The contribution of rehabilitative nursing techniques to the recovery of patients who have had cerebral vascular accidents

This study represents the attempt of the investigator to determine the effectiveness of a consistent rehabilitative nursing care plan applied to a selected group of patients with cerebral vascular accidents. For the experimental group a 23 bed medical unit in a 275 bed private hospital was selected fro the study. An inservice teaching program of basic nursing measures directed toward rehabilitation of the patient with cerebral vascular accident was developed by the investigator. All staff members in the experimental unit attended the inservice program. Basic nursing measures advocated in the teaching program were adapted to individual needs of the experimental group of patients. The investigator supervised the nursing care give to the experimental group. The experimental group consisted of five male patients between the ages of fifty-four and sixty-five. The cerebral vascular accident of each was caused by a thrombosis, and the prognosis based on the doctor's judgment was fair to good with expected progress. The study in this unit covered a period of four months. A record of the progress of this group in ambulation and self care activity was kept for the duration of the hospital stay. A medical unit in a private hospital with a 382 bed capacity and a medical unit in a private hospital with a 450 bed capacity were selected as sources for the control group. The five patients with cerebral vascular accidents in the control group met the same criteria for selection as the experimental group. The selection of patients was done in the same four month period. The control hospitals did not receive the inservice teaching program of nursing care advocated by the teaching program. A review of literature was done pointing out the need for more stress to be placed on rehabilitation in nursing practice. The institution of immediate rehabilitative nursing care measures on patients with cerebral vascular accidents was emphasized. The inservice teaching plan developed for the study by the investigator is centered a round four basic nursing measures: positioning, range of motion, self care activities, and ambulation. The t test was use to test the significance of the difference between the progress of the experimental and control group in self care activity and ambulation. Findings of this study were: A sample of selected patients with a cerebral vascular accident who received a consistent nursing care plan directed toward rehabilitation assumed self care activities more readily than a comparative control group, members of which did not receive this nursing care plan. The patients under this nursing care plan also ambulated more readily then those who were not. A significant statistical difference was shown. The investigator recommends as a result of this study and a review of literature that more scientific research in the application of nursing care should be done.

THE CONTRIBUTION" Olf REHABILITATIVE NUBSING TECHNIQtIES TO TH'E RECCVERY OF PATIENTS WHO HAVE HAD CEREBRAL VASCULAR ACCIDENTS by Loretta Brooks Klassen A thesis submitted to the faculty of the university of Utah in partial fulfillment of the requirements for the degree of MAS TER OF SO IENOE Department of Nursing University of Utah June. 1964 UtffVERSlTY OF UTAH LIBRARIES This Thesis for the Master of Science Degree by Loretta Brooks Klassen has been approved April, 1964 Chai~, Supervisory Committee Reader, Supervisory/Committee Reader~ Supervisory Committee ACKNOWLEDGMENTS Grateful acknowledgments are given to my chairman. Mrs. Ellen Greene" and members of my coromi t tee ~ Dean Mil dred Quinn and Dr" Cecil Samuelson. for their valuable assistance in the preparation of this study. Special t hanks are given to Mrs. Hazelle Macquin and Miss Annetta Bilger for their helpful suggestions to increase the readability of this thesis. The participation of the three hospitals involved in this study was greatly appreciated. The cooperation of nursing service and nursing education in the experimental hospital was invaluable to the success of this research effort. A sincere thank you to my husband for his sustained moral support. iii TABLE OF CONTENTS CHAPTEB PAGE I II III INTBODUCTION • The Problem . . . . . . . . . . . . . . . . . . . • • • • • 1 . . . . . . . Statement of the problem Importance of the stu~. Limitations •••• Definitions of Terms Used. · . • . . . • . . • • • • • . • • 2 • • • • • • • • • • • • • • • • • 2 • • • • • • • • • • • • • • • • • 2 · . . . . • • • • • • • • • • • • 4 · . . . . . . . • • • • • • • • • 5 Patient with cerebral vascular accident. . . . • • • · • • 5 Rehabilitation. . . . . . . . • • • • • • • • • • • • • • 5 Specific nursing care measures • • • • • • • • • • • • • • 5 Nursing personnel. Contracture. • • • · . . . 5 • • • • • • • • • • • • • 5 Movement toward ambulation . . . . . . . . . . • • • • • • b Self care activities . . " . . .. • • • • • • • • • • • • • b Organi zation of Thesi s • • • • • • • • • • • • • • • • • • • b BmVIEW OF TEE LITERATURE · . . . . . . • • • • • • • • • • 7 Literature on Neurological Implications ••••••••••• 7 Literature on the Nurse and Rehabilitation ••••••••• 9 DES IGN AND METHODOLOGY Materials Used • • • · . . . . . . " . . . . . . . · . . · . . . . . . . . . . . . . . . Inservice teaching plan. · . . . . . . . . . . . . . . . .lb .18 .18 Summarized care plan. • • • • . • • • • • ••••• 18 The sampl e • • • • • • • • • • • • • • • • • • • • • • • .18 iv CHAP'lSR Self care activities chart Movement to ambulation chart Cont rol setting. Experimental setting • Statistical method. IV RESULTS. V DISCUSSION. Collecting the Data. Recommendations. VI StMMABY. BIBLIOGBAPHY • • • • • • APPENDIX A • APPENDIX :B • APPENDIX C APPENDIX D • APPENDIX E • • • • v • • • PAGE .18 .18 .19 .19 .20 .21 .21.1- .2l+ • .2b • • • • • • • .28 • • • • • • • ·31 ·3b ·38 .40 • .43 .4b CHAPTIR I INTRODUCTION The prevention of deformities and the promotion of progressive ambulation of patients ,·,ri th long term illnesses are largely the respon-sibilities of the nurse, physician, physical therapist, and the patient himself. It is the nurses' responsibility to start the rehabilitative process when the patient first enters the hospital. Nurses can do much to prevent the development of deformi ties by employing the principles of good body alignment, of range of motion, movement toward ambulation, and self care activities. Although these principles and the measures derived from them are taught in basic nursing programs, as pointed out in the review of literature, adeq,uate nursing skills ~e not often resulted from the teaching. The nurse in the present dew hospital situation usually does not place enough emphasis on rehabilitative techniques. At the present time there are approximately one and one-half million hemiplegic patients in the United States. The united States Public Health Service has estimated that 800,000 persons suffer a paralytic stroke yearly.l In most cases the patient does not die. Only one in ten need accept helplessness. Ninety per cent can be taught to walk again, and thirty per cent can be taught to do gainful ~~rK.2 lPublic Health Service, Cerebral Vascular Diseases and Strokes (Publication No. 513), pp. 1-11. 21.:Q1g,o 2 Most hemiplegic patients are admitted initially to a general hospital, and it is during this early state that treatment should be started in order to prevent complications.3 I. THE P ro:SLEM Statement 2i ~problem. The purpose of this study was to com-pare the progress made by two groups of patients who have had a cerebral vascular accident. One group of patients, experimental group, received a planned program of nursing care consciously directed toward rehabili-tation of the patient. The second group of patients, control group, did not receive this planned nursing care program. In order to ex&nine the difference in progress made qy these two groups of patients, experimental and control, the following hypotheses were formulated and tested by statistical procedures: 1. There will be a significant statistical difference in the time it takes the experimental group to assume self care activities in comparison to the control group. 2. There will be a Significant statistical difference in the time it takes the experimental group to ambulate in comparison to the control group. Importance of ~ study.. Medical and nurSing personnel need to learn what and recognize how rehabilitation measures can be incorporated into nursing care so that the patient who has had a cerebral vascular accident may be restored to his fullest phySical potential and resume a 3Arthur Heather, Manual of ~ for the Disabled Patient (New York: The Macmillan Company. 19bO), p. 1. 3 satisfying role in the family unit and the community. Rehabilitation has been enlarging in scope since World War II. The increased longevity of the population, resulting in increase in the number of patients with long term illnesses, has given rise to new demands in the area of rehabilitation. A dynamic program of rehabilitation may stimulate many long term patients to become more independent and assume more useful life activities. A team of cooperating experts is a first requirement for an effective rehabilitation programo One essential member of this team is the nurse. To make her maximum contribution the nurse needs to be aware of the specif-ic nursing care measures she can institute to facilitate the rehabilitation of the long term patient. Hartigan states that many nurses are not familiar with the concept of nursing care which is every patient1s right today. The nurse does not realize that much of the rehabilitative process is implicit in good nursing care. According to Hartigan: They are unaware of the fact that properly carrying out a single nursing technique is tremendously important in the patient l s total recovery. They regard rehabilitative nursing as something apart. something special and complicated and expensive, sore thing that begins when the patient goes to the physical therapy department or when he begins occupational therapy, something whiah the nurse must go aw~ and take a special course to learn. Hartigan lists four factors which are implicit in nursing and which illustrate facets of nursing care which are most often overlooked. The factor most pertinent to this study was recognition that within simple 4Helen Hartigan, ''Nursing Besponsi bili ties in Rehabili tation, U NurSing Outlook (December, 1954) t p. 650. 4 nursing procedures there is much that can be done which will set the patient well along the road to full rehabilitation.5 Limitations. One limitation of this st~ was the relatively small number of patients in the three hospital settings used for the study who had had a cerebral vascular accident. The members of the comparative samples of the control and experimental groups were matched as having ~l) a diagnostic statement of thrombosis in the cerebral artery, l2) a doctor's prognosia of fair to good ~th progress expected, and (3) an age range of fif~-four to sixty-five. However, the following limitationa should be noted: 1. Diagnostic tests are not accurate enough to determine to a fine degree the amount of cerebral damage. 2. Studies have indicated that success in rehabilitation does not correlate with the severity of the neura-logical insult, but rather with factors in the lives of patients such as (l) they had a job to go to; (2) they had a home to go to; (3) the, had someone who loved them. 3. A certain amount of function will return to the affected side in spite of lack of planned rehabilitation measures. 4. Presence of secondary condit1ons.6 5Ibido. pp. 650-b51. 0Howard Bu.sk:, ".Rehabili tation of the Elderly Neurologic Patient, II ~ Neurologi~t ~ Psychia.t.r!g, ~spj'.9~~~ Q'f. lhe Di!Q}"de}'! p! M1M \ November, 1955). pp. ~25-429. 5 Despite these limitations indications are that good nursing care facilitates the patient's progress. Numerous references quoted elsewhere in this study support this statement. I I • DB INI TI ONS OF T.BllMS USED Patient with cerebral vascular accident. In this stud¥ a patient wi th a cerebral vascular accident is any patient who has had a thromboSiS" occlUSion, or hemorrhage of an arterial vessel in the cerebrum. ApprOXimately 75 to 80 per cent of strokes are due to cerebral artery thrombosis. 7 Rehabili tation. "Rehabilitation is a process which assists an ill or handicapped person to regain his maximum p!'wsical, mental, social, economic, and vocational usefulness. uS Specific nursing £!r! mea.s~rJ!!. The specific nursing care measures employed with the experimental group constituted a planned program of nursing care which involved specific instruction and supervision of the nursing personnel in techniques of body alignment, range of motion, move-ment to ambulation and self care activities. N1xrsing personn!l. Nursing personnel are those individuals in the hospital setting who give direct nursing care to the patient. Contracture. A contracture is a pathological state in which the muscle has undergone some degree of fibrosis. 7Heather, Q2. cit., pp. 1-2. 8 . Hartigan, 9.P.. ill.. .. t p. b49. Movement toward ambulati~~. In this study movement toward ambulation refers to the patient's increased ability from day to day to move from a dependent to a less depen.dent sta.te. ~ ~ activ~~jes. Self care activities are those functions the patient is able to perform independently, or with help, in the areas of eating and drinking. personal hygiene, dressing, and elimination. III. ORGANIZATION OF THESIS The rema.inder of this thesis is organized into five chapters: Chapter II contains the review of literature. Chapter III describes the Jr~t~odology used and the samples studied, Chapter IV is devoted to results. Chapter V to discussion, nn(1 Cl:.apter VI j.s the summary. C~TER II REVIEW OF THE LITERATURE A great deal has been written about rehabilitation and neurological involvement of motor pathways of the patient with a cerebral vascular accident. Literature relating to the nurse's role in rehabilitation of these patients is, however, Q.ui te limited. Only those references which seemed particularly pertinent to this study have been digested or quoted in this review. I. LITERATURE ON NEUROLOGICAL IMPLICATIONS According to Peele. giant pyramidal cells called Eetz cells are located in the voluntary motor area of the brain. The pyramidal fibers from these cells lead through the internal capsule through the brain stem. Same cross and go over to the opposite side of the spinal tract. others do not. These fibers which make up the motor pathway end upon lower motor neurons which innervate skeletal muscles. l Extra pyramidal fibers either run in close association with the pyramidal fibers or synapse in the basal ganglia where the fibers go to the lower motor neurons. These extra pyramidal fibers control integration of movement and inhibition of impulses.2 Any lesion in the pyramidal tract usually involves the basal ganglia. The chief function of the basal ganglia is influence over the ITalmage Peele. ~ Neuroanatomic Basis for Clinical Neurology lNew York: McGraw Hill Book Company, Inc., 19b~ pp. 387-394. 2Ibid. adaptabili ty and tonus of muscles whether voluntary or involuntary. Thus when the basal ganglia are involved in any lesion this inhibition is blocked and, in the case of a cerebral vascular accident, eventual spasticity will occur on the side of the paralyzed extremity. According to Peele, the favorite site of vascular involvement in the patient who has had a cerebral vascular involvement is along the distribution of the middle cerebral artery, frequently involving one of the arteries which supply the internal capsule, and the adjacent portion of the basal ganglia. The patient who has such an involvement may be flaccid for a few days or weeks ~d then the affected extremity will usually become spastic and contractures may develop within a few days if proper care is not given.4 Since involvement occurs on the side of the body opposite to the area of the brain involved, rehabilitation measures are often based on the knowledge that some fibers do not cross over in the pyramidal tract, and these fibers can be used for re-education of muscles on the affected extremi ty. After edema!) which has resulted from the lesion, subsides a certain amount of movement ""rill automatically retum. This process is aided by keeping the patient in good body alignment, maintaining what muscle tone is present. medications, range of motion exercises, and encouragement to move from a dependent to a more independent state. 9 II. LITERATURE ON THE NUBSE AND REHABILITATION Increasing emphasis is being placed on rehabilitation as indicated in the following statement taken from a rehabilitation study~ Rehabilitation as a recognized health effort began as isolated programs that were devised for obvious defects in bodily function which made a normal life impossible. The needs and circumstances of the blind person, the deaf person and the crippled child were such conditions •••• Rehabilitation has been changing and enlarging in scope, especially since World War II, and as a consequence of medical specialization. The need for rehabilitation ser­vices has vastly increased since more people survive with long term, often incurable illness or injury lmental or p~sical). Specific rehabilitation programs are developing as a major bulwark of society to offset these problems. Primarily, rehabilitation is both a concept and an attitude toward long term health needs which take into account the significance and impact of illnes$ on the person, his family and society. Second, it is a real process which utili2es a body of techniques developed for particular problems in health and welfare or within the particular skills and training of various profeSSional groups.5 According to Spencer, the nurse has a role in these profeSSional groups. Hartigan states that effective programs of medical rehabilitation are put together under knowledgeable medical direction by teams of competent and skillful people who have diverse training. One of the teams required is the nurSing team. b Madden and Affeldt describe the functions of this nurSing team in rehabilitation. NurSing care which includes methods of reducing environmental hazards, attention to proper pOSitioning, range of motion, 5w. A. Spencer and Others, "Rehabilitation in Concept and in Practice," Southern Medical Jo~. 55 (July, 19b2), p. 721. b Hartigan, .Q.E. £.i.t., pp. b'4 9-b50. 10 and gradual increase in a patient's activity is important. These measures should be routinely and consistently provided by all nursing personnel at all times. Madden and Affeldt pointed out that administrators and p~sicians have had too little experience with patients who receive this type of care to expect and demand it. When administrators have learned its value they will expect such service and will provide the necessary funds to support it.7 This observation was reinforced by Morrissey. She stated that tl:e importance of preventing deformity appears to be insufficiently stressed in the basic nursing programs, and the techniques of prevention are not widely used in actual practice. This she argued must be corrected if rehabilitation minded nurses are to be developed.8 In caring for the patient who has had a cerebral vascular accident the long range goal towards which the nurse is working is to help a particular patient prepare as much as possible for the realistic demands of daily living which he will encounter when he leaves the hospital. Deaver pOints out that the greatest need at the present time is for physicians and nurses to realize that the rehabilitation process starts when the patient is admi tted to the hospital. IIFar to many patients come to the rehabilitation centers with contractures, pressure sores and wi thout a desi re to be rehabilitated. u9 7Barbara Madden and John Affeldt, "To Prevent Helplessness and Defonnities," ~ American Journal of Nursing, b2 (December, 19b2) , pp. 59-blo SAlice Morrissey, liThe Nurse and Rehabili tation, II ~ American Journal .2i NurSing, 51+ lNovember, 1951+), p. 1354. 9George Deaver, IIRehabili tation." The American Journal .Qi. NurSing... 59 (September, 1959), p. 1278. 11 When an individual is subjected to permanent or long term incapacitation. he must learn to modify his p~siological, psychological. and sociological resources. The same stresses of adaptation to life and the demands of family and society now far exceed his lessened capacity, reduced or rendered less effective by chronic illness.... The attainment of realistic goals of living demand solutions other than restrictions of the activities of life, isolation. and withdrawal into custodial care. The disabled individual can indeed find his own useful and satisfying place in society, but he needs farSighted guidance and specific help in measuring and pacing his own attempts toward rehabilitation.IO Spencer and colleagues state that the art of rehabilitation 1s in essence the process of individually assisting a disabled person to dire~ and utilize his own basic adaptive powers. A regulated program is re-quired that successfully challenges him to achieve realistic goals as quickly and safely as possible. This challenge and the preservation of his integrity, initiative, and opportunity for self direction are basic.11 Rusk notes that in a good rehabilitation program the patient who has had a cerebral vascular accident is not a lost cause and that many can be taught ambulation and self care. Husk lists the following objec-tives in caring for the patient who has had a cerebral vascular accident: 1. To prevent deformities. 2. To treat deformities if they occur. 3. To retrain the patient to ambulate. lOW. A. Spencer, 2£. cit., p. 722. lIW. A. Spencer, ~. s!1., p. 723. 12 4. To teach the patient to perform the activities of daily living and to work with the unaffected arm and hand. 5. To retrain the affected arm and hand to maximum capacity. bo To manage facial paralysis and speech disability if present o12 The nurse can support all of these objective& in the clinical area. Therapy is complemented by simultaneous or sequential assistance by a variety of professional workers. Spencer points out: The positive attributes of this orientation to rehabilitation are concerned with the p~siological, psychological, and sociological competence of the person, and the influence these factors have in rehabil­itation.... This then, is the meaning of care of the "whole person, It ucomprehensive care tI or 'total care. tl13 Peszzynski states: The rehabilitation goal or the pOint of reference for the patient's prognosis, maw be any point on a scale. It ranges from recovery of the ability to work to enabling a physically and mentally dependent patient to improve to at least such a degree that the economically and psychosocially more desirable situation of his living at home is feasible.14 Bruell and Simon report that studies have shown that the age of the patient, time between onset of the cerebral vascular accident, commencement of intensive physical rehabilitation, and the patient's blood pressure readings are correlated with final outcome.15 l2Howard Rusk, Rehabilitation Medicine (St. Louis: T.he C. V. Mosby Company, 1958), pp. 505-510. l3w. A. Spencer, QR. cit., p. 724. l4.Mieczyslow Peszzynski, "The Behabili tation Potential of the Late Adult Hemiplegic, If The American Journal 2.! Nursing, 63 CApril, 19b3) , p. Ill. l5J. K. Bruell and J. I. Simon, "Development of Objective Predictions of Recovery in Hemiplegic Patients, fI Archives Physical Medic~t 41 lDecember, 19bO), ppo 5b4-5b9. 13 Peszzynski states that within recent years, attempts have been made to correlate data or initial evaluation ~nth the final results of rehabilitation. Indications are with continuing work a fairly high degree of prediction will be possible in the future. Such statistical correlations are simply more exact methods of defining the experiences a clinician has accum~ lated. The statistical approach will have to remain primarily a research tool for some time yet. However, improvements in the techniques of measuring different functions of normal and brain-damaged persons bear promise that modern techniques such as electronic computer processing of clinical data will yield practical highly reliable methods of predicting the outcome of rehabilitation for the hemiplegic patient.1b Peszzynski points out some of the means of assessment of the hemiplegic's progress. Prognosis is usually good when urinary incontinence does not last over three to four dBfs. Also the prognosis is better if bowel incontinence does not last over three to four weeks. Reports show that patients who have developed knee flexion contractures of twenty degrees or over seldom learn to walk or to transfer unassisted from bed to wheelchair. Peszzynski also pOints out that in any case there is a necessity to train the patient and his family to do daily range of motion, work toward bowel and bladder control, and to help the patient as much as possible to learn self care.17 Rusk emphasizes that the beginning steps of rehabilitation belong in the hospital. The major difference between general and rehabilitation l6Peszzynski, Q£. cit., p. 112. l7Peszzynski, ~. £!i., pp. 112-113. lLl-care is a matter of emphasis. Three phases of care for the patient with a cerebral vascular accident are pertinent in the hospital: (1) Eliminate p~sical disease if possible, l2) Reduce or alleviate disease if possible, (3) Work with the patient. Although some outstanding rehabilitation programs in various parts of the world have demonstrated that rehabili­tation to the point of self care and even to full or limited employment is possible for many of the chronically ill who have been hospitalized for long periods, patients in few hospitals receive comprehensive rehabilitation service. From hospitals we hear complaints that the chronically ill are responsible for over crowded conditions, but few hospitals provide the third phase of medical care, which would permit many of these to leave the hospital. It is only within the general ho~ital that such servicea can be brought to the patient at the earliest possible time and costly and damaging phfsical, emotional, social, and vocational sequellae of the acute disease process or trauma be alleviated or minimized. If any major attack is to be made on the problems of chronic disability, the general hospital and the individual practicing p~sician must be the focal points of that attack. It ia only in general hospitals that auch services can be brought to the patient at the earliest possible time.lS Emotional, spiritual and social factors are an inherent part of rehabilitation. Physical rehabilitation is impossible if the patient has psychological or social disabilities with which he is unable t~ work. Worries, anxieties, and disillusionment must be looked at before the patient can turn to new goals. Many patients with hemiplegia are not motivated in the common usage of the term. Such patients may appear apathetic in doing anything 18Howard Rusk, tlBehabili tation Belongs in the General Hospital, fI The American l..ournal of Nursing, b2 l September, 19b2), p. b3. 15 asked. Treatments such as exercises, ambulation, and self care activities should be continued. Usually awareness of progress will eventually motivate the patient. The preceding review of literature indicated there is a definite need for more emphasis to be placed upon the concept of rehabilitation. Basic techniques of rehabilitation must be made a part of the medical programs of hospitals. This concept must permeate all phases of the patient's care. The following chapters present a nursing care approach with special emphasis on rehabilitation. CHAP!lSR III DESIGN AND METHODOLOGY In determining the method to be used in this study a review of literature was done and experts in the field were consulted to advise on criteria for selection of the samples to be studied, criteria for evaluation of self care activities and of movement to ambulation. The method utilized for this study progressed through several stages: 1. A plan for inservice teaching involving the care of the patient with a cerebral vascular accident was developed by the author of the study, a graduate student in medical surgical nursing. 2. The teaching plan was utilized in clinical conferences held for the personnel in the clinical area utilized for the stu~. The conferences were conducted by the investigator of this study. The personnel included everyone in the unit involved in nursing care. The clinical conferences were utilized for teaching and planning for the care of the experimental group of patients. An initial conference was held using the teaching plan outlined for instruction in basic concepts of care for the patient with a cerebral vascular accident. Other conferences were held periodically to review and discuss individual nursing care plans each time a new patient for the experimental group was admitted to the unit. 3. A basic summarized pri.nted care plan was given to each staff member atte'nding the initial conference. This summarization outlined nursing measures advocated in the teaching program. 4. The nursing care plans were instituted on the group of patients designated as the "experimental group. It 5. Day to day records ,,!ere kept on the progress of the experimental group in self care aetivi ty and ambula­tion. These records \\rere kept on forms developed 'by the author of the study. b. The srune progress records were kept on a group of patients designated as "control patients" at two other hespi tals. These two hospitals did not use the inser~.rice teaching program developed by the author or participate in the conferences for adapting the recommended nursing measures to the individual patient. 7. The i ratio was utilized to test the significance of the difference between the progress made by the control and experimental group in self care activity and ambulation. 17 18 MATERIAtS USED Inservice t~~hing plan. The teaching program developed by the author and utilized in the inservice education was made up of rehabili t8=· tive measures that should be incorporated in the nursing care of the patient with a cerebral vascular accident. Teaching cen tered around four points: positioning, range of motion, self care activity, and pro­gression to ambulation. This teaching plan constitutes Appendix E. Summarized ~ plan. A printed outline of nursing measures ad­vocated in the teaching plan was given to each staff member following the initial conference. These nursing measures were adapted to each patient as individual needs were evaluated by the investigator and personnel. This outline can be found in Appendix D. The sample. The patients selected from the three hospitals were between the ages of fifty-four and sixty-five. The cerebral vascular accident of each was caused by a thrombosis, and the prognosis based on the doctor's judgement was fair to good with expected progress. Records of setivi ty were kept on both the experimental group in hospi tal X and the control group in hospitals Y and Z. Self ~ activities chart. A functional activity chart was developed and kept which indicated functions the patient was able to per­form independently, or with the help of someone, in the areas of eating and drinking, personal hygiene, dressing, and elimination. This chart may be found in Appendix A. Movement to ambulation chart. A chart was set up to record the daily ambulation of the patient. This chart may be found in Appendix B. 19 The charts on the control group were kept b,y the head nurses after careful instruction from the investigator. The charts in the experimental area were kept by the investigator in charge of the study. These records were kept for the entire span of the patient's hospital residence~ Control setting~ The control setting consisted of t~ro medical. units, one in a 382 bed private hospital and one in a 4?O bed private hospital~ The nurse conducting the study was notified when a patient was admitted with a cerebral vascular stroke to the two control units. Spe­cific information relative to the patient I s age, presence of secondary conditions, availability of hospital insurance, marital status, number of children, and occupation was obtained from each patient's chart by the investigator. The nature of this information is indicated in Appendix C. The charts for recording self care activity and movement toward ambulation ,.,ere left ",i th the head nurse. Experimentsl setting. A 23 bed medical unit in a 275 bed private hospital was selected as the experimental unit. In the experimental setting, the inVestigator instituted the in­service teaching program. The same cmrts used in the con trol setting for recording self care activity and movement toward ambulation were used. The same information was obtained from the charts. Teaching in the clinical conference was reinforced by the investigator who supervised the personnel as they incorporated these nursing measures in their daily care of the patients. Each group of nursing personnel assigned to care for the patient throughout the twenty-four hour day was similarly instructed and supervi sed. 20 The basic reason for this study was discussed with personnel be-fore teaching took place. The following pOints were brought out: 1. The purpose of the nursing personnel involvement in rehabilitation as stated in the Justification for the Problem. 2. The need for their cooperation to make the study a success. Statistical method. In using the i test for testing the signif-icance of the difference between two independent means, the following formula was used: t - D/SED D - The difference be­tween the number of dependent days of the control and the experimental group. CHAPTER IV RESULTS After each patient in the control and experimental group had been discharged from the hospital, the results were tabulated from the charts in the following way: (1) The total number of days the patient was depender,t \'trae totaled from t:r~e self care activi ty chart. This inclu.ded both the dBlfs marked N in which the patient could not help himself t and the ds.ys marked H in which the patient could perform the activit,y with help but not indepeLdently_ This was done to simplify statistical analysis. (2) The same method of tabulation was followed in totaling the number of days the patient was dependent on the ambula-tion chart. A table was made listing the total number of days each patient was dependent in self care activity in both the control and experimental group_ TABLE I NUMBER OF DEPENDENT DAYS FOR OONTROL AND nPERIMENTAt GROUPS IN SELF CARE ACTIVITY Control Group Experimental Group X X Patient I 31 Patient I 10 II lb II 11 III 24 III 7 IV 22 IV 7 V 24- V ~ 117 42 x. - Number of dependent days 22 A similar table was made listing the total number of d~s each patient was dependent in ambulation in the control and experimental setting. TABLE II NUMBER OF DEPENDENT DAYS FOR CONTBOL AND EXPERIMENTAL GROUPS IN AMJ3ULATION Control Group Exnerimental Group X X Patient I 25 Patient I 8 II 13 II b III 28 III 8 IV 22 IV b V ~ V ~ III 35 X - Number of dependent days A i test was used to determine if the mean difference in dependent days was reliably greater for the control grou.p than for the experimental group. A i of b.47 (df-g) indicated that the difference was significant at the .001 level of confidence in self care activity. A i of 7.24 (df-g) indicated a Significant difference at the .001 level of confidence in ambulation. The findings of this study led to several conol usions which have Significance for those concerned with progressive patient care. First, the data supported the hypotheSiS that a sample of patients who received nursing care intentionally directed toward rehabilitation assume self care activities more readily than a comparative control group, 23 members of which did not receive this program of nursing care stressing measures aimed at rehabilitation. There was a very significant statis­tical difference in the progress of the experimental patients a8 compared with the control patients. Secondly, there was a 8ignificant difference in the ability of the members of the experimental group to progressively ambulate more rapidly than those in the control group_ CHAPTER V DISCUSSION Ie. C OLLEC TING THE DATA Personnel in the experimental hospital were cooperative in carrying out the nursing care plan. However, a frequent complaint was that there was not enough time to give adequate care consistently to these patients. Complications arose due to the fact that staffing in this particular area was not always stable. Personnel exchanges wi th other clinical areas were common. As a result of this the teaching plan bad to be adapted frequently to bedside teaching to incorporate new personnel coming to the unit. The investigator found more interest was shown by the personnel in the individual patient when teaching was done at the bedside" The value of this bedside teaching was doubled as relatives '\4,rere often present and participated in the sessions. These informal teachi.ng sessions turned out to be an essential. part of the teaching program. For convenience the clinical conferences were held during personnel working hours. This meant in some of the initial conferences in which basic reha'bili tative nursing measures were discussed all levels of staff were represented. This included registered nurses from three year programs g nurses aides, and practical nurses. This presented problems of adapting material to the level of the learner. Again through informal teachi.ng sessions at the bedside some compensation was made by adapting more to the level of the individual. 25 The investigator was given class time for teaching involving the student nurses. The homogeneous grouping facilitated the teaching approach. The frequent conferences held to review nursing measures and evaluate the individual patient in the experimental group were very use­fulo These conferences were frequent, informal, and involved small numbers of t\ft10 and three at a time. Student nurses in the clinical area were particularly helpful. They were helpful both in their participation in instituting the nursing care plan and in eliciting the interest of nonprofessional personnel. The investigator found that close contact with the experimental area was necessary for any degree of consistency. Personnel seemed to 10le interelt without this support. This was particularly true when the individual patient would seem to ShO~1 an apathetic attitude in his care and progress. The nursing care plan ,\Tas greatly facilitated by students accompanying the individual patient to physical therapw. Information such as method of walkingD getting out of bed, and progress in range of motion was obtained and reported back to the clinical area. This consis­tency was most helpful in avoiding confusion in the patient. A real problem was finding enough patients to meet the criteria. Over a period of four months the nursing care plan was instituted on ten patients with cerebral vascular accidents. Five of these patients met the criteria of the study. 2b The investigator found frequent contact with the head nurse at the control hospitals was helpful. Contacts were made at least once a week at both control hospitals. The head nurses were most cooperative and consistent in their participation. The difficulty again was finding enough patients to meet the criteria of the study. Data at the control hospita~were collected on a more limited number of patients. Five patients were selected from a group of eight as most closely meeting the criteria for the stud¥'. II. RECOMMENDATIONS It is upon the basis of conclusions drawn from this study that the following recommendations are made: 10 Further research should be conducted using the same inservice teaching plan and hypotheses but wi th a larger sampling of patients both in the experimental and control groups. 2.. Teaching plans such as the one used for this stuc\y should be developed for other types of patients and nursing care plans instituted to determine the influence of this approach to nurSing care. 30 This study has particular implications in the clinical areas for curriculum buildir~. It is recommended that this and similar studis be reviewed in connection with efforts to improve clinical content of undergraduate and graduate nursing curricula. 40 The t~ro charts utilized for collecting data in the stud¥ could be at tached to charts of patients who have had cerebral vascular accidents and be checked by the nurses giving care to these patients. 27 This would not only provide continuity of care, but would place a greater emphasis on progressive care. 5. ThiS study could be utilized for the basis of an inservice teaching program in relation to the care of the patient who has had a cerebral vascular accident. CHAPTER VI SUMMA.BY This stu~ represents the attempt of the investigator to determine the effectiveness of a consistent rehabilitative nursing care plan applied to a selected group of patients with cerebral vascular accidents. For the experimental group a 23 bed medical unit in a 215 bed private hospital was selected for the study. An inservice teaching pro­gram of basic nursing measures directed toward rehabilitation of the patient with a cerebral vascular accident was developed by the investigator. All staff members in the experimental unit attended the inservice pro-gramo BaSic nursing measures advocated in the teaching program were adapted to individual needs of the experimental group of patients. The investigator supervised the nursing care given to the experimental groupo The experimental group consisted of five male patients between the ages of fifty-four and sixty-five& The cerebral vascular accident of each was caused by a thrombosis, and the prognosis based on the doctor's judgement was fair to good with expected progress. The stu~ in this uni t covered a period of four months. A record of the progress of this group in ambulation and self care activity was kept for the duration of the hospital st~. A medical unit in a private hospital with a 382 bed capacity and a medical unit in a private hospital ~~th a 450 bed capacity were selected as sources for the control group. The five patients with cerebral vascular accidents in the control group met the lame crt terta for selection 29 as the experimental group. The selection of patients was done in the same four month period. The control hospitals did not receive the inservice teaching program developed by the investigator or participate in the supervised program of nursing care advocated by the teaching program. A review of literature was done pointing out the need for more stress to be placed on rehabilitation in nursing practice. The institu­tion of immediate rehabilitative nursing care measures on patients with cerebral vascular accidents was emphasized. The inservice teaching plan developed for the study by the investigator is centered around four basic nursing measureSI positioning, range of motion, self care activities. and ambulation. The i test was used to test the significance of the difference between the progress of the experimental and control group in self care activity and ambulation. Findings of this stu4y were: A sample of selected patients with a cerebral vascular accident who received a consistent nurSing care plan directed toward rehabilitation assumed self care activities more readily than a comparative control group, members of which did not receive this nurSing care plan. The patients under this nursing care plan also ambulated more readily than those who were not. A significant statistical difference was shown. The investigator recommends as a result of this stu~ and a review of literature that more scientific research in the application of nursing care should be done. BIBLIOGRAPHY BIBLIOGBAPHY A. BOOKS Anthony!> John C. Textbook of Anatomy ~ Physiology. St. Louis: The C. V. Mosby Company, 1959. Best~ Charles H., and Norman Taylor. The Physiological Basis of Medical Practice. Baltimore: The Williams and Wilkins Company. 1961. Goldthwait, Joel E •• and others. Essentials of ~ Mechanics in Health and Disease. Philadelphia: J. B. Lippincott Company. 1952. Heather 0 Arthur. Manual of ~ i2£ the Disabled Patient. New York: The Macmillan Company, 19bo. Larson, Carroll. and Marjorie Gould. Calderwoodl~ Orthopedic Nursing. St. Louis: C. V. Mosby Company, 19b1. Morrissey, Alice B. Rehabi1i t~t:lQ!!. Nursing. New York: G. P. Putnam1s Sons, 1951. Peele, Talmage. The Neuroanatomic Basis for Clinical Neurology. New York: McGraw-Hill Book Company, Inc., 19b1. Busko Howard, and others. Rehabilitation Medicine. St. Louis: The C. V. Mosby Company, 1958. Winters!) Margaret. Protective ~ Mechanics in Daily Life ~ ~ Nursing. Philadelphia: W. B. Saunders Company, 1959. B. PUBLICATIONS OF THE GOVERNMENT AND O'I!HER ORGANIZATIONS American Academy of Orthopedic Surgeons. Measuring and Becording 2! Joint Motion, 19b3. Kenny Rehab!li tation Institute. Kenny Rehabilitative Nursing Techniques Selected Equipment Useful in the Hospital. Home, Q£ Nursing ~. Kenny Rehabilitation Institute. Rehabilitative Nursing Techniques Bed ~ositioning an~ !~~sf~ Pr~~~dures ~ the Hemiplegic. Public Health Service, U. S. Department of Health, Education and Welfare. Strike ~ !i Stroke, For.m EM 232 Public Heal th Service Publica,tion No. 513.. Cardiovascular Diseases. C. PERIODICALS Abdallah, Faye, and Josephine Strachan. "Progressive Patient Care," The American Journal of Nursing, 59 (May, 1959), pp. 649-6?? 32 Bruell, J. H., and J. I. Simon. "Development of Objective Predictions of Recovery in Hemiplegic Patient, II Archives Physical Medicine, 41 (December, 1960), pp. 5b4-569. Coval t, Donald. "Early Management of a Patient wi th a Stroke, II Medical Times, 56 (April, 1958), pp. 449-455. Dahlin, Bernice. "The Home Bound Adul t," Nursing Outlook, 4 (September, 1962)0 ppo 592-593. Deaver, George. "Rehabili tation, II ~ American Journal of Nursing, 59 (September, 1959), pp. 1278-1281. Drake, Mel bin. "Rehabilitation, II !h! American Journal of Nursing, 60 (August, 1960), pp. 1105-ll0b. Gilbertson, Evelyn. "The Nurse and Rehabili tation, Mental. Health Aspect, " The American Journal of Nursing, 5~ (November, 1954) pp. 1358-1359. Greer.e, Georgine, and Lavina Robins. "A Rehabilitation Nursing Record, II The American Journal of Nursing, 61 (March, 1961), 82-85. Hartigan, Helen. "Nursing Reaponsibili ties in Rehabili tation, " Nursing Outlook, 2 (December, 1954), pp. 649-651. Hurd, Georgina. "Teaching the Hemiplegic Self Care,lI The American Journal of N~rsing, b2 (September, 1962), pp. b4-b8 Jerome!) Mary. "The Bed Patient, II The .American Journal of NurSing, 59 (September, 19,9), p. 1279. Jones, Florence Terry. liThe Nurse I s Responsi bili ty in Rehabili tation, " The American Journal of NurSing, 48 (February, 1948), pp. 74-76. Johnson, Dorothy. liThe Significance of Nursing Care," The American Journal of Nursing, 61 (November, 19b1) t pp. 63-bb. Kidron, Do Po "The Hemiplegic Profile: Early Investigation and Treatment of Stroke in the Elderly," Psychiatria ~ Neurologis, 143 (April, 19b2), pp. 250-249. Knight, Geoffrey. "Ischaemic Strokes," Postgraduate Medical Journal, 58 (July, 19b2), pp. 39b-40l. 33 Knocke, Lazelle S. flBole of the Nurse in Rehabili tation, II The American Journal of Nursing, ~7 (April, 1947), pp. 238-241. Lane, Harriet, ":Rehabili tation Nurse, II Nursing Outlook, 2 (March, 1958)" pp. 157-159. Lowman, Edward, and Howard Ru.sk. itSelf Help Devices: Aphasia Therapy, Part I; Professional Evaluation, II Postgraduate Medicine, 33 (July, 1962), pp. 79-81. Madden, Barbara, and John Affeldt. uTo Prevent Helplessness and Deformities, If The American Journal of Nursing, b2 {December, 19b2) , Pp. 59-bl. Moore. Dorothy. ttThe Hemiplegia Patient as a Person," Public Heath Nursing, (October, 1948), pp. 511-517- Morrissey, Alice B. "Psychosocial and Spiri tual Factors in Behabili tat ion, " The American Journal Q! Nursing, 50 (December, 1950), pp. 763-7b4. Morrissey, Alice:B. tiThe Nurse and .Rehabilitation. 1. The Bole of the Nurse, tt The .American Journal 2i Nursing. 54 (November, 1957), pp. 1354-1355- Morrissey, Alice B. liThe Nursing Techniques in Rehabi1i tation, It The American Journal of NurSing, ~9 tSeptember, 19~9), pp. 545-?5l. Peszzynski, Mieczyslow. liThe Rehabilitation Potential of the Late Adult Hemiplegia," ~ American Journal 2i. NurSing, 63 (April. 1963), pp. lll-ll~. Reeves, Elizabeth. "The Aphasic Patient, tl Nursing Outlook, 11 tJuly, 19b3), pp. 522-52~- Rubin, David. "Geriatric Rehabili tation--The Challenge and the Goal, II California Medicine, 97 tSeptember, 1902), pp. 170-193. Rusk, Howard. "Implications for Nursing in Rehabilitation. II The American Journal of Nursing, 48 (February, 1948), pp. 7~-76. Rusk, Howard. "Rehabilitation :Belongs in the General Hospital. II The American Journal of NurSing, 62 (September, 19b2), PP.62-63. Rusk, Howard 0 "Rehabili tation of the Elderly Neurologic Patient, II ~ Neurologic and PsychiatriC Aspects of 1h! Disorders of Aging, 35 (November, 1958), pp. 425-429. Ru.sk, Howard. tfStress as a Therapeutic Friend. It The ~ Virginia Medical Journal, 54 {November, 1958), pp. ~25-~29. Smi th, Genevieve. itA Stroke is not the End of the World, It !b! American American Journal of Nursing, 57 (March, 1957), pp. 303-30,. Spencer. w. A •• and others. "Rehabilitation in Concept and in Practice," Southern Medical Journal, 55 (July, 19b2), pp. 721-728. Steinberg, Frank. "Bahabi1i tation and Restoration of the Chronically III Geriatric Patient. II Journal 2i.1h!. American Geriatric Society, 10 (July, 19b2), pp. b18-b25. Taylor, Winnifred. ItThe .Ambulatory Patient. It .!b!. American Journal 2! Nursing, 59 (September, 1959), p. 1280. Whi tehouse, Frederick. "Stroke, tI The American Journal of Nursing, b3 (October, 19b3), pp. 81-87. APPENDIX .A. Day 1 stands for a.a.V admitted EVALUATION OF SELF Q!g ACTIVITY ~ UNAFFECTED ~ DATE OF CoVoAo _______ _ DATE AJl.lITTED _______ _ EATING AND DRINKING 1 2 '3 Lt 5 b 7 8 Drink from glass or cu.p Eat solid foods wi th s"ooon Eat solid foods with fork Cut wit.h t"n.,.k Pnu.,. 1; n-u; ds PERSONAL HYGIENE Wash face &: hands Wash trunk and legs Brush teeth Comb & brush hair Shave or put on make up Use facial tissue Shower Tub bath DRESSING Put on bathrobe Remove bathrobe Remove slippers ;Put on sl ippers Button clothing ELIMINATION Ask for bedpan or urinal Use bathroom or commode with help Use bathroom or commode without help 3b I. Place I letter if able to perfonn independently. Ho Place an H letter if able to perform wi th help. N. Place an N letter if unable to perfonn. 9 10 11 12 l~ 114· 1111 APPENDIX :s Day 1 on chart stands for day ad.mi tted .. TUlmS SELF PULLS SELF UP TO SITTING POSITION SITS ON SIDE OF BED MOVES FRQ.1 BED TO WHEELCHAIR STANDS AT THE SIDE OF THE BED WITH HELP MOVES FBOM STANDING POSITION TO CHAIR PROGRESS TOWARD .AM:BULATION DATE OF C.VoAo ____ _ DATE ADMI TTED ____ _ 1 2 ~ 4- 5 6 7 8 g, 10 ~. 2 "3 4 11 b 7 g C1 10 1 2 '3 4- 5 b 7 8 9 10 1 2 3 4 '1 b 7 8 9 10 1 2 "3 4 '5 b I g 9 10 1 2 1 4 5 b 7 g 9 flO I. Place an I letter if able to perform independently. H. Place an H letter if able to perform "rl th help. No Place an N letter if unable to performo 11 12 I; 14 1~ Ib 17 11 12 1-; 14 15~ Ib 17 11 12 13 11.1- 1'5 Ib 17 11 12 13 11.1- 15 1b 17 11 12 Ij 14 1'5 Ib 17 11 12 1'3 114- 1'1 Ib 17 APPENDIX C TABLE I INFORMATION OBTAINED F.H)M CHART OF EACH PATIENT WITH A CllmIBRAL V ASOULAR ACCIDENT Oontrol Group Patient I II III IV V l.e.e bO ~8 22 b2 b2 Secondary Elevated "Cllg1t1gng No Ulcer No blood :eressure No Heal th Insurance Yes Yes Yes Yes Yes Married Yes Yes Yes Yes Yes Children 3 5 2 3 J4. Retired No No No Yes No O~cu:eation Farmer Laborer Laborer Farmer Farmer Will patient go home? Yes Yes Yes Yes Yes Physical Tl;un:a1?l: Yes Yes Yes Yes Yes 41 TA'BI&! II INFOlMATION OBTAINED FroM CRA.llT OF EACH PATIENT WITH A CEREBRAL VASCULAR ACCIDINT Experimental Group Patien~ I II III IV V ~e 24 2Z 6~ 2~ bl Secondary Elevated Elevated conditions blood :2ressure No No No blood :2ressure Health Insurance Yes Yet Yea Yea Yea Wife Married Yea Yea Yel dead Yes Children 14- 5 3 3 14- Retired Yes Yes No No Yes OccuEation Farmer Farmer Farmer Laborer Farmer Will patient go home? Yes Yes Yes Yes Yes Physical The raE!: Yes Yes Yes Yes Yes AP.PllN'DIX D 4J Foms PROVIDED FOR NURSES ON EXPERIMENT.AL UNIT PROGRAM FOR CARE OF THE PATIENT WITH A CEREBRAL VASCULAR ACClDEN'T 1. Change position at least every two hours. 2. Range of motion four times per day taking each joint through five times. Both the unaffected and affected side. 3. Encourage the patient in self care activities in all areas. 1. Drink from glass or cup. 19. Ask for bedpan or urinal. 2. Eat solid foods with spoon. 20. Use bathroom or commode 3· Eat solid foods with fork. wi th help. 4. Cut wi th fork .. 21. Use bathroom or commode 5. Pour liquids. wi thout help. b .. Wash face and hands. 7. Wash trunk: and legs. B. Brush teeth. 9. Comb and brush hair. 10. Shave or put on make up. 11.. Use facial tissue .. 12. Take shower. 13. Take tub oath. l~. Put on bathrobe. 1:>. Remove bathrobe. lb. Remove slippers .. 17. Put on slippers. 18. Button clothing .. ~. Encourage movement toward and into ambulation going through these steps. 1. Turn self. 2. Pull self up to sitting position. 3. Sit on side of bed. ~. Move from bed to wheelchair. 5. Stand at the side of the bed with help. b. Move from standing position to chair. APPENDIX I 46 TEACHING PLAN USED IN THE CLINICAL CONFEBmNCE NUBSING CARE OF TEE PATIENT WHO HAS HAD A ClmrBRAL VASCULAR ACCIDENT I. ~ Bange Goal il! Nursing ~ ill1b! Hospital There is one long range ultimate objective towards which all nursing is geared in the care of a patient who has had a cerebral vas­cular accident. This is to help this particular patient prepare as much as possible for the realistic demands of daily living which he will encounter when he leaves the hospital. Meeting this objective is the responsibility of man, people. The nurse in instituting specific nursing care measures facilitates the patient's ability to live as normal a life as possible. Everyone involved in the welfare of this patient has the same goals but separate roles in approaclb­ing them. II. Specific Measures iQt Attaining Goals 1. Maintain adequate respiration. Immediate life saving measures: ll) Keep airway open. (2) Give oxygen if necessary. (3) Maintain adequate circulation by emergency administration of drugs. 2. AlleViate pain. {l) Medications. (2) Comfort measures. 3. Promote rehabilitation. (1) Positioning. {2) Bange of motion. {3) Self care activity. t4) Progression to ambulation. The third objective, rehabilitative measures, is the focus for attention in this conference. III. Behabilitative Measures (l) POSITIONING Preparation 2i ~ In order to facilitate positioning the bed is prepared before the patient arrives. 1. Bedboard--Supports segments of the bodr and prevents sagging of the hips. 2. Backrest--Tb prevent contractures and provide rest alternate from 0 degrees to 90 degrees. 3. Footboard--Supports the foot at right angles to prevent the development of foot drop and shortening of the calf muscles and heel cord. Also it keeps the covers off the feet, thus reducing discomfort and allowing for more movement of feet. 4. Bedrail--Provides hand-hold for leverage and a feeling of security and safety. The bed-lying position of the patient who has had a cerebral vas­cular accident should counteract gravitational pull which is the underlying cause of most contractures. 48 Since the muscles are weak, the patientls affected extremities must be supported at all times. In positioning the patient the following points must be kept in mind: 1. The weakest muscles should be subjected to the least amount of tension. 2. At first the side-lying position is permitted only on the unaffected Side. For the first few days the patient is kept on his back, or turned to a thirty degree angle on the unaffected Side, and later on the affected Side. While in the back-lying position, the affected upper extremity i8 frequently repositioned. These changes both help to keep the patient comfortable and to prevent decubiti. When the p~sician approves, the patient can be placed in the prone position for thirty minutes or three times a d8¥ as tolerated. Many patients find this position very restful. The patient1s position is changed at least every two to four hours and more often if necessary or desired. When the position is changed the movement helps to put the patient 1s jOints through range of motion and assists in prevention of decubiti. Facilitates Movement 1. Pullrope--Assists the patient to sit up. 2. Trapeze--{When the patient is able to utilize it). Helps patient to move in bed and to sit up. 3. Turn sheet--Facilitates turning activity. The patient who has had a cerebral vascular accident is usually flaccid for a period of time. After the first few weeks the affected side usually becomes spastic. However, cases ~e been reported in 49 which the patient remained flaccid permanently or became spastic within the first few d~s after the cerebral vascular accident. Begardless of the course of the sequelae, nursing measures are important to prevent contractures. Upper extremi ty Common Contractures ( Demons t rat e) Internal rotation of the shoulder. Adduction of the arm at shoulder level. Flexion of the elbow. Flexion of the wrist. Flexion of the fingers. Flexion of the thumb. Lower extremity Flexion of the hip. Flexion of the knee. External rotation of the hip. Plantar flexion of the foot. Supination of the foot. Upper extremi ty Supine Position ( Demonstrate) 1. Cradle the patient's forearm on your forearm. support the elbow with the hand. If possible the patient's arm is abducted so that a 90 degree angle is formed between the chest wall and upper arm and between the upper and lower arm. A large pillow is placed under the forearm to support it, yet to allow as much external ro­tation as possible. Shoulder and elbow joints are to be kept at the same level. 2. The patient's wrist and hand are supported on a small pillow with the wri st extended. 3. A hand roll is placed diagonally across the palm of the patient l s hand. The thumb is placed around the roll in opposition to the index finger. The other fingers are then wrapped around the roll. This maintains the hand in a functional position. Sufficient external rotation 50 The affected shoulder joint is abducted to a 90 degree angle and the el bo", is flexed to 90 degrees. As the shoulder joint is externally rotated the forearm is supi­nated. This forearm is supported on a folded pillow placed above the affected shoulder. The older the indivi­ual the less likely he is to raise his arm in this wB1 and use this range of motion. Such conditions as arthritis are more likely to have occurred in a person of this age group and to limit use of the shoulder. Elbow extended Abduct the arm at 45 degrees shoulder level. Extend the elbow fully, with the forearm resting on the bed in supi­nation and the hand roll in place. The wrist is kept in extension. In order to prevent tightness alternate the flexed and extended elbow positions. This position also facilitates supination in range of motion. Lower extremity 51 1. The patient's feet are placed with the heels and toes firmly against the footboard. The top of the patient's knees and his toes should point toward the ceiling. 2. To prevent external rotation of the hip, a trochanter roll can be placed along the side of the hip. The roll is placed well under the buttock and extends from just above the hip joint to two inches above the popliteal space. Each joint of the affected arm, beginning at the shoulder, is positioned on pillows slightly higher than the preceding one. This is done to prevent edema from developing. Side-lying Positioning ~Demonstrate) Turning preparations 1. Tell the patient what you are going to do and how he can help. 2. The patient is moved to the side of the bed. 3. A turning sheet extends from the shoulders past the hips. The patient is turned on his uninvolved side. 52 4. The patient's normal foot is placed under the involved ankle. 5. The involved leg is lifted with the normal foot under the ankle. The movement is towards the involved side. b. Flex the normal knee and raise the hips. Move toward the involved side. 7. Have the patient push against the mattress or side rail with the unaffected arm. 1. The involved arm is placed across the abdomen and the normal leg under the involved leg. 2. It is important that the patient do a8 much of this movement as possible. Position of upper extremity The involved arm is brought forward. The forearm is supported on a folded large pillow placed in front of the patient. This is to prevent abduction and internal rota­tion of the shoulder. Extend the wri8t and put the hand roll in place. Position of lower extremity The normal leg is nearly straight. The involved leg is flexed at the knee and brought forward. The involved leg is supported with pillows. Face-~ Position (Demons t rate) Turning preparations 53 1. Tell the patient what is to be done and how he can help. 2. Assist the patient to move down in the bed so that the heels are in a space between the mattress and the footboard. 3. Have the patient bring the normal arm up over the head to help in turning. 1. Assist the patient to turn on the normal side as demonstrated in the side-lying position. 2. Have the patient do as much himself as possible. Positioning 1. Place a pillow under the knees. 2. Place a bathtowel lengthwise under each shoulder to prevent adduction. 3. Abduct and extend the involved arm and place it in pronation with a hand roll in place. ~. The call light is placed within reach of the uninvolved hand in case the patient becomes uncomfortable. 5. The prone position is important because it stretches the muscles in back of the legs. Also the knees can be flexed in this position to make it a rest position. (2) RANGE OF MOTION There should be from one to four range of motion exercise periods a dSfD depending on the severity of the disability~ If not specified by the doctor or physical therapist, decision as to the number of exer­cise periods is determined by the nurse. The nurse must be aware of the cause of the cerebral vascular accident. If the cause were a thrombosis with no secondary condition, rehabilitation coUld start on the second d~ by application of range of motion. If the condition were a result of hemorrhage, it ~'ould be necessary to wai t longer (usually 5-6 days). The nurse explains the procedure to the patient. Each joint is moved gently through its full range from three to five times during each exer­cise period. A joint which has reduced range is moved more often and an attempt is made to increase its range with each successive movement. Each joint is moved slowly and gently to the point of pain allowing time for relaxation between each movement. The nurse observes the patient's facial expression to determine 'AThen he is experienceing pain, or he may verbally state that he is having pain. In order to prevent loss of muscle tone on the unaffected side the joints are taken through range of motion. If the patient is able thi s sho11.1d be accomplished by active movemen t both in exercising and in his daily self care on the affected extremity. When the arm is moved through passive range of motion it is sup­ported at the elbow and wrist joint. The nurse's hands are cupped and even pressure exerted on the joints. The lower extremity is supported at the aukl e and knee joints. 55 Usually the arm is the last to regain function. The finer move­ments of the hand being most affected. In doing range of motion, diffi­culties are found particularly in the shoulder joint in carrying out outward rotation and in the forearm movements of pronation and supination. This is due to the fact these movements are learned later in the develop­mental process and require more control from the nervous system. ·i.hen doing passive range of motion the patient is in a supine position on a flat bed without pillows or support with his arms resting comfortably at his sides. Bestrictive clothing should be removed. The purpose of range of motion is to maintain the normal mobility and action of a joint, and to increase the range of motion of a joint where the mobility has been limited. Definitions of Movements 1. Flexion is a decrease in the angle between adjoining bones. 2. Extension is an increase in the angle between adjoining bones. 3. Abduction is movement of a part of the body away from the mid­line of the body. 4. Adduction is movement of a part of the body toward the mid-line of the bodf. ,. Rotation is a movement in which a bone moves around a central axis without undergoing displacement from this axis. b. The movement of the radius on the ulna during pronation and supination is a special form of rotation. 1. The sagittal plane is a plane parallel to the longitudinal axis of the body which passes through the bod¥ from front to back dividing it into a right and left partu 2. The frontal plane is a plane parallel to the longitudinal axis of the body passing through the bod¥ from side to Side dividing it into an anterior and a posterior part. 3. The transverse plane is a plane perpendicular to the longitudinal axis of the body which passes through the bod¥ at any given level and divides it into an upper and lower part. l 56 In describing range of motion the extended lIanatomioal position" of an extremity is zero degrees. The number of degrees of movement permitted by the joint is noted in brackets. 1. Shoulder movement s The shoulder is a ball and socket joint permitting six major move-ments of the arm in the shoulder jOint. a. Shoulder flexion b. Shoulder extension The arm is moved forward and upward in the sagi t tal plane of the body. (O'!.lScf) The arm is returned from the flexed position to the extended anatomical position through the sagittal plane. llSO~~) lMargaret Winters. Protective ~ Mechanics in Daily Lif~ and NursiM. tPhiladelphia and London: W.:B. Saunders Company, 19b1), p. 3. c. Shoulder abduction d. Shoulder adduction e. Shoulder internal rotation f. Shoulder external rotation 200 E1. bow movements 57 The arm is moved away from the mid-line of the body in the frontal plane. toO _ 1800 ) The arm is moved toward the mid-line of the bo~ or beyond it in the frontal plane. toO _ 75°) The arm is in the position of 90 degree abduction. The elbow i8 flexed at 90 degrees. The ante-rior forearm is moved forward toward the bed. Rotation is in th e t ransverse p1a ne. '\0 °_ 70°') The arm is in a 90 degree abduo-tion position. The elbow is flexed to 90 degrees. The dorsal forearm is moved backward toward the bed. Rotation takes place o • in the transverse plane. to - 90 ) The elbow is a hinge type of joint permitting flexion and extension. aoo Elbow flexion The elbow joint is moved through the sagittal plane until the palm of the hand nearly touches the shoulderoo (0°_ 150°) b. Elbow extension 3. Forearm movements The elbow is moved through the sagittal plane from flexed position to the extended anatomical position. (150°_ 00) The forearm is capable of rotating upon itself and the two move­ments thus produced are called pronation (palm down) and supination (palm up). The forearm is a pivotal joint. a. Pronation The elbow is flexed to a 90 degree angle. Rotate the palm downward. b. Supination 4. ~ movements This movement occurs in the trans-verse p1a ne. ',0 0_ 80") The elbow is flexed t Q a 90 degree angle. The forearm is rotated palm upward in the transverse plane.. (0· - 80") The wrist is composed of the freely movable joints called condyloid jOints. aa Wrist flexion be Wrist extension Palmer flexion or movement of the wrist forward in the sagittal plane. (Ot» _ 80°) Dorsiflexion or movement of the wrist from flexion to the extended anatomical position through the sagittal plane. (0·- 70·) 59 5. Finger movements The interphalangeal joint is a hinge joint. a. Finger nexion b. Finger extension c. Thumb opposition b. Hip movements Each finger is curled indivi-dually in the sagi ttal plane" {distal joint--(f - 90°, middle joint--OO - 100·, proximal joint-- Movement through the sagi ttal plane to extended anatomical posi tion. {l~g:_ rf) Oppose each flexed finger tip with the thumb. Movement occurs in sagittal, frontal, and t rans-verse planes. (Cannot be accu.­rately measured in degrees). The hips is a ball and socket joint permitting 8ix major movements of the leg in the hip joint. 8. Hip flexion b. Hip extension The knee is brought toward the body through the sagittal plane. {0° - 120°) The leg is brought from 8 flexed posi tion through the sagi t tal plane to the extended anatomical position. (120o_ 0°) c. Hip abduction d. Hip adduction e. ~ extlrnal rotation f. Hip internal rotation 7. ~ movements 60 The leg is moved away from the mid-line of the body in the frontal plane. (OO_ 45°) The leg is moved toward the mid­line of the body in the frontal plane. (0' - 30°) The hip and knee are flexed through the sagi ttal plane. The i:nee is rotated outward and the foot moves toward the mid-line of ~ ~le bod;y. Rotat ion occurs in the tranaveree plane. (0°_ 45~ The hip and knee are flexed.thr~gh the sagittal plane. The knee is rotated inward and the foot mov. away from the mid-line of the body. Rotation occurs in the transverse plane. (0· _ 450 ) The knee is a modified hinge jOint. a. Knee flexion The knee is brought towards the bod;y through the sagi ttaJ. plane. leI - 135°) b. ~ extension 8. Ankle movements The knee is brought to its extended anatomical position from the flexed position. l13So- 0·) The ankle is a modified hinge jOint. a. Ankle dorsiflexion The foot is pOinted upward through the sagi ttal plane. lcf- 2ft) b. Ankl e plan tar flexion The foot is pointed downward through the sagi ttal plane. lOo_ SO·) 61 c. Circumduction Botate ankle on axis in the transverse plane. lCannot be accurately measured in degrees). 9. .lQ.Qi movements The mid tarsal joints of the foot are gliding joints. a. Inversion b. Eversion The foot is plantar flexed, supinated, and adducted. lOG_ 35°) The foot is dorsiflexed, pronated and abducted. toO_ 15°) (3) SELF CA.I(E ACTIVITY Encourage the patient through the self care activi ties and in ambulation in steps indicated in Appendix A and Appendix B.