Stroke Rehabilitation Care - Essay Example

?STROKE REHABILITATION Stroke Rehabilitation Introduction Rehabilitative care is one of the most crucial aspects of patient care and recovery. Rehabilitation helps ensure that patients recover from their illness and eventually regain their normal activities. For health care professionals, rehabilitation is a major challenge because many patients may be uncooperative throughout the process, and as health professionals, they may not be equipped with the proper skills to help ensure the efficacy of the rehabilitative process (Laws and Amato, 2010, p. 70). This study shall evaluate the stroke rehabilitation of an elderly male. It shall consider the assessment, planning, implementation, and treatment in clinical practice. It shall critically analyse the efficacy of the care given to the elderly patient – with a sharp focus on rehabilitation. It shall also critically evaluate the role and function of team members and their contribution to the rehabilitation process. It shall discuss the psychological outcomes for the patient and carers, while taking into account the longer term needs of the patients. This paper is being conducted in order to establish a comprehensive understanding of stroke rehabilitation, especially among elderly patients. Discussion Patient Profile The patient in this case is a 65 year old elderly male, married, with three grown children. He was admitted three weeks ago for a headache and the sudden onset of the following: difficulties in speaking and swallowing, left sided paralysis, and a tingling sensation of his extremities. Upon admission, he was immediately assessed. After subsequent diagnostic processes, he was diagnosed for an embolic stroke. The appropriate intervention was later carried out to remove the embolus. At which time, his condition was assessed. Due to a 10 minute lack of oxygen supply to his brain, he suffered from left-sided paralysis with his mobility and speech severely compromised. He was then discharged from the neurological care unit and onto the rehabilitation clinic. Assessment of patient The assessment of the post-stroke patient was mostly an assessment of his mobility and his ability to conduct his daily activities. The patient was assessed on the following areas before a plan for rehabilitation was conceptualized by the rehabilitation team: neurological aspects, including level of consciousness, cognitive disorders, motor deficits, disturbances in balance and coordination, somatosensory deficits, disorders of vision, unilateral neglect, speech and language deficits, and pain; presence of comorbid diseases; functional health patterns, including bladder and bowel function, swallowing disorders, nutrition and hydration, skin breakdown, physical activity endurance, and sleep patterns; presence of depression and other affective disorders; neuropsychological function; and family functioning and other contextual factors. All of these aspects were assessed using standardized assessment tools. These tools have included the following: Glasgow Coma Scale, Modified Rankin Scale, Measures of Disability of Daily Living, Mini-Mental Status Examination, Berg Balance Assessment, Rivermead Mobility Index, Hospital Anxiety and Depression scale, Family Assessment Device, and Quality of Life Assessment scale (Warlow, van Gijn, and Dennis, 2008, p. 534). Assessment results Based on the assessment, the patient scored 12 out of 20 on the Glasgow Coma Scale. This was based on the recommended scale to measure the patient’s level of consciousness (Herndon, 2006, p. 366). He scored 4 out of 6 on the Modified Rankin Scale. This scale is used to measure a patient’s level of disability (Stroke Center, 2010). The patient scored 87 out of 126 on the Functional Independence Measure Test. This test assessed the patient’s ability to carry out independently his daily activities (DeLisa, Gans, and Walsh, 2005, p. 986). On the Mini-mental Status Examination, he scored 23 out of 30. This test assessed his mental functioning and mental response (New Mexico Aging and Long Term Services, 2011). In assessing his fall risk, he scored 24 (medium fall risk) in the Berg Balance Assessment test. This test is used to evaluate a patient’s risk of falling based on overall variables present in the patient’s physiology and environment (American Academy of Health and Fitness, 2011). On the Rivermead Mobility Index, he scored 5 out of 16. This test is used to measure the patient’s mobility and disability status (Comi, Kesselring, and Thompson, 2010, p. 154). Based on the Hospital Anxiety and Depression Scale, he scored 13 (abnormal) on the anxiety scale and 9 (borderline abnormal) on the depressed scale. This scale is used to evaluate the mental health status of the hospitalized patient (Sexual Violence Research Initiative, 2011). On the Quality of Life Assessment Scale, the patient scored 76 out of 220. This scale is often used to evaluate the overall quality of the patient’s life, considering the different aspects of his physiological and psychological health (Doyle, Hanks, and Cherny, 2005, p. 209). Planning After the abovementioned assessment scales and processes were carried out on the patient, a plan for care and rehabilitation was conceptualized by the health care rehabilitation team. The plan was individualized to fit the patient’s needs and circumstances (Geyer and Gomez, 2009, p. 15). In general however, the plan included specifications of interventions for the following aspects: activities of daily living: bathing, grooming, dressing, and feeding; physical activity skills: transferring, walking, and or use of the cane; speech and language skills to improve communication; psychological support for coping skills to overcome depression; and family support and intervention (NIH, 2010). Implementation of interventions and treatment 1. Goal: to improve and relearn the conduct of his ADLs (activities of daily living). Intervention This process was done with the assistance of the occupational and recreational therapists. These therapists assisted in the improvement of motor and sensory abilities. They helped the patient in relearning the skills in the conduct of his daily activities, including his personal grooming, preparation of meals, and even housecleaning. The occupational therapist also assisted the patient on how to drive safely despite his left-sided weakness. The occupational therapist carried out the therapeutic and learning process by carrying out the process in small stages. The interaction and sessions with the occupational therapist is spread over the span of the three month rehabilitation period. Each day brought about a daily task to accomplish and master with the therapist. After each task was taught, the therapist practiced such activity or task with the patient in sequence. Through this process, the patient was gradually able to relearn his daily activities and to carry these out despite his left-sided weakness. The therapist also taught the patient strategies in order to adjust his environment to fit his current condition. The therapist suggested that the patient have some of his clothes’ buttons changed to Velcro fastenings in order to make fastening easier. This technique is very much supported by experts on stroke rehabilitation (Day, Paul, and Williams, 2009, p. 2107). The therapist also suggested to the patient and his family that adjustments to the patient’s home have to be made; these improvements included the installation of grab bars in the bathrooms and some of the halls in the house. All in all, the therapist taught the patient new ways of doing his daily activities and to be independent in the conduct of these activities. Critical analysis Assisting the patient in regaining the independent conduct of his daily activities is an important part of the rehabilitative process. For stroke patients, it is important for them to regain control of their lives and of their activities, and eventually regain their independence in the conduct of such activities (Fisher, 2010, p. 1199). Gaining independence in the conduct of daily activities brings forth various advantages and disadvantages for the patient. For one, it helps to improve the patient’s self-esteem and eventually it helps prevent and reduce the probability of post-stroke depression for the patient (Cramer and Nudo, 2010, p. 296). In a paper by Saxena, et.al., (2006, p. 339) the authors sought to establish data on whether depressive symptoms and cognitive status and improvements independently influenced functional status and recovery among post-stroke patients. Their study covered about 141 post-stroke patients undergoing rehabilitation. The study revealed that by improving the depressive symptoms of stroke patients, it is possible to improve function recovery. However, the level of functioning gained after strokes is determined by neurological and cognitive factors (Saxena, et.al., 2006, p. 339). This is in line with other studies which indicate that the improvement of depressive symptoms through therapeutic remedies can be curtailed or limited by cognitive impairment. It is therefore important for the therapists to address these issues in stroke patients. Teaching elderly post-stroke patients to safely conduct their ADLs also helps reduce fears of falling (Moreland, et.al., 2007, p. 1). Many patients who have compromised mobility fear that they might fall and injure themselves when they would carry out their daily activities. And this fear often prompts them to avoid performing their ADLs. A study by Scheffer, et.al., (2007, p. 19) sought to establish the investigate the relationship between FOF and possible consequences among community-dwelling older persons. Their study covered 28 relevant studies and it established that there is a major variation in the prevalence of fear of falling among older people. Knowing the risk factors of this fear is important in conceptualizing strategies to decrease the fear and improve the quality of patients’ lives (Scheffer, et. al., 2007, p. 19). All in all, this study concluded that the fear of falling has major detrimental consequences for elderly adults. Interventions should therefore be focused on reducing their fear of falling and improving their conduct of their ADLs. In order to ensure that rehabilitation patients recover well, the conduct of their daily activities has to be relearned because it would help ease their anxieties related to possible injuries or falls. In other words, they would gain confidence in their movements and their daily activities. In a paper by Saka, et.al., (2009, p. 40) the authors set out to evaluate the cost-effectiveness of a combined early supportive discharge and stroke units can help ensure improved patient outcome. This paper covered costs in health service and societal costs as measures of efficiency. This study was able to establish that using the stroke unit and following it up with the early supportive discharge helps ensure cost effectiveness and general efficiency of care (Saka, et.al., 2009, p. 40). It is therefore important to apply a combined in-house stroke unit approach alongside early discharge with the aid of rehabilitation. Through this study, it is possible to deduce the importance of continuing patient care after discharge. It is therefore important for the family to assist the patient in gaining independence in his ADLs in the post-discharge period. This study was able to point out that doing everything for the patient and not allowing him to conduct his ADLs actually can set back his recovery and decrease his health outcomes. In another study, the authors set out to evaluate the impact of depression on recovery in the ADLs of stroke patients (Hackett, et.al., 2005, p. 1330). In the course of the study, the authors were able to establish that for patients who were more depressed, they were more likely to have different patterns of recovery in their ADLs. Those with major depressive disorders were more impaired in the conduct of their ADLs and their physical activities (Hackett, et.al., 2005, p. 1330). Through this study, the authors were able to deduce that detecting and diagnosing the patients for depression at the soonest possible time is paramount in the recovery of post-stroke patients undergoing rehabilitation. In the case of the patient being studied in this paper, he was diagnosed and assessed for depression before his admission to the rehabilitation centre. This is a crucial diagnosis because it cues in the medical team to other related mental health issues which may impact on the patient’s recovery, especially on the conduct of his ADLs. Although the patient may not seem capable of gradually and independently performing his ADLs, experts claim that patients can re-learn and regain their independent mobility and physical activity (Pohl, et.al., 2007, p. 17). These are all elements needed towards reaching post-stroke status for these patients. Studies also indicate that stroke patients who incur brain damage and loss of function can still recover these losses with these functions being “taught” or learned by other parts of their brains (Barnes, 2005, p. 229). Through the repetition of these activities, the patient can regain these motor movements. He can also gradually make adjustments in his physiological habits in order to accommodate weakness of muscles or loss of function (Hogan, et.al., 2006, p. 606). The studies mentioned above further emphasize the importance of teaching the patient’s conduct of his ADLs during the rehabilitative period, with the eventual goal of ensuring the patient’s overall recovery and increased independence. 2. Goal: To improve the physical activity of the patient, including transfers, walking, and the patient’s use of his cane; exercise and appropriate physical activities. Intervention This process was done with the supervision and guidance of the physical therapist, occupational therapist, and the nurse. Daily activities and exercise based on prescribed number of hours were scheduled. These activities helped to strengthen the patient’s muscles, especially on his left side. They were meant to help regain the patient’s left-sided mobility. The patient was also taught how to carry out these activities on his own for possible continuation after discharge. The patient was also taught how to safely get up from a lying position on his bed, with and gradually without assistance. Eventually, he was also taught how to safely sit up on his bed, how to swing his legs to the floor, and then how to stand. Walking with assistance using his cane was also taught to the patient. These activities were meant to improve his independence; and they helped him gradually regain his mobility. They were also meant to keep the patient safe, as well as to prevent falls and injuries from his activities. Critical analysis Teaching and assisting the patient in safely moving, transferring, sitting up, standing up, walking, and navigating a room with a cane are also beneficial interventions for the patient. The physical therapist and the nurses are the most appropriate individuals to assist in this stage of the patient’s care. Assessing the patient’s ability to sit-and-reach is also an important addition to the care process because it helps determine the extent of the patient’s mobility. In a paper by Blum and Korner-Bitensky, (2008, p. 559), the authors sought to determine the reliability of the Berg Balance Scale and to determine its capacity in predicting the mobility of patients who are recovering from acute stroke. After the test, the study revealed that the results established by the SRT are reliable results and they can be used to predict the mobility of patients suffering from acute stroke (Blum and Korner-Bitensky, 2008, p. 559). The importance of regular and prolonged time for physical activity and therapy is also an important part of the rehabilitative process. The more time spent for physical mobility, the faster and the better the outcomes for regaining mobility for the stroke patient. This too was highlighted in the Egerton, et.al. (2006, p. 8) study where the authors set out to measure the actual upright activity of inpatient stroke patients in an attempt to evaluate the influence of disability, physiotherapy contact time, and amount of activity recorded since the stroke. The results were measured and compared using the Rivermead Mobility Index. The study revealed that there was a relationship between upright activity and walking speed and physiotherapy time (Egerton, et.al., 2006, p. 8). In effect, the study pointed out that with longer physiotherapy contact time, better quality of inpatient rehabilitation and mobility can be seen. The importance of relearning motor movements is an important part of the rehabilitation process because it helps ensure that the patient would be able to regain his physical health and mobility. In a study by Dora and Chan (2006, p. 191), the authors set out to evaluate the efficacy of the motor relearning approach in securing physical functioning after a stroke. In the course of research, the authors were able to establish that patients who were in the motor relearning group were able to manifest better performance in the different tests for mobility (Dora & Chan, 2006, p. 191). All in all, the study was able to reveal that motor relearning programs are effective programs in enhancing the functional recovery of stroke patients. This study helps support the rehabilitation process applied by the health care team for the stroke patient. By applying methods to assist the patient in regaining his mobility, they were able to ensure that the patient would relearn most of his motor functions and general mobility. 3. Goal: To improve patient’s language and his communication skills Intervention The expertise of the speech therapist was utilized in order to improve the patient’s language and communication processes. This speech therapist helped the patient re-learn the different functions of communication and speech, including: speaking, understanding, reading, writing, improving memory, solving problems, and understanding numbers. The speech therapist carried out speech exercises with the patient. These exercises were meant to reinforce these activities in the brain. These were part of the daily activities of the patient which had to be repeated at regular intervals. The improvement of communication skills for stroke patients is also known as aphasia treatment (Steen, 2009, p. 131). This was applied for the patient in this study. It was noted that the intensity of the speech therapy process was high and was often tedious for the patient to go through. As highlighted by Vega, (2008) it is important for the intensity of the therapy to be high because the outcome for the patient would be better if more hours are set aside for the process. Vega (2008) also mentions that the application of different stimuli can increase the efficacy of the aphasia treatment. In effect, including stimuli like music, pictures, drawings, and other auditory stimuli, can help increase the outcome of the therapy (Vega, 2008). As noted, during the speech therapy of the patient, he and the therapist were in a room with pictures and with music that the patient preferred. In the process, the patient became more relaxed through the music. He also became gradually in learning the words and their pronunciation when he saw pictures and visual representations of said words. Vega (2008) also mentions that a gradual increase in the difficulty of the language exercises can improve the health outcomes. This was applied to this patient, with daily sessions starting out through 1 hour daily exercises, and after a week, it was increased to 2 hour daily sessions, and on the third week, it was increased to three hour sessions. 4. Goal: To reduce and treat his depression Intervention The patient underwent cognitive-behavioral therapy for his depression and anxiety. He was also given antidepressants. Critical analysis Cognitive behavioural therapy and the use of anti-depressants is also an important intervention for the post-stroke patient because a patient’s mental state often impacts on a patient’s health outcome (Chan, 2007, p. 71). In a paper by Hama, et.al. (2007, p. 1046), the authors conducted a study to evaluate the impact of post-stroke depression and antidepressant therapy on functional recovery. The study revealed that for depressed patients undergoing rehabilitation, they had less and slower progress in terms of functional recovery (Gainotti, 2001, p. 258). The study highlighted the importance of also treating post-stroke depression during the rehabilitation process in order to ensure that the patient would also recover his functions and his mobility. The impact of post-stroke depression on patient rehabilitation was also emphasized in the study by Gaete and Bogousslavsky (2008, p. 75). In their study, the authors established that depressed patients, in contrast to non-depressed patients, manifested greater functional impairment during the rehabilitation process. Moreover, their coping strategies seemed to be weaker. In effect, the study established that depression is manifest in stroke patients and it often has a negative impact on patient rehabilitation. Health professionals therefore need to include treatment for depression during the rehabilitative process among stroke patients. 5. Goal: To include the family in the plan of the patient’s care and to educate the family in the patient’s care. Intervention The family was encouraged to involve itself and to assist the patient during the recovery process. They were told to express their encouragement for the patient and to be active in the rehabilitative process. They were also taught how to assist the patient while in the clinic in preparation for when the patient would be discharged into their care. Critical analysis Family participation is an important component of rehabilitation because it helps ensure that the patient has the physical, as well as the emotional support of his family. In the paper by Osawa and Maeshima (2010, p. 170), the authors set out to establish the impact of family social support in improving unilateral spatial neglect in patients with Acute Right Hemispheric stroke. The study was able to establish that these variables were significantly affected by high levels of family support and that the more severe the stroke is, and the greater the support needed from the family. Eventually, with better support rendered to the family, a better functional status for the patient may be seen (Osawa & Maeshima, 2010, p. 170. The applied intervention for this patient is therefore appropriate to meet the needs of the patient. Family support was also emphasized by Romualdez (2011) as a source of encouragement during times when the rehabilitative process may be difficult for the patient to cope with. Family can also serve as company for the patient, ensuring that he has less time to feel depressed or anxious about his condition (Anderson, 2006, p. 74). Studies also point out that family presence can help ensure that members also learn about the process of rehabilitation – and to ensure the continuity of the process upon discharge (Hoeman, 2007, p. 22). In the case of the elderly patient, the family was instructed not to let the patient become too dependent on them. It is important for the members of the family to offer and give help only when it is needed (Stein, Harvey, and Macko, 2009, p. 674). For example, the simple act of getting to and from the toilet may take forever with the patient doing such task on his own. And it would actually seem faster and easier for a family member to just carry the patient to and from his bed or his chair to the toilet. However, doing such things for the patient – not allowing him to gain independence in his activities – would do nothing for his recovery. It would actually be setting back his rehabilitation. In effect, allowing the patient to independently carry out his tasks, even if they may take longer, is the better and more beneficial move (Brust, 2006, p. 125). Based on the above tasks, the care administered to the patient was geared towards the primary goal of rehabilitation – that is, for the patient to re-learn his normal and daily activities, to regain independence in the conduct of these activities, to avoid injuries and further deterioration of his health, and to ensure that he would recover his mobility and normal communication processes (Greenwich Hospital 2005, pp. 1-2). Role of the multidisciplinary team In the care of the patient, the team of medical health professionals were on hand to ensure the efficacy of the rehabilitative process. The physiotherapists were there to focus on limb weakness, abnormal muscle tone, balance, and mobility issues. They also had to work closely with the occupational therapists in order to achieve these goals (Pollack, et.al., 2008, p. 519). The occupational therapists were there to teach the patient independence in his ADLs, to guide the patient in his personal hygiene and other activities. They also had to work closely with the physiotherapists in order to achieve these goals. The speech therapists focused on communication and speech functions, as well as his chewing and swallowing (Horn, et.al., 2005, p. 101). The nurses assisted in bladder and bowel functions, as well as in solidifying the rehabilitation gains for the patient. They also spent the most time with the patient and his family (Royal College of Nursing, 2007, p. 6). The neuropsychologist also had an important function. He assisted the patient in regaining his memory and his concentration; in addressing his difficulties in planning, and in teaching him problem solving skills (Moser, 2006). All of the members of the team also assisted the patient in his perceptions, awareness of his body parts, and visual field loss. The social worker also had an important role to play because she evaluated the patient’s social network and the quality of his life. They also counselled the patient and his family and arranged community participation in the patient’s care (Viandante, 2011, p. 2). The rehabilitation physician was the leader of the team. He led the team and worked closely with the nurses in dealing with patient co-morbidities; in this case, the patient’s diabetes and hypertension. He was also there to help deal with complications of treatment, which included the patient’s depression and anxiety (Selzer, 2006, p. 588). He also directed the patient’s care while coordinating and consulting with the other members of the health care team based on the member’s expertise. Coordination and collaboration is an important aspect of the rehabilitation because it helped ensure that all the patient’s needs were addressed and given sufficient attention by the members of the team (Goldstein, et.al., 2005, p. 690). Conclusion Based on the above presentation and critical analysis, it is appropriate to say that the patient received adequate and appropriate rehabilitation care from the medical team. The team was equipped with the right skills and knowledge to ensure efficient care and they worked well with each other in order to deliver proper care to the patient. Based on the literature, the chosen interventions for this patient can be deemed appropriate and efficient. 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