Care of patients with hemiplegia at hospital and

positioning

1. Care of patients with hemiplegia at hospital and home A case based discussion Justin Thomas

2. Case summary 65 year old gentlemen rt handed person from Kanauj k/c/o T2 DM* 27 years poorly controlled on OHAs Old h/o CAD( nstemi 10 years back on ecospirin and mononitrate ) DOA:19/12/17 presented with sudden onset of weakness of lt.side of the body since 2 days

3. HOPI Patient was apparently normal 2 days back Complaint started as sudden weakness of left side of the body at 10 am while he was standing and doing day to day activities He fell down and lost consciousness for 10 minutes Bystanders noticed facial deviation to rt.side a nd he could could not move lt.side of the body

4. Contd. 10 minutes after his consiousness improved that he opened eyes to call and moving rt.side of the body spontaneously Then he developed multiple episodes of vomiting and became drowsy again He was taken to local hospital where he was given antibiotics,iv fluids and mannitol His weakness gradually improved that he could move lt.arm and lt. foot spontaneously but not upto previous extend Dysarthria was present as facial palsy persited and he was not able to eat and drink

5. Contd. No h/o convulsion,headache or bowel/bladder incontinence No other cranial nerve involvement He was reffered to here on 3 rd day of stroke for further management He is a vegetarian and no h/o any addictions

6. On examination Hr=88/min Bp=100/70 mm hg Rr =18/min no pallor,lymphadenopathy,edema CVS:s1 s2 normal,no murmers R/s:clear,AEBE P/A:soft,no hepatosplenomegaly

7. Cns examiation He is consious oriented GCS15/15 Pupils= b/l consricted but reacting to light,no skew devaiation Lt.LMN facial palsy present No other cranioneuropaties were present

8. Motor examination Bulk was normal in all muscles There was hypertonia of lt.side Power was grade 5 in all rt.side and 4-5 in lt.side with loss of dexterity on lt.hand movements Reflexes were exagerated on lt.side except ankle reflex which was absent on both sides Plantar was flexor bilaterally

9. Contd. Sensory examination including jps was normal. No cerebellar signs were present No signs of meningeal irritation was present

10. discussion 65 year old male with sudden onset of lt.sided hemiparesis with h/o cad,DM with vomiting and maximum weakness at onset of disease with gradual improvement on history and pupillary and LMN facial involvement with grade 4-5 lt.hemiparesis implies an acute stroke most probably bleed in lt.brainstem

11. Ct brain

12. Hospital stay Since he was not able to take feedings orally he was started on ryles tube feeding and was catheterised internally with foleys.initialblood counts,LFTs,rfts was normal except for hyponatremia His vitals including 6 hrly blood sugar were closely monitored.he was on amlodipine 10mg od.insulin was given on a sliding scale and salt 10g /day was started he was advised lateral positioning and care of bowel,back and bladder.he developed fever on day 10 th of bleed and chestexamination revealed rt.sided crepitatation.cxr was sugggestive of rt.sided neumonits in apical lobe(?aspiration) and he was started on ceftriaxone and vancomycin . 2 hrly lateral positioning and 10 min chest physiotherapy was advised

13. Contd. Fever was persistent on antibiotic day 3 and counts were on increasing trend. He also developed superficial phlebitis of both upper limbs Antibotics were upgraded to cefepime and clindamycin and magso4 dressing was applied locally Fever came down on 3 rd day of antibiotic revision and edema of both hands dissappeared He was advised limb physiotherapy on 15thdayof bleed.7 day course of antibiotics were completed and counts and sodium came back to normal.blood pressure and blood sugar normalise with atenelol and metformin and glimipride alone. He could take sips of water orally and 2-3 biscuits

14. Contd. So he was discharged on day 23 rd of bleed with advise to take care of hs feeding,bowel,bladder,his movements and physiotherapy On discharge his facial palsy was still persisting,lt.side grade 5.he was able to locomate with others help only and with ryles tube and external catheter insitu

15. Management of stroke patients in hospital

16. Complications of Prolonged Bed Rest Neurological: bedsores contractures aspiration of gastric contents entrapment neuropathies Pulmonary Atelectasis Pneumonia Hypoxemia Cardiovascular Venous thromboembolism Syncope because of diminished baroreceptor Activity

17. Stationary Positions Supine Position: Ventilation and perfusion are greater in dependent areas of the lungs than in the anterior areas In healthy lungs, adequate matching of ventilation and perfusion (V/Q match) can be achieved in the supine position In diseased lungs , prolonged placement in the supine position can alter the V/Q match Fluid associated with pulmonary edema accumulates in the dependent areas of the lungs Perfusion , however remains constant in the dependent areas resulting in V/Q mismatch

18. Semi-recumbent Position With Head of Bed Elevation Head of bed (HOB) elevation- important component of the semi-recumbent position, must be considered for patients who are receiving RT feeding to prevent aspiration of gastric contents and VAP Drakulovic and colleagues- found a significantly greater incidence of VAP in patients who did not have HOB elevation. Grap and colleagues -VAP was more likely to occur in patients who spent more initial mechanical ventilation time with HOB elevation of less than 30 HOB elevation >30 may increase the risk of pressure ulcer formation

19. Contraindications to HOB Elevation in Critically Ill Patients Cardiovascular Low cardiac index Hypotension Neurological Stroke Processes of care Procedure in progress in which HOB elevation is inappropriate Prone position

20. Lateral positioning Based on relevant lung pathology and hemodynamic stability Placement of the diseased lung(PNEUMONIA/ATELECTASIS) in the dependent lateral position results in greater perfusion to a diseased poorly ventilated lung and impairs gas exchange P atients with unilateral lung pathology should be placed in a lateral position with the “good” lung down In pulmonary abscesses/pulmonary hemorrhage, it is important to keep the affected lung in the dependent position

21. Prone Position P rone positioning in critically ill patients with acute lung injury and/or ARDS improves pulmonary gas exchange and reduces the rate of VAP Possible mechanisms- better drainage of pulmonary secretions, reopening of atelectactic units in the dorsal regions of the lungs and minimizing ventilator-induced lung injury The optimal response may occur during the early edematous phase of ARDS when atelectasis and lung edema predominate

22. Manual repositioning Patient is placed in a side-lying position with the pelvis rotated approximately 30 deg from the supine position The current standard of care is to reposition patients every 2 hours

23. Positioning of unconscious patient Neutral or side-lying position should be adopted Pillow in between the legs to prevent internal rotation, adduction, and inversion of upper leg

24. Positioning of unconscious patient

25. Positioning of unconscious patient Trochanter roll- refers to cylindrical prop such as a rolled up towel/blanket/linen , positioned around the lateral hip/thigh area of an individual to provide added support to the hip/leg regions and prevent the legs from rolling outwards The purpose is to keep a patients hips/legs properly aligned when the body is unable to support itself to avoid contractures, physical discomfort, tendon damage and other ailments

26. Flaccid quadriplegia patient posturing Patients with flaccid quadriplegia should be positioned in frog like posture Shoulder supported with pillows in axilla and under knee and the hips are slightly abducted Splinting of hands and use of footboards -preventing contructures

27. Positioning of quadriplegic patient

28. Positioning of the hemiplegic hand

29. Positioning of flaccid hand Avoid permitting the hand and the arm to hang or remain at the patient's side for extended periods. Avoid permitting the hand to rest in a position of wrist drop Avoid leaving splints on for long periods of time. Check frequently for pressure areas (reddened areas) and edema. Do range of motion exercises daily to prevent contractures Avoid rough or excessive range of motion exercises

30. Positioning of flaccid hand

31. Positioning of flaccid hand The hands may be clasped together. Splints may be indicated. The type of splint should be determined by the needs of the individual patient. Note: Check the skin for pressure areas each time the splints are removed. Gentle range of motion exercises should be done daily.

32. Positioning the spastic hand In order to inhibit flexor spasticity, the use of a hard cone rather than a soft roll is preferred The fingers are positioned around a hard cone with the thumb at the narrow end. loose non-elastic strap may be used to keep the cone in place. The forearm may be turned to any position. Changes in forearm rotation are beneficial.

33. Varied hand positions The wrist should not be bent. It should be in neutral position (straight) or slightly extended. The fingers may be extended with the palm down. The fingers may be left in a relaxed position, with the palm up.

34. Positioning of Hemiplegic patient Hemiplegic arm forward at the shoulder; elbow extended and hand supported with the palm up Unaffected arm supported forward on the pillow Pillow behind back Both legs bent at the hips and knees; pillow in between

35. Hemiplegic patient lying on unaffected side Hemiplegic arm supported forward on two pillows Pillow behind back Both legs bent at the hips and knees, a pillow in between

36. LYING ON BACK 3 pillows supporting both shoulders and head Affected arm on pillow Optimal pillow beneath affected hip Feet in neutral positon

37. LYING ON BACK

38. Left hemiplegic patient sitting on bed Hemiplegic arm supported on two pillows Trunk in midline Pillows under unaffected arm as required

39. Left hemiplegic patient sitting on wheel chair Lap tray on wheelchair Pillow under hemiplegic arm with shoulder abducted, forearm pointing forward and hand supported

40. Single person transfer of left hemiplegic patient

41. Two person transfer of left hemiplegic patient

42. Two person transfer of left hemiplegic patient

43. Wrong way of transfer of left hemiplegic patient

44. Turning patient on bed

45. Home based care of Stroke Survivors

46. Introduction… When a stroke patient returns home, the home environment can impact a person’s recovery. The home includes the social and cultural environment such as the people who live there, as well as the physical aspects of the home such as steps and layout. It is important that the home environment be one that supports continuing recovery and safety for the patient.

47. Physical Aspects of home It is a good idea for the patient to have a trial visit at home before they are discharged from the hospital so that changes and corrections can be made before returning home. Some disabilities may not be noticed until the stroke survivor returns to daily tasks Since each person is unique, changes to the home are most effective when they meet one’s specific needs.

48. Whom to involve… P rofessional occupational therapist can help to determine the best home modifications to suit your individual situation. O rganized by rooms in the home. S uggestions seem simple, the effects of such alterations have the potential to greatly increase the safety, independence, and general comfort level of the stroke patient.

49. Problems…. addressed.. Bathing Communicating Dressing Eating Toileting Walking, getting around Writing

50. Before modifications.. Assess the functional ability & disability Pre stroke routine of the patient Habits and Hobbies of patient Other family members concern & interest Council all family members and involve them in integrated time wise care. Care must be individualised according to patient disabilities and needs.

51. Modifications Bathroom modifications Bed room modifications Kitchen modifications Over all purposes is to prevent trauma and injuries, enhance independence and minimal disturbance with family’s routine life.

52. Bathroom modifications… The bathroom is the most dangerous part of the house for anyone with physical disabilities. It is difficult to move about on small, slippery surfaces, and falls onto hard tile can cause significant injury.

53. Contd. Many simple items, such as non-slip flooring and scrub brushes, are easy to purchase and install. Important safety devices like tub benches and toilet chairs. Professional installation will be required for major bathroom modifications, such as sturdy handrails and replacement fixtures

54. Modifications… Bathroom should be @ minimum possible distance from living room of patient. If possible within the same room. Install grab bars at exist of living room at reachable height than near by wall connecting both places and than at entrance of bath room.

55. Contd … A bathmat or non-skid bath decals on the floor of a shower or tub can help a person feel more stable while getting into and out of wet and often slick area. Flooring outside the bathtub or shower should be a non-buckling and non-slick surface, which can be obtained by the use of rugs with non-slip backing.

56. Bedroom Of all the rooms in the house, it seems most important that your bedroom be a place where you can feel comfortable and safe. Because this is a private area of the home for you, it should be tailored to meet your needs. To increase your independence in your bedroom, you may need to reorganize your clothing and personal items so that they are accessible by you, the stroke survivor. To increase your safety, you need to be sure that help is within reach if needed.

57. Contd. It is also important to consider the room from a night time perspective: adequate lighting, clear pathways, and access to a toilet are essential in order to avoid accidents in the dark. Storing and Accessing Clothes Dressing Sleeping

58. Contd. When a stroke survivor returns home, he may find himself unable to access his clothes due to where or how they are stored. By changing the type of handle from one that requires fine finger movements to open the door or drawer to one such as a cabinet handle or d-loop, which can be opened with a fist, the person may again be able to access his clothing with little or no assistance.

59. Contd. The height of clothes in a closet or drawers in a dresser may also be a problem for stroke survivors. This problem can often be solved or lessened by lowering the closet bar or organizing the dresser so that frequently used clothes are in the most easily accessible drawers.

60. Dressing To eliminate difficulties in getting dressed, stroke survivors can avoid clothing that may be difficult to put on. The National Stroke Association suggests to “avoid tight-fitting sleeves, armholes, pant legs and waistlines, as well as clothes which must be put on over the head.” Clothes should fasten in the front. Velcro fasteners or elastic in place of buttons, zippers and shoelaces can make fastening clothes easier.

61. Contd. A reacher , button hook, dressing stick (for putting on clothing and socks and reaching items from a closet). M irror that hangs around the neck, sock aid (which is used to put on socks when someone has difficulty reaching his feet), long handled shoe horn, and elastic shoe strings can all be used in this process.

62. Contd. To avoid accidents in the night due to being unable to get to the bathroom soon enough, a stroke survivor may want to keep a commode chair near the bed. A three-in-one commode chair has three features: a raised seat, grab bars on both sides of the chair, and a removable bucket. During the day or when it is not needed, the commode chair can be kept in a nearby closet.

63. Contd … Stroke survivors must understand that accidents are sometimes unavoidable. To deal with them, blue pads can be placed underneath sheets on the bed. Blue pads are pads, often washable and reusable, with a cloth and waterproof side to prevent staining on furniture. Keep bedspread clear of walking paths. Keep a telephone and light switch or lamp within easy reach of the bed.

64. Other things to be taken care of Reduce clutter Remove free-standing floor and table fans Remove hazardous furniture (e.g., high-back chairs, pedestal tables, easily moved furniture) Remove mirrors if they cause delusions or hallucinations Remove or lock up sharp or breakable objects Remove or reverse inner door locks or keep keys accessible Remove small rugs without nonskid backing

65. Advice Tab.Atenalol 25 mg od Tab.Ecospirin /Av 75/10 mg OD Tab.nononitrate 20mgod Tab.metformin 500mg tds Tab.glimipride 1mg od Continue range of motion movements,proper positioning and homciliary stroke care as advised r/a 2 months in Tue/Thursday NEM-1 OPD