stroke is a physical condition that needs to be addressed as early as possible to get better recovery and a good prognosis.

1. +`

2. POST CVA REHABILITATION
Presented By Supervisor
Maj Syeda Nafeesa Mumtaz Maj Muhammad Ikram
RN,RM,Rehab Nurse Rehab Medical Specialist
OJT in occupational therapy(uk) HoD Rehab Deptt CMH Nowshera

3. CONTENTS
 Aim
 Case Presentation
 Case Discussion
 Definition
 Epidemiology
 Types of stroke
 Risk factors
 Signs and symptoms
 Blood supply
 Rehabilitation
 Nursing management
 Conclusion

4. AIM
To emphasize on early Rehabilitation
not only to save life BUT
To improve both quantity and quality of
life of patient.

5. Patient Profile
Name : XYZ
Age : 86 Yrs
Sex : Male
Address : Nowshera

6. Presenting Complaints
*pictures are displayed with patient's permission*
Difficulty in walk
Weakness Rt half of
body
Slurring Of speech

7. History of present illness
History

8. 8
Dependence
ADLS
Bladder/Bowel
care
Transfers
Mobility
Ambulation
Functional History

9. PAST HISTORY
DM IHD
HTN CVA

10. Family History
Vocational History
Retired Audit Officer In karachi
No history of
Diabetes
Hypertension
Stroke

11. Personal History
Married
Has three children
Non smoker non addict
Graduate

12. Socioeconomic History
Belongs to a well established family
Resident of Karachi
Easy road access
Nearby hospital facilities

13. Examination

14. 14
 Vitals
 Pulse : 78/min Regular
 B.P : 168/85mmHg
 R.R : 16/min
 Temp : 98.4
o
F
 Jaundice
 Pallor
 Cyanosis
 Clubbing
 lymphadenopathy
Not present
General Physical Examination

15. EXAMINATION (cont…)
Chest
CVS
Abdomen

16. NormalTone
0/5
Normal
Increased Tone
5/5Power
Hyperreflexia Reflexes
Right Left
Reflexes
Power
Musculoskeletal Examination

17. Musculoskeletal Examination
NormalTone
5/5Power
NormalReflexes
Increased Tone
0/5 Power
Hyperreflexia Reflexes
Right Left
Plantar Flexion
response
PlantarExtensor
response

18. Investigations
 CP/ESR
 RFT,s
 LFT,s
 PT PTTK
 Xray chest
 CT scan Brain

19. CTCT Scan

20. Medical Diagnosis
Ischemic stroke Lt ,
hemiplegia Rt

21. Rt Hemiparesis
Potential for
Thromboembolism
Medical
Problems
Self care dependent
Ambulation dependent
Transfer skill dependent
Physical
Problems
Health Issues
Psychological
Problems
Anxiety

22.  Patient and family education.
 Prevention of secondary medical complications.
 Independence in ADLs ,mobility and ambulation.
 Bladder management
 Psychotherapy
 Physiotherapy
 Occupational therapy
Goals

23. Management Plan
Positioning
Physical
therapy
Gait training
Occupational
Therapy
Speech
Therapy
Psycho
therapy
ADL’s
Training

24. Posture And Positioning

25. Physical Therapy
Physiological
standing
Electrical muscle
stimulation @100
contractions x BD
*

26. Therapeutic Exercises

27. Therapeutic Exercises (cntd………..)

28. Occupational Therapy

29. Parallel bar training
Ankle foot orthosis
Knee immobilizer
Co ordination exercises
Standing balance
Gait Training

30. Pharmacotherapy
Tab Lipiget 1xHS
Tab Eziday 50mg 1/ 2xOD
Tab Qalsan D 1xOD
Tab Ibert folic 1x OD

31. Orthotic Devices
Ankle Foot Orthosis (AFO)
Knee Immobilizer
Wrist Hand Orthosis
(WHO)

32. Outcome After
Rehabilitation
Independent
sitting
balance and
walk with
support
achieved on
34 th day

33. Case Discussion

34. REHABILITATION
Derived from the Latin word
‘Habilitas’ which means ‘to make
able’
The first department of physical
medicine established at Mayo
clinic in 1936

35. STROKE
A stroke is caused by the interruption of the
blood supply to the brain, usually because
of
a. Rupture of blood vessel
b. Blockage by blood clot

36. Types Of Stroke
 Ischemic stroke  Hemorrhagic stroke

37.  Ischemic
Hemorrhagic
TYPES OF STROKE

38. Epidemiology
Third leading
cause of death
in U.S.
Leading cause
of severe
disability in
U.S.
One-third to
one-half have
disability
Most common
reason for
rehabilitation

39. Signs And Symptoms
The five warning signs of stroke are ;
1. Sudden weakness on one side of the body
involving the face , arm or leg.
2. Dizziness , loss of balance or coordination.
3. Sudden severe unexplained headache.
4. Sudden confusion and difficulty in
understanding or speaking.
5. Visual impairment of one or both eyes.

40. Risk Factors
Modifiable
 Hypertension
 Diabetes
 Smoking
 Hyperlipidemia
 Other cardiac disease
 Obesity
 Life style

41. Nonmodifiable
 Age
 Gender
 Race/ethnicity
 Family history

42. Effect of a Stroke
 Weakness on the side of the body opposite the site of
the brain affected by the stroke
 Spasticity
 Balance and/or coordination
Aphasia Or dysarthria
 bodily neglect or inattention
 Pain, numbness or odd sensations

43. (Contd……)
 Problems with memory, thinking, attention or learning
 Being unaware of the effects of a stroke
 Trouble swallowing (dysphagia)
 Problems with bowel or bladder control
 Difficulty controlling emotions (emotional lability)
 Depression
 Difficulties with daily activities

44. Stable neurological status
Significant persisting neurological deficit
Sufficient cognitive function to learn
Sufficient communicative ability to interact
with the therapist
Admission Criteria For Rehabilitation

45. Rehabilitation Goal
To restore lost abilities as much as possible.
To prevent stroke-related complications.
To improve the patient's quality of life.
Promote re-integration into family, home,
work, leisure and community activities.

46. Successful Rehabilitation
Depends on
 how early rehabilitation begins
 the extent of the brain injury
 the survivor’s attitude
 the rehabilitation team’s skill
 the cooperation of family and caregiver

47. LEVEL OF STROKE REHABILITATION
Day rehabilitation
Outpatient therapy
Home therapy
Intpatient rehabilitation

48. Multidisciplinary Team
PATIENT
PSYCHOLOGIST
PHYSIATRIST
OCCUPATIONAL
THERAPIST
NURSE
DIETICIAN
SOCIAL
WORKER
PHYSICAL
THERPIST

49. General Nursing Care of Stroke
 Nutrition
 Dysphagia Screening
to prevent risk of aspiration pneumonia
and determine feeding mobility
 Early mobility
to prevent DVT, pulmonary emboli
 Bowel and bladder care –
best to avoid urinary catheter insertion
but if necessary remove as soon as possible

50.  Falls prevention
 Skin care
 Positioning
 Body alignment
General Nursing Care of Stroke
(Contd…..)

51. Occurs when body alignment is not maintained
or when the patient’s position is not changed
often enough
 Pressure ulcer (bedsores) result when unrelieved
pressure on a bony prominence interferes with
blood flow to the area
 Contractures occurs when a joint is allowed to
remain in the same position for too long
Complications

52. Emergency Nursing Interventions In The
Hyperacute Phase Of Stroke:
The First 24 Hours
 Stroke symptoms can evolve over minutes
to hours.
 Nurses should be aware of unusual stroke
presentations.
 Assessments include:
Neurological assessment, vital signs ,
temperature, and should be done not less
than every 30 minutes.

53. Stroke Prevention
 Stop smoking
 Exercise regularly
 Improve eating habits
 Take medication as
prescribed
 Reduce stress level
 Maintain a healthy
weight
 Get regular medical
check-ups

54. Goal of Rehabilitation Nursing
“Goal of rehabilitation nursing is to assist the
patient to attain and to maintain optimum
health as it is defined by the patient.”
(Hoeman, 2002)
 Promote maximum functional ability
 Optimal health
 Adaptation to an altered lifestyle

55. Areas Of Concern
 ACTIVITY OF DAILY LIVINGS (ADL,S)
 MOBILITY
 COMMUNICATION

56. Activity of daily living
SELF CARE
1.Feeding
2.Grooming
3.Toilet use
4.Bathing
5.Dressing
Adapt or specially design device

57. Universal cuff

58. Adapted Feeding Spoons

59. Modified utensils

60. Modified Grooming Aids

61. (Contd……. )

62. ( Contd…… )

63. Modified Plug
Modified key holder

64. BATH AND TOILET MODIFICATION

66. Transfer Aids And Techniques

67. MODIFIED BEDS

68. MOBILITY AIDS

69. SHOULDER SUPPORTS

70. ASSISTIVE DEVICES
(WHO)

71. Poor Prognostic Factors
Advanced age
Recurrent stroke
Medical or surgical instability
Severe memory problems
Impaired cognition

72. Prognosis
 The prognosis of a stroke patient depends on the
severity of brain tissue damage.
 Recovery from stroke is generally fastest in the first
weeks after onset, with measureable neurological and
functional recovery occurring in the first month after
stroke.

73. Conclusion
 Early referral to rehabilitation unit
benefits the patient to improve his/her
ADLs and motor function.
 Complete recovery is not always
possible, however, living an enjoyable life
is still within reach.