Question

John Green, a 71-year-old patient, is being discharged from the rehabilitation unit 8 weeks after an ischemic stroke. The patient’s spouse stated that they used to enjoy going to golf outings with their friends, but the patient has not played golf since he had the stroke, and she does not want to try to golf once her husband is discharged home because he has to use a walker and can barely ambulate. She also states that her husband still has trouble speaking, and his short-term memory is not very astute so it would be embarrassing to be on a golf outing with him. The patient’s spouse has worn the same outfit to the rehabilitation unit the past 3 days, and the nurse notices the patient’s hair is unkempt and his affect is flat. The rehab nurse has made arrangements with the social worker for a physical therapist, speech therapist, and occupational therapist to provide three sessions of therapy at the patient’s home for the next 4 weeks, and then a reevaluation will follow to determine if the patient will need further therapy. The patient is able to sit independently, stand independently, and use a walker. The patient is able to ambulate 30 feet with the walker, and then he requires a short rest before he is able to ambulate another 30 feet. The patient slurs words occasionally and has hesitant speech. The patient has problems with short-term speech.

1. What educational topics should the nurse provide the family about home care for the patient after stroke?
2. What assessment of the spouse does the nurse need to make, and what should the nurse suggest?

Answer 1

+ Patient education on:

*Teach patient to resume as much self care as possible; provide assistive devices as indicated.
*Have occupational therapist make a home assessment and recommendations to help the patient become more independent.
*Coordinate care provided by numerous health care professionals; help family plan aspects of care.
*Advise family that patient may tire easily, become irritable and upset by small events, and show less interest in daily events.
*Make a referral for home speech therapy. Encourage family involvement. Provide family with practical instructions to help patient between speech therapy sessions.
*Discuss patient’s depression with the physician for possible antidepressant therapy.
*Encourage patient to attend community-based stroke clubs to give a feeling of belonging and fellowship to others.
*Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation.
*Encourage family to support patient and give positive reinforcement.
*Remind spouse and family to attend to personal health and wellbeing.

+To enhance Family Coping

*Provide counseling and support to the family.
*Involve others in patient’s care; teach stress management techniques and maintenance of personal health for family coping.
*Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for the patient that he or she can do.
*Develop attainable goals for the patient at home by involving the total health care team, patient, and family.
*Encourage everyone to approach the patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to the family that emotional lability usually improves with time.

+Improving Communication

*Reinforce the individually tailored program.
*Jointly establish goals, with the patient taking an active part.
*Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat the patient as an adult.
*Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s sentences.
*Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
*Maintain patient’s attention when talking with the patient, speak slowly, and give one instruction at a time; allow the patient time to process.
*Talk to aphasic patients when providing care activities to provide social contact.

+Improving Thought Processes

*Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.
*Support patient: Observe performance and progress, give positive feedback, convey an attitude of confidence and hopefulness; provide other interventions as used for improving cognitive function after a head injury.

+Preparing for Ambulation

*Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone, when indicated).
*Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if needed).
*Begin walking as soon as standing balance is achieved (use parallel bars and have a wheelchair available in anticipation of possible dizziness).
*Keep training periods for ambulation short and frequent.

+Spouse should be informed about the patient condition and educate her about the signficant role they will play while patient gets back home .
*reniforce her that the treatment will be more effective when all the family member Support the patient .