximum of 90 mg), with 10% of the total dose administered as an initial bolus over 1 minute, and the remainder infused using an infusion pump over 60 min.

The most important adverse effects of t-PA are bleeding complications, including intracerebral hemorrhage. Following the guidelines for administering the medication and close monitoring of blood pressure may help to reduce their incidence. The patient will likely be admitted to a critical care or a stroke unit, where continuous cardiac monitoring and frequent neurological assessments are initiated. Blood pressure should be closely monitored after t-PA administration and kept below 180/105 mm Hg.³ Antithrombotic drugs (anticoagulants, such as heparin, and antiplatelet agents, such as aspirin) should be avoided for 24 hours after t-PA administration.

Depression

Depression is a common and serious problem in the patient who has had a stroke; it affects both right- and left-sided stroke survivors. Incidence for depression in stroke patients ranges from less than 10% to more than 50%. Risk factors for developing depression include increased severity of stroke and a history of depression and cognitive or physical impairment.⁹ Depression can complicate the recovery process by affecting a survivor’s motivation for participation in a physical therapy program and for compliance with medications.

Attaining an Effective Rehabilitation

A multidisciplinary team of healthcare professionals that includes the family caregiver has been most effective in achieving early rehabilitation of patients with strokes. The broad goals of rehabilitation are the prevention of further disability, the maintenance of remaining abilities, and the restoration of as much function as possible in activities of daily living (ADLs) and social roles.

Many of us take activities of daily living for granted, but they are the functions a person must be able to perform to live independently. These important skills include —

• Dressing
• Walking and transfers, with or without mobility aids
• Toileting
• Bathing and grooming
• Eating

Constraint-induced movement therapy (CIMT) is a rehabilitation technique that relies on the concepts of overcoming learned non-use and facilitating cortical reorganization (brain “rewiring”). CIMT involves having patients perform repetitive tasks with their weak arm during therapy sessions that last up to 6 hours a day.¹⁰

Healthcare providers can evaluate rehabilitation by using the Functional Independence Measure instrument, a part of the Uniform Data System for Medical Rehabilitation. The Functional Independence Measure contains basic indicators that assess the level of disability and measure consistent performance — what tasks and at what level the patient actually performs — and not what he ought to do according to diagnosis. Categories include self care, transfers, mobility, locomotion, sphincter control, communication, and social cognition.^11,12

Therapists should be cautious when using an instrument that applies the same set of standards to each patient regardless of the area of injury. Besides measuring functional ability, caregivers should consider the patient’s psychological state, such as depression, and the extent to which a patient’s social functioning has been restored. If the outcomes do not meet patients’ expectations, their coping abilities may be compromised. Coping strategies, previous abilities and newly learned adaptive techniques, and the presence of an involved caregiver, such as a family member, can be instrumental in returning a patient to community living. For example, Mr. Donovan and Mr. Slater made positive strides toward returning to the community after two months in an intensive rehab setting.

Mr. Donovan’s judgment skills remain poor and he continues to neglect his left side. Still wheelchair-bound, he must wear an external catheter for urinary incontinence. His wife has participated in all his therapies, and she realizes that her husband needs assistance with transfers and with dressing.

Mrs. Donovan works outside the home. With the help of the social worker, she has made arrangements for her husband to attend an adult day care center during her working hours. This is a viable option for patients unable to remain alone. Mrs. Donovan will have assistance from family members on weekends. She may find it helpful to attend a caregiver support group.

Mr. Slater has learned to dress with minimal assistance. He can feed himself and he is continent. He can ambulate safely with a four-pronged cane in the home setting. His wife also has participated in therapies, attended staff meetings, and has been able to make the necessary safety modifications to their home. Bars have been installed in the bathroom to facilitate toileting. A transfer tub seat has been ordered for safe bathing.

Mr. Slater’s communication skills have greatly improved and he can make his needs known. He speaks in fragmented sentences, sometimes describing the thing he wants rather than naming it. Word retrieval is still difficult for him. But with cuing and understanding on the part of his wife, Mr. Slater continues to make progress. He is returning home to a reasonable quality of life.

Both of these patients have been able to return to community living because of early rehabilitation, family support, and community services — critical factors in keeping patients like Mr. Donovan and Mr. Slater out of nursing homes and adding quality to their lives.

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