NUR246 TOPIC 7 LECTURE

Neurovascular Disorders: Rehabilitation Nursing

Cerebrovascular Disorders

Overview of Stroke Types

  • Ischaemic Stroke: Characterized by very little blood flow to neurons due to blockage from blood clots.

    • Thrombotic Stroke: Caused by a blood clot that forms in the arteries supplying blood to the brain, often associated with atherosclerosis.

    • Embolic Stroke: Results from an embolus (blood clot or debris) traveling through the bloodstream and lodging in a narrow brain artery.

    • Transient Ischaemic Attack (TIA): A temporary episode of neurological dysfunction; symptoms typically last less than one hour.

  • Haemorrhagic Stroke: Occurs due to a burst blood vessel, causing bleeding into brain tissue before clotting halts the leak.

Major Types and Pathophysiology of Stroke

  • Internal Carotid Artery: Supplies the anterior circulation of the brain.

  • Vertebral Arteries: Supply the posterior circulation of the brain.

  • Continuous blood flow is critical, providing oxygen and glucose to neurons at a rate of 750 to 1000 mL/min (20% of cardiac output).

  • If blood flow is interrupted:

    • Neurological metabolism alters in 30 seconds.

    • Stops in 2 minutes.

    • Cellular death occurs within 5 minutes.

Risk Factors for Stroke

Non-modifiable factors include:

  • Age: Risk doubles after age 55.

  • Gender: Higher incidence in men; more women die from strokes.

  • Ethnicity: Higher risk in Indigenous Australians and Māori populations; family history also contributes.

Modifiable factors include:

  • Hypertension, smoking, heart disease, high serum cholesterol, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of exercise, poor diet, and substance use.

Transient Ischaemic Attack (TIA)

  • Associated with an increased risk of stroke.

  • Symptoms are short-lived, usually lasting less than an hour but warrant immediate medical evaluation since one-third of TIAs progress to ischaemic strokes.

Manifestations of Stroke

Right-brain Damage

  • Results in left-side paralysis (hemiplegia) and characterized by:

    • Left-side neglect

    • Spatial-perceptual deficits

    • Impulsivity and poor safety awareness

    • Impaired judgment and time concepts

Left-brain Damage

  • Results in right-side paralysis (hemiplegia) and features:

    • Impaired speech/language (aphasia)

    • Cautious behavior

    • Awareness of deficits leading to depression and anxiety

    • Difficulty with language comprehension and mathematics

Signs and Symptoms of Communication Deficits

  • Aphasia: Damage to language centers causes various types:

    • Receptive Aphasia: Loss of comprehension.

    • Expressive Aphasia: Loss of ability to produce language.

    • Global Aphasia: Total inability to communicate.

  • Dysphasia: Impaired communication abilities; used interchangeably with aphasia.

    • Non-fluent aphasia involves minimal speech fluency with slow output.

    • Fluent aphasia demonstrates meaningless but grammatically correct speech.

Other Signs and Symptoms

  • Emotional Response: Unpredictable emotional outbursts, often exacerbated by depression and physical impairments.

  • Cognitive Function: Memory and judgment can be affected differently depending on which hemisphere suffered the stroke; left-brain strokes tend to produce more cautious behavior, while right-brain strokes lead to impulsiveness.

  • Spatial-Perceptual Alterations: Particularly from right-side strokes, causing incorrect self-perception and agnosia (inability to recognize objects).

  • Elimination Issues: Urinary and bowel function problems may arise but are often temporary; prognosis for normal bladder function is generally good post-stroke.

Interprofessional Care and Rehabilitation Post-Stroke

  • Rehabilitation becomes vital after stabilization, focusing on reducing disability and enhancing optimal functioning.

  • Collaborative evaluations by rehabilitation specialists aid in developing patient care strategies.

Nursing Assessment for Stroke

Subjective Data

Key health backgrounds to assess:

  • History of hypertension, prior strokes, TIAs, cardiac issues, diabetes, family history of related conditions.

  • Medication history including anticoagulants and compliance to treatment.

  • Functional health pattern inquiry regarding diet, elimination, activity, and cognitive perception.

Objective Data

  • Emotional responses, respiratory function abnormalities, cardiovascular status, gastrointestinal and urinary function alterations, and neurological assessments highlighting motor and sensory deficits.

Preventive Nursing Interventions

  • Promote healthy lifestyles to reduce stroke incidence by targeting modifiable risk factors and educating on early stroke symptoms.

  • Implement measures to prevent skin breakdown, including pressure relief and early mobilization efforts.

Assistive Devices

  • Various assistive eating devices include specially designed knives, forks, cups, and plates to accommodate loss of motor control.

Communication Strategies with Patients with Aphasia

  • Effective nursing communication strategies should be implemented to facilitate interaction, utilizing visuals, written communication, and ensuring patient comfort.

Tracheostomy Management

Types and Care

  • Understanding tracheostomy components and care routines is crucial for nurses. Ensure sterile techniques and proper assessments during suctioning and tracheostomy care.

Suctioning Protocol

  • A detailed suctioning procedure must include pre-assessment, patient explanation, necessary equipment preparation, sterile techniques, and ongoing patient monitoring following suctioning passes.

Enteral Feeding and Nutrition Management

Feeding Tubes

  • Various types of enteral feeding tubes (e.g., nasogastric, gastrostomy) have specific guidelines for placement and management to maintain safety and efficacy in feeding.

Medication Administration Guidelines

  1. Ensure correct tube placement and use appropriate methods to confirm position before administration.

  2. Medication should be prepared and administered in a manner that prevents clogging the tubes, while also considering patient safety and comfort.

  3. Post-administration protocols include flushing the tube and monitoring for residual volumes to reduce aspiration risks.

Rehabilitation Nursing for Stroke Survivors

  • Rehabilitation is a comprehensive approach involving ongoing effort to maximize patient capabilities in physical, mental, and social aspects.

  • Emphasis should be put on engagement with patients in their recovery journey, adapting interventions according to progress and involvement of family members.

Addressing Emotional and Sexual Concerns

  • Nurses play a critical role in supporting emotional health, helping patients deal with loss, and addressing sensitive issues such as sexual health post-stroke, fostering open communication and trust.

Rehabilitation Nurse – Role, Skills, Qualifications, and Challenges

Role:

  • Supports patients with physical, cognitive, or psychosocial impairments to regain independence.

  • Develops and implements individualised rehabilitation care plans.

  • Educates patients and families on self-care, mobility, adaptive equipment, and lifestyle changes.

  • Collaborates with a multidisciplinary team including physiotherapists, occupational therapists, and doctors.

Skills:

  • Clinical assessment: Mobility, functional status, and vital signs monitoring.

  • Patient education: Teaching exercises, wound care, and chronic disease management.

  • Communication & teamwork: Coordinating care across disciplines.

  • Problem-solving: Adapting care plans to patient progress and barriers.

Qualifications:

  • Registered Nurse (RN) with AHPRA registration.

  • Postgraduate certification or training in rehabilitation nursing is advantageous.

  • Experience in acute care, aged care, or community health is beneficial.

Challenges:

  • Managing patients with complex, chronic, or multiple disabilities.

  • Motivating patients with limited progress or low engagement.

  • Balancing physical care, emotional support, and rehabilitation goals.

  • Coordinating with family members and multidisciplinary teams under resource constraints.

Stroke Patient Care Plan – Concept Map (Exam-Friendly)

Pain:

  • Assess pain (headache, musculoskeletal, spasticity).

  • Provide analgesia, repositioning, and comfort measures.

Psychosocial:

  • Support emotional wellbeing; screen for depression or anxiety.

  • Encourage family involvement and social interaction.

Elimination:

  • Monitor bowel and bladder function.

  • Implement continence aids, scheduled toileting, and hydration.

Education:

  • Teach patient and family about stroke, medications, lifestyle changes, and prevention.

  • Use simple, clear instructions with demonstrations.

Mobility:

  • Assess strength, balance, and coordination.

  • Provide physiotherapy, safe transfers, walking aids, and exercise programs.

Communication:

  • Assess for aphasia or dysarthria.

  • Use speech therapy, communication boards, and simple instructions.

Nutrition:

  • Assess swallowing (dysphagia) and dietary needs.

  • Provide texture-modified diet, hydration, and monitor weight.

Hygiene:

  • Assist with bathing, oral care, and grooming.

  • Encourage independence where possible; prevent skin breakdown.