NURSING CARE BEYOND 24 HOURS

After the first 24 hours, the nursing staff can begin to focus on other patient management issues that may arise. During this same period, acute rehabilitation is started, usually within 24–48 hours, and continues from stroke onset to four days following ischemic stroke and from onset to seven days following hemorrhagic stroke. Following this acute stage, the patient is transferred to a setting that provides comprehensive long-term stroke rehabilitation.

During the postacute phase, the following assessments are completed:

Mental status (memory, attention span, perception, orientation, affect, speech/language)
Sensation and perception (patients usually have decreased awareness of pain and temperature)
Motor control (extremities, swallowing ability)
Nutritional and hydration status
Skin integrity
Activity tolerance
Bowel and bladder function
Function in daily activities

The major nursing care planning goals for patient can include:

Improved mobility
Avoidance of shoulder pain
Maximize functional independence in self-care
Sensory and perceptual deprivation relief
Prevention of aspiration
Bowel and bladder continence
Skin integrity maintenance
Improved thought processes
Improved communication
Improved sexual function
Absence of complications

Nursing interventions during this stage include:

Improving mobility and preventing deformities
Ambulation
Preventing shoulder pain
Enhancing self-care
Managing sensory-perceptual problems
Assisting with nutrition
Attaining bowel and bladder control
Improving thought processes
Improving communication
Maintaining skin integrity
Improving family coping
Helping the patient cope with sexual dysfunction
(Belleza, 2021)

(See also “Rehabilitation in the Acute Stroke Setting” later in this course for occupational therapy, physical therapy, and speech-language therapy interventions.)

Impaired Physical Mobility

Impaired physical mobility may be related to hemiparesis, loss of balance and coordination, spasticity, or brain injury. Nursing interventions for improving mobility and preventing deformities include:

Positioning to prevent contractures, including using measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies
Applying a splint at night to prevent flexion of an affected extremity
Preventing adduction of an affected shoulder using a pillow placed in the axilla
Elevating an affected arm to prevent edema and fibrosis
Positioning fingers so that they are barely flexed by placing the hand in slight supination (when upper extremity spasticity is noted, avoiding use of a hand roll and using a dorsal wrist splint)
Changing position every two hours; placing patient in a prone position for 15 to 30 minutes several times a day to maintain hip extension
Collaborating with physical and occupational therapy to establish an exercise program and to receive instructions for correctly performing active and passive range-of-motion exercises
Providing full range of motion four or five times daily to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation; if tightness occurs in any area, performing range-of-motion exercises more frequently
Encouraging exercising to prevent venous stasis
During exercise, observing for signs of pulmonary embolus or excessive cardiac workload (e.g., shortness of breath, chest pain, cyanosis, and increasing pulse rate)
Supervising and supporting the patient during exercises; planning frequent short periods of exercise; encouraging patient to exercise unaffected side at intervals during the day
Teaching patient to maintain balance in sitting position and standing and walking as soon as standing balance is achieved
(Belleza, 2021)

Acute Pain

Patients may experience pain related to hemiplegia and disuse. Interventions include:

Using proper patient movements and positioning; placing flaccid arm on a table or pillows when the patient is seated; use of sling when ambulating
Never lifting the patient by the flaccid shoulder or pulling the affected arm or shoulder
Elevating arm and hand to prevent edema
Administering analgesic agents as indicated
(Belleza, 2021)

Self-Care Deficits

Following a stroke with functional deficits, the patient requires assistance in managing self-care, which includes bathing, hygiene, toileting, dressing, grooming, and feeding. The nursing care plan to enhance self-care may include:

Collaborating with the interdisciplinary team, including occupational therapy
Encouraging personal hygiene activities as soon as the patient can sit up; selecting activities that can be done with one hand
Working with the patient to set realistic goals and add a new task daily
Encouraging the patient to carry out all self-care activities on the unaffected side
Ensuring that the patient does not neglect the affected side, providing assistive devices as necessary
To help improve morale, making sure the patient is fully dressed during ambulatory activities
Assisting with dressing activities using clothing with hook-and-loop (Velcro) closures; putting the garment on the affected side first
Keeping the environment uncluttered and organized
Providing emotional support, encouragement, and positive feedback for accomplishments and efforts
(Belleza, 2021)

Disturbed Sensory Perception

Sensory perception disturbance includes kinesthetic, tactile, or visual problems related to altered sensory perception, transmission, and/or integration. To help manage sensory perceptual difficulties, nursing care includes:

Approaching the patient with decreased field of vision on the side where visual perception is intact; placing all visual stimuli on this side
Teaching the patient to turn and look in the direction of the defective visual field to compensate for the loss
Making eye contact with the patient and drawing attention to the affected side
Increasing natural or artificial lighting in the room; providing eyeglasses to improve vision
Reminding the patient with hemianopsia of the other side of the body and placing extremities so the patient can see them
(Belleza, 2021)

Impaired Swallowing (Dysphagia) and Nutrition

In order to maintain nutrition and hydration and avoid aspiration for patients with dysphagia, the nursing care plan includes:

Observing the patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained in the mouth, or nasal regurgitation when swallowing liquids
Starting enteral diet within seven days of admission following acute stroke (early feeding has been found to reduce the risk of death)
Consulting with the speech-language therapist to evaluate gag reﬂexes and to assist in teaching alternate swallowing techniques:

Advising the patient to take small boluses of food
Informing the patient of foods that are easier to swallow
Providing thickened liquids or pureed diet as indicated

Having suction equipment available at the bedside, especially during early feeding attempts
For patients with dysphagia, using nasogastric tubes for feeding in the early phase of stroke (first 7 days) and percutaneous gastrostomy tube if unable to swallow safely for longer than 2–3 weeks
Preparing for tube feedings by elevating the head of the bed and checking tube placement; administering the feeding slowly; ensuring the cuff of tracheostomy tube is inflated (if applicable); monitoring and reporting excessive retained or residual feeding
Having the patient sit upright, preferably in a chair, while eating and drinking, maintaining upright position for 45–60 minutes after eating
Advancing the diet as tolerated
Considering nutritional supplements for those who are or are at risk for malnourishment
Implementing oral hygiene protocols to reduce risk of pneumonia
(Belleza, 2021; Powers et al., 2019; LNC, 2021b)

Alteration in Bowel and Bladder Elimination

It is common for patients to have problems controlling their bladder and/or bowels following a stroke. Urinary incontinence is more common than fecal incontinence. Around one half of stroke patients will have some form of incontinence, and for many, it is temporary. Only around 15% of stroke patients will still have continence issues a year after stroke.

When a person experiences a stroke, brain damage can occur near the micturition center of the brain, and bladder function can be impacted. Loss of bowel control can also occur post stroke. Most stroke patients have motor impairments that can interfere with the ability to reach a restroom in time, leading to functional incontinence. Poststroke incontinence symptoms can be improved and can be cured; however, it takes time (Fosnight, 2021).

Urinary problems may include:

Urgency
Frequency
Nocturnal incontinence
Functional incontinence
Reflex incontinence
Overflow incontinence

Bowel problems can include:

Fecal incontinence
Constipation
Constipation with overflow
Fecal impaction

The nursing care plan for prevention or improving bowel and bladder problems includes:

Collaborating with physical and occupational therapy
Performing intermittent sterile catheterization during periods of loss of sphincter control
Analyzing the patient’s voiding pattern and offering urinal, bedpan, or bedside commode on patient’s voiding schedule
Assisting male patients to an upright posture for voiding
Establishing a regular time (e.g., after breakfast) for toileting
Initiating a bladder and bowel training program
Performing a bedside bladder ultrasound after voiding to check for residual early in the program
Providing high-fiber diet and maintaining fluid intake of 2,000–3,000 ml per day unless contraindicated
Requesting and administering stool softeners or laxatives
Administering enemas if needed
(RNpedia, 2022; Belleza, 2021)

Risk for Injury

A very common complication of acute stroke is injury, in particular those resulting from falls. The decline of neuromotor performance caused by the stroke contributes to the majority of falls in stroke survivors. Other injuries can also occur as a result of loss of visual field, changes in depth perception, presence of diplopia, or other visual impairments, as well as impaired sensory awareness, including position of body parts and joint sense. Patients may be inattentive to body parts and segments of the environment, and may lack recognition of familiar objects/persons.

Interventions include:

Implementing a falls prevention protocol
Encouraging patients with nondominant (right) hemisphere injury to slow down and check each step or task as it is completed
Reminding patients who have a dominant (left) hemisphere injury to scan the environment
Encouraging making a conscious effort to scan the rest of the environment by turning head from side to side
Giving short, simple messages and questions and step-by-step directions
Keeping the environment simple to reduce sensory overload and enable concentration on visual cues; removing distracting stimuli
Monitoring the environment for safety hazards
Teaching patients to concentrate on body parts (a mirror can be used to help adjust to the misconception that a body part is not part of their body)
Providing patients with wheelchair seat belts or supportive harnesses, if clinically indicated
Placing items the patient uses within easy reach, such as call light, water, urinal, ambulatory devices
Responding to a call light as soon as possible
Encouraging patients to wear their eyeglasses and hearing aids and ensuring that these items are within reach and accessible
(Scruth, 2020)

Risk for Impaired Skin Integrity

Stroke patients are at risk for skin breakdown as a result of the inability to feel or move extremities, incontinence, inability to communicate needs, pain, discomfort, and decreased nutritional status. Nursing interventions include:

Performing regular skin assessment with emphasis on bony areas and dependent body parts during hospitalization and inpatient rehabilitation using an objective scale such as the Braden Scale or Norton Scale
Providing skin hygiene measures, such as using emollients for dry skin and keeping the skin clean and dry
Maintaining nutrition and hydration
Turning and repositioning every two hours; positioning patient on affected side for only 30 minutes at a time
Encouraging the use of lifting devices to move or reposition the patient in bed
Minimizing skin friction and providing pressure relief via early mobility, using specialized mattresses, wheelchair cushions, and seating until sufficient mobility returns
(Wayne, 2022)

Impaired Communication (Aphasia/Dysphasia)

Speech problems following stroke sometimes resolve within hours or days. Some problems, however, are more permanent and require speech and language therapy to improve communication. There are four broad categories of communication problems:

Expressive (Broca’s) aphasia: Knowing what one wants to say but unable to find the words
Receptive (Wernicke’s) aphasia: Hearing what is said or reading but unable to make sense of the words
Anomic or amnesia aphasia: Having difficulty using the right names for objects, people, places, or events
Global aphasia: Inability to speak, understand speech, read, or write
(RNA, 2020)

Nursing interventions for patients experiencing impaired communication may include:

Collaborating with speech-language therapy, along with active patient participation, to establish goals
Reinforcing the individually tailored program
Making the milieu conducive to communication
Remaining sensitive to the patient’s reactions and needs
Responding to the patient in an appropriate manner and treating the patient as an adult
Providing emotional support and understanding to allay anxiety
Avoiding completing the patient’s sentences
Being consistent in daily routines; providing a written schedule, checklists, or other means to help with memory and concentration (e.g., communication board)
When speaking to the patient, speaking slowly, giving one instruction at a time, and allowing the patient time to process
Talking to aphasic patients while performing care activities to provide social contact
(Belleza, 2021)

Emotional Changes

Emotional changes are common after a stroke and can impact rehabilitation outcome. Stroke patients may experience feelings of irritability, anger, forgetfulness, carelessness, or confusion. These emotional responses, however, tend to improve over time.

Patients may also experience pseudo-bulbar affect (PBA), in which there is a disconnect between the frontal lobe (which controls emotions) and the cerebellum and brain stem (where reflexes are mediated). The effects are uncontrollable and occur without an emotional trigger. These individuals have involuntary bouts of crying, laughter, or anger that may be out of proportion to the situation. They may also have inappropriate emotional responses, such as laughing in sad or somber occasions. They may also rapidly switch between laughing and crying.

Stroke patients often experience anger that is directed toward hospital staff as well as family members. This anger may be the result of damage to the brain, the loss of ability to communicate, or inability to make choices about their daily activities. The only way for a patient to exert control may be to refuse to do tasks or to be involved in treatment.

Stroke patients can easily become irritated, frustrated, and angry and may use language that they did not use prior to the stroke. This may occur when the person is attempting to accomplish something that formerly was easy and has become difficult post stroke.

Nurses are among the members of the rehab team who address the psychosocial needs of patients by providing support and guidance to improve coping. Occupational therapists as well are responsible for promoting coping and adjustment to the consequences of stroke.

Interventions can include:

Speaking in a calm and gentle tone using a nonthreatening approach
Recognizing triggers and striving to avoid them whenever possible
Offering distractions such as engaging in a different task or exercise
Using redirection and diversion to help alleviate stimulation and discomfort
Scheduling rest periods in between activities
Placing the patient in a calm, low-stimulus environment with low lighting and few individuals
Avoiding pressuring or requiring the patient to make a decision

It is important to explore the patient’s previous methods of dealing and coping with life’s problems and the presence and quality of their support systems in order to build on past successes and to mobilize resources (AHA, 2022d; NurseStudy.Net, 2022).

DEPRESSION AND ANXIETY

Two of the most common emotional/psychological problems that can result from a stroke are depression and anxiety. Depression affects one third to two thirds of stroke survivors. Anxiety affects about 20%.

Many patients may experience bouts of crying, feel hopeless, and withdraw from social activities. Others may experience general feelings of fear and anxiety, which may result in acute anxiety attacks.

Depression following stroke may make rehabilitation more challenging. Risks for the development of poststroke depression (PSD) include physical disability, severity of stroke, prestroke depression, or cognitive impairment. Clues for PSD can be subtle, such as declining to participate in therapy.

Interventions for depression include:

Assessing for history of depression
Performing an early depression screen
Providing interventions to enhance rehabilitation
In the absence of contraindications, administering antidepressants as ordered, including monitoring the patient closely for effectiveness and side effects
(Green, et al., 2021)

When working with patients experiencing anxiety, it is important to remain calm and in control in order to work effectively with the patient. Interventions for anxiety include:

Maintaining a calm, nonthreatening manner
Establishing trust by listening, showing warmth, answering questions directly, offering unconditional acceptance, being available
Remaining with the patient at times when levels of anxiety are high, reassuring the patient of their safety and security
Moving the patient to a quiet area with minimal stimuli
Providing reassurance and comfort measures
Administering antidepressants and anxiolytics as ordered and monitor for effectiveness and side effects
Observing for increasing anxiety
(Vera, 2022)

SELF-MANAGEMENT, FAMILY SUPPORT, AND EDUCATION

Self-management for survivors of stroke seeks to optimize independence in the posthospital environment by offering support and education to both patients and caregivers on the skills of decision-making and problem-solving, as well as establishing goals for stroke prevention and recovery. Teaching should begin in the acute setting.

Examples of self-management interventions include:

Providing the family with information about the expected outcome of the stroke and counseling them to avoid doing things for the patient that the patient can do for themself
Encouraging family to support patient and give positive reinforcement
Enhancing self-efficacy with activities of daily living
Teaching problem-solving skills and strategies
Engaging patients in occupational therapy and other rehabilitation programs
Teaching stress management techniques and maintenance of personal health for family coping
Incorporating information for survivors of stroke and their family caregivers on provisions for stroke care after discharge
Developing attainable goals for the patient at home by involving the full healthcare team, patient, and family
(Green et al., 2021; Belleza, 2021)