Movement and Positioning in Stroke Patients - Essay Example

?Movement and Positioning in Stroke Patients Introduction Stroke, or cerebrovascular disease, is the most important neurologic disease in adult life.It is the sudden occurrence of focal neurologic deficit due to an infarct or hemorrhage in the brain. It is the third most common cause of death in the United States, and its effects can be debilitating to the patient and the caregivers (Ropper and Brown, 2005). The effects of stroke can be divided into two categories: impairments and disabilities (Gordon et al., 2004). Impairments are changes in the body structure and function. Disabilities, on the other hand, are limitations in the performance of the activities of daily living. These can be affected not just by the physical effects of the disease, but by psychological and social factors. Impairments and disabilities can worsen with time if no intervention is done. It may lead to further deterioration due to immobility or reduced activity, leading to complications such as thrombus formation, decubitus ulcers, and pulmonary embolism. Patients may also become more dependent on others and have decreased normal social interactions. All of these can have a profound effect on a person’s well-being. Backe, Larsson, and Fridlund (1996) investigated how patients conceived their life situation during the first week after the onset of stroke. They uncovered deep psychological trauma in the patients, wherein they had feelings of unreality, awareness of a changed role in life, feelings of a changed perception of the body, and feelings of being confused. Patients were also found to have a heightened sense of loss of capability and awareness of living in a confined space. Fortunately, some patients also developed an appreciation for the importance of support and encouragement and a will to look for new opportunities after the onset of stroke. One of the important debilitating effects of stroke is immobility. Convertino, Bloomfield, and Greenleaf (1997) saw in their study that bed rest and restricted physical activity brought about by stroke can lead to reduction of exercise capacity and deconditioning of the patient. This paper looks into the care of stroke patients, particularly in their movement and positioning. It presents points on the importance of movement and proper positioning and gives an overview of the current recommendations on physical activity and exercise for stroke patients. It also discusses the role of nurses in the management of stroke patients and in rehabilitation programs. It concludes with learnings from the literature review and critical appraisal and recommendations on how to apply these to nursing practice. The Importance of Movement and Positioning Stroke as a disease process can be progressive. Even though the cerebrovascular event that leads to the neurologic deficits is acute, its sequelae can continue to build on each other, leading to progressive deterioration of the patient. One important example of this is immobility. Due to neurologic deficits, a patient may have difficulty moving. This can lead to development of contractures, muscle atrophy, and nerve palsies (Summers et al., 2009). Current practice advocates early mobility for stroke patients. Summers et al. (2009), in their statements regarding the comprehensive care of the acute stroke patient, recommends that stroke patients may be initially kept on bed rest but should be mobilized once hemodynamically stable. It has been found that early mobilization reduces the risk of atelectasis, pneumonia, DVT, and pulmonary embolism. Aside from early immobilization, a longer term rehabilitation program has also been found to be effective in stroke patients. Ernst (1990) reviewed the literature on rehabilitation and physiotherapy among stroke patients and found that it was associated with improvement in functional status and lower incidence of secondary complications such as pneumonia and ulcers. Furthermore, Gordon et al. (2004) found in their review of literature that aerobic exercise can enable activities of daily living to be performed with less energy expended. This is valuable especially for stroke survivors who have developed intolerance for moderate activities. This can also ease the ambulation for hemiparetic patients. Exercise can also lead to changes in parameters that reduce the risk for another stroke. Patients were also found to have improvements in transfer time, motor performance, and static and dynamic balance after rehabilitation. Ernst (1990) states that in order to be effective, rehabilitation should begin as soon as possible and should continue for a long period of time. Convertino, Bloomfield, and Greenleaf (1997) say that effective rehabilitation should enhance orthostatic stability, maintain aerobic capacity, and maintain musculoskeletal integrity. Indredavik et al. (1999), in their assessment of different stroke units, described that shorter time to start of mobilization and stabilization of diastolic BP led to better outcomes among stroke patients. Other factors that may be of important in getting the desired outcomes are the presence of specially trained staff and the involvement of relatives. Alexander (1994) advocates the development of a rehabilitation algorithm, which would guide the health care team in selecting patients to enroll to a rehabilitation program. This algorithm should be based on the functional independence of the patient at admission and the patient’s age. Duncan et al. (2002) stresses the importance of rehabilitation guidelines as adherence to them was associated with improved patient outcomes among a cohort of 288 stroke patients followed for 6 months. Proper positioning is also important to help patients avoid complications of hemiplegia, such as spasticity and contractures. Carr and Kenney (1992) states that health care professionals should encourage patients to adopt “reflex-inhibiting” patterns of posture. Currently, the consensus is on positioning the patient with the affected shoulder protracted, spine straight, fingers extended, and avoiding external rotation of the affected hip. Current Recommendations on Physical Activity and Exercise among Stroke Survivors Gordon et al. (2004) released a statement covering the current recommendations regarding physical activity and exercise for survivors of stroke. This statement was a consensus of multidisciplinary councils. Their recommendations included goals for physical activity and exercise, preexercise evaluation, and exercise programming. They also covered issues such as poststroke sequelae, barriers to initiation of physical activity and exercise among patients, and the importance of rehabilitation. Involving different councils and covering all relevant topics in their scientific statement ensured that the users will see the value of physical activity and exercise for stroke patients and apply it to their practice. Goals of physical activity and exercise Gordon et al. (2004) set three major goals for stroke patients: preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness. To prevent complications of prolonged activity, current practice recommends that an exercise regimen be initiated as soon as possible. The regimen must be individualized to the patient, and should be designed to regain prestroke levels of activity. This can be as simple as intermittent sitting or standing while still admitted at the hospital. On discharge, the patient may already start remedial gait training or walking. To decrease recurrent stroke and cardiovascular events, it is important to first identify the patient’s risk factors. The goal is to reduce these risk factors by having a healthier lifestyle. Engaging in aerobic activities can have positive effects on blood sugar levels, body weight, blood pressure, inflammatory markers, and cholesterol levels. Lastly, increasing aerobic fitness can reduce the risk for stroke and make the execution of activities of daily living easier. Preexercise evaluation Gordon et al. (2004) stresses that while the councils recommend exercising for stroke patients, exercise is not without risk. To minimize potential harm, appropriate screening must be done. The exercise program should be well-designed, and there should be continuous monitoring and patient education. Among the major potential hazards of exercise are musculoskeletal injury and sudden cardiac death. To detect susceptible patients, all stroke patients should undergo a complete medical history and physical examination. The aim is to identify neurological complications and presence of medical comorbidities. Graded exercise testing should be conducted. The goal is to optimally assess the patient’s functional capacity and cardiovascular response to exercise. It is important to evaluate such parameters as heart rate and rhythm, ECG, and blood pressure. It is also important to take note of the patient’s subjective assessment. The mode of testing should also be appropriate to the patient and his or her capabilities. As part of the preexercise evaluation, it is important to assess possible emotional barriers to compliance with the program. The patient’s level of familial support, depression, and fatigue should be assessed as these factors could affect his or her motivation and level of engagement in activity. These factors can even lead to development of an acute illness. Involving the family early on in the program leads to better patient adherence. The patient’s social surrounding should be assessed, such as inquiring if the patient’s neighborhood is conducive for walks, or if there are nearby swimming pools or facilities that the patient can use. All of this information will be beneficial in tailoring a rehabilitation program for a patient. Exercise programming Gordon et al. (2004) recommends four modes of exercise: aerobic, strength, flexibility, and neuromuscular. Aerobic exercises consist of large-muscle activities, such as walking, treadmill, or stationary bicycle. It aims to increase independence in ADLs, increase walking speed and efficiency, improve tolerance for prolonged physical activity, and reduce the risk for cardiovascular disease. Current literature recommends that aerobic exercise be done 3-7 days a week for 20-60 minutes per session. Strength exercises consist of circuit training, using weight machines or free weights, and isometric exercises. The goal is to increase independence in activities of daily living. It should be done 2 to 3 days a week, with 1-3 sets of 10-15 repetitions of 8-10 exercises involving the major muscle groups. Flexibility exercises involve stretching. It aims to increase range of motion of involved extremities and prevent contractures. It is recommended to be done before or after aerobic strength straining. Properly done stretching should hold each stretch for 10-30 seconds. Neuromuscular exercises involve coordination and balance activities. It is done to improve level of safety during the performance of activities of daily living. These should be done 2-3 days a week, better if on the same day as strength activities. In designing an exercise regimen, the health care personnel should regard these recommendations only as a guide. Each patient has a unique combination of comorbidities and neurologic deficits. Also, each patient would have a different level of motivation and adaptability. Other factors such as depression, fatigue, family support, and cognitive deficits also contribute to a patient’s compliance to an exercise regimen. Careful assessment of each patient’s needs and individualization of the exercise programs are important to optimal results and prevention of injuries and harm. Role of Nursing Care in the Management and Rehabilitation of Stroke Patients Nurses have an important role in the management and rehabilitation of stroke patients. Hawkey and Williams (2007) published a handbook on the role of the rehabilitation nurse. In the book they identified eight categories in which a rehabilitation nurse can influence care: the development of essential nursing skills, therapeutic practice, coordination, empowerment and advocacy, clinical governance, advice and counseling, political awareness, and education. Essential nursing skills refer to care and consoling, which remain central to nursing. Nurses should be able to provide emotional and psychological support, as well as physically help the patient do activities of daily living. In therapeutic practice, nurses have important roles in the rehabilitation process. Because they are with the patient for the most part, they can be important sources of information about the patient’s disease and outcomes. The nurse can also provide the other members of the medical team with information regarding the patient’s subjective experiences and expectations. Coordination is also part of a nurse’s responsibilities. Because of the nurse’s close contact with the patient and the family, he or she can function as an advocate for the patient and the key person in coordinating the efforts of the health care team. This can be done by providing accurate and timely information and being familiar with all aspects of care. Education consists of patient education and nursing staff education. Patient education is vital in the success of any rehabilitation program. It can lead to increased independence and can give the patients the motivation they need. Nurses have a vital role in educating patients. They are better able to become acquainted with each individual patient’s learning styles and cognitive capacities, and can therefore tailor the way they present material to the patient. Because of their pivotal role in patient education, it is important that nurses have sufficient knowledge about their patients’ conditions. They should be updated about the current trends and recommendations, and offer their thoughts to the medical team as well. Empowerment and advocacy is another important aspect of nursing care. While showing utmost care and concern for the patient is important, the focus of the nurse should be in enabling the patient to be as independent and autonomous as possible. This can be achieved by continuously communicating with the patients as well as motivating them and providing them with opportunities to enhance their well-being. Nurses have a role in advice and counseling. Being listened to can have major impact on a patient’s well-being, and listening to patients is an important feature of advice and counseling. Counseling skills are important in supporting the emotional needs of patients, which can have impact on their physical and psychological well-being. Nurses can also play a big role in encouraging patients to stop smoking or have a healthy diet, which can significantly lessen the risk factors of another stroke or the development of other lifestyle diseases. By listening and offering advice, nurses can also help the patient organize his or her thoughts regarding the disease, the possible outcomes, and the options for intervention. Lastly, clinical governance is a field for nursing care as well. Nurses have a responsibility to continuously improve the quality of their services and ensure high standards of care. This is done by having clear lines of responsibility and accountability, quality improvement, and risk management. Summers et al. (2009) in the scientific statement on a comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient, further details the role of nurses. Firstly, the nurse has a role in the management of acute stroke from the prehospital setting. Because nurses are sometimes the first to see a patient that could be having a stroke, they should be knowledgeable and trained regarding stroke. Recommendations on education priorities include: knowing how to administer a validated prehospital stroke assessment, being trained to determine the last known well time, and using stroke assessment approach to gather basic physiological information about the patient and communicating this to the receiving hospital. In the hospital setting, Summers et al. (2009) also recommend that nurses assume a big role. Nurses should monitor the patient’s first transfer from the bed to an upright position and assess for deformities. Joints on the paralyzed side must be positioned higher than joints proximal to it. When repositioning or moving patient, the nurse must carefully avoid pulling on the affected arm and shoulder. Nursing interventions such as range-of-motion and positioning techniques can be done to prevent complications of immobilization. Outside the hospital, the nurse also has a role in stroke education in the community, certification of primary stroke centers, and initiatives in quality improvement. Many other studies support the observation that having nurses in stroke units led to better patient outcomes. Burton and Gibbon (2005) showed that continued intervention of a stroke nurse after discharge was associated with improved patient perceptions of general health, reduced negative emotional reaction and perceived social isolation, reduced carer strain, and reduced deterioration in physical dependence. Langhorne and Pollock (2002) tried to identify the components of an effective stroke unit care. Centering on the components relevant to nursing care, it was found that better patient outcomes were seen in stroke units who had nurses with expertise in stroke and rehabilitation. Better outcomes were also seen in units where nursing practices were closely coordinated with the multidisciplinary team and where nurses took part in providing information to patients regarding their disease, rehabilitation, and recovery. Currently, the actual role of nurses in the management of stroke is still far from ideal. This is primarily due to problems that the nurses encounter in their work. Seneviratne, Mather, and Then (2009) described some of the problems of nurses working in stroke units. Nurses experienced limited work space and lack of time, both of which can interfere with their ability to maximally help patients. Gibbon and Little (2007) also found that nurses felt inadequately prepared to participate fully in stroke rehabilitation. However, the research also showed that improving the nurse’s understanding of the disease had a positive effect on his or her involvement in rehabilitation. Jones et al. (1998) also showed in a study that formal teaching interventions can produce significant improvements in nurses’ knowledge of moving and positioning stroke patients. All of these point to a need for further research and actual policies to improve nurse’s knowledge and working conditions. Conclusion This paper looked into stroke and its debilitating effects on the patient, with special focus on the effects of immobility. This highlighted the importance of proper movement and positioning of stroke patients, as well as the importance of a rehabilitation program. Currently, there are recommendations on how physical activity and exercise should be initiated among stroke patients. The literature offers convincing evidence on the need for this. This paper also discussed the role of nursing care in stroke management, particularly in movement and positioning. There is still so much to improve on, such as in educating and training nurses on how to properly carry out their tasks. However, the bigger emphasis is in recognizing the encompassing role of the nurse in providing care for the patient. Stroke can be very debilitating, primarily due to its acuteness and its life-changing effects. Nurses can be pivotal in addressing the patients’ concerns about physical changes, and are called on to be gentle and understanding about patients’ new-onset physical limitations. Furthermore, rehabilitation interventions are deeply grounded in motivational relationships. Nurses are in a good place to nurture motivation in patients and help them adapt to the psychosocial consequences of their disease. References Alexander, M. P. (1994). Stroke rehabilitation outcome, a potential use of predictive variables to establish levels of care. Stroke, 25, 128-134. Backe, M., Larsson, K., and Fridlund, B. (1996). Patients’ conceptions of their life situation within the first week after a stroke event: a qualitative analysis. Intensive and Critical Care Nursing, 12(5), 285-294. 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Seneviratne, C., Mather, C. and Then, K. (2009). Understanding nursing on an acute stroke unit: perceptions of space, time, and interprofessional practice. Journal of Advanced Nursing, 65(9), 1872-1881. Summers, D. et al. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke, 40, 2911-2944. Read More