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For Rehabilitation
to be successful it must be a co-ordinated team effort involving patients
and their families. The programme must be consistent with short term achievable
goals. Morale is all important. Co-operation between nurses and, above
all, family carers ensures that the patient can look to the future with
confidence. It is this confidence that gives stroke people the will to
strive for ever higher levels of recovery.
The aim is to maximise
recovery and help the patient return to maximum independence. This can
best be achieved when the patients and their families are involved with
the team - Doctor, Nurses, Physiotherapists, Occupational Therapists,
Speech and Language Therapists, Psychologists and Social Workers.
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Problems associated
with each stroke are identified. These may include:
- Paralysis
- Communication
Problems
- Swallowing
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- Urinary
Incontinence
- Mental
& Emotional Problems
- Fatigue
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Short term realistic
goals are set with the patient and his/her family and the Health Care
team. The role of the family carers is crucial.
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Good positioning
of the stroke patient is most important.
Positioning in
bed.
(a) Lying on
the stroke side
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This should
always be encouraged with the stroke shoulder well forward so that
the body weight is supported on the flat of the shoulder blade and
not on the point of the shoulder.
Place the
stroke leg with the thigh so that it is in line with the trunk,
and bend the knee slightly.
The unaffected
leg should be brought forward and placed with the knee bent on a
pillow in front of the affected leg for comfort. This prevents the
patient rolling onto his back.
Lastly, bend
the head forward a little.
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(b) Lying on the
unaffected side.
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Again the
stroke arm should be well forward, keeping the elbow straight and
supported on a pillow.
The stroke
leg should be brought far enough in front of the body to prevent
the patient rolling on to the back, the knee bent and leg supported
on a pillow.
A small pillow
can then be placed under the patient's waist to maintain the the
line of the spine.
When lying
on the side position, the patient should have two pillows only under
the head.
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(c) Lying on the
back
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This is the
position most likely to encourage spasticity, but some patients
do like to lie on their back for a while and it will be required
for some treatments.
Place two
pillows under the patient's head and help him bend his head slightly
towards his unaffected shoulder and gently turn his head towards
his stroke side but do not uses force.
A small pillow
is placed under the buttock of the stroke side and should extend
just to the knee, this will relax the leg and prevent it turning
out at the hip.
A pillow
is placed under the stroke arm which is kept straight at the elbow
and if possible, the palms of the hand facing upwards.
The bed must
be the correct height to promote independence and safety for the
patient, family and health care workers.
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Sitting position
in a chair
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The patient
should sit upright - well back in the chair - and should not slump
to one side.
A table should
be used to support the stroke arm which then rests on a pillow.
The arm should
be positioned with palm facing downwards, fingers and thumb straight
and elbow straight.
The stroke
leg may need to be supported by a pillow beneath the buttock on
the stroke side to prevent the knee rolling outwards and so keep
the foot flat.
The Occupational
Therapist will advise on the appropriate type of chair for safety
and independence.
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Nursing care will
involve setting up a programme of regular toileting to promote continence.
A chart or a diary may be useful. Sometimes drug treatment may be necessary.
Restoration of continence can provide a tremendous psychological boost
for patients and give them the confidence to participate in therapy and
social events. Adequate fluid intake and the use of natural bran products
and fibre-rich foods are important. A raised toilet seat and grab rails
are essential for safety and independence.
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The nutritional
problems that may arise following a stroke include:
- A limit
on the patient's ability to feed himself
- Visual
defects which may result in food being left on the plate because
it has not been seen
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- Inability
to remember how to feed oneself
- Difficulty
in swallowing
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Great progress
can be made here, especially in the early stages. Goals for working with
the patient might be:
- Creating an
atmosphere that encourages communication
- Encouraging
patients to express themselves - e.g. through writing or gestures
- Use of picture
or alphabet boards
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The patient may
experience:
- Emotional lability
which may result in him laughing or crying on the slightest pretext
and often inappropriately
- Reduced tolerance
to stress
- Fear, hostility,
anger, frustration
- Withdrawal and
isolation
- Depression
The nurse must
be supportive by listening and providing a safe comfortable environment.
It is important to work closely with the family to ensure they fully understand
the nature of the problem.
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The nurse works
closely with the Social Workers in getting the patient ready to leave
the hospital. The process includes:
- Early contact
with the patients family so they can observe therapy, learn about stroke
and the support services available such as the Volunteer Stroke Scheme,
Home Help, Meals on Wheels. The new video on stroke will be a great
help here.
- Assessing what
are the patient's and the family goals for discharge.
- Evaluating what
type of help and supervision will be required at home.
- Teaching the
patient and his family about the use of assistive devices.
- Encouraging
weekend leave or overnight stay at home to determine the patient's ability
to function at home.
- Early ordering
of equipment or adaptive devices to ensure their arrival before discharge.
- Making referral
to the Community Care Services including the Public health Nurse and
the GP.
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