S t ro k e R e h a b i l i t a t i o n

Maureen Le Danseur, MSN, CNS, ACNS-BC, CRRN, CCM

KEYWORDS
 Stroke rehabilitation  Rehabilitation nursing  Functional abilities

KEY POINTS
 To outline the admission criteria for acute inpatient rehabilitation.
 To expand understanding of the rehabilitation nurses role in stroke recovery.
 To highlight the importance of the interdisciplinary team approach.
 Discuss the psychosocial aspects of post-stroke care.

INTRODUCTION

Approximately 795,000 people experience a stroke annually, and 60%, or approxi-

mately 465,000 of those require some type of rehabilitation.1 Not all strokes are
created equal, they are as unique as the patients who experience them. During the
acute hospitalization, families are searching for predictive signs of recovery, and as
nurses we want to provide them that support. Unfortunately, it is not often plausible
to predict the recovery trajectory that any stroke patient will take. What we do know
is that, with timely interventions, we are seeing improved outcomes,2 although com-
plete recovery may not be possible. The rehabilitation goal is to improve quality of
life, attaining independence, along with facilitating and encouraging family and com-
munity participation.

REHABILITATION ADMISSION CRITERIA

The Centers for Medicare and Medicaid Services criteria for admission to an inpatient
rehabilitation facility (IRF)3 include the following:
 The patient must require active and ongoing therapeutic intervention from multi-
ple disciplines, which can include physical therapy (PT), occupational therapy
(OT), speech language pathology (SLP), and orthotics/prosthetics. One of these
disciplines must be PT or OT.
 Patients must require and be able to participate in an intense rehabilitation pro-
gram. This includes 3 hours of therapy per day for at least 5 days per week, start-
ing on the day of admission.

Sharp Memorial Rehabilitation Center, 2999 Health Center Drive, San Diego, CA 92123, USA
E-mail address: [email protected]

Crit Care Nurs Clin N Am - (2019) -–-

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2 Le Danseur

 There must be a reasonable expectation that they will make measurable im-
provements due to the program. For this to occur, the patient must be medically
stable.
 They require physician oversight from a rehabilitation physician to assess their
physical and rehabilitation needs.
 They require a coordinated interdisciplinary approach to rehabilitation.
Inpatient rehabilitation criteria is strict and often the reason patients are not
accepted. Though after a stay at a skilled nursing facility (SNF) or a long-term acute
care facility (LTAC), with improvement in their clinical status they may be escalated
to an IRF when appropriate.

THE DIAGNOSIS

Your stroke patient is now ready for transfer to an IFR and you are calling to give
report. Never underestimate the value of a detailed diagnosis during both the acute
and rehabilitation phase. Knowing whether the patient had a right versus left hemi-
spheric stroke and a detailed description of their deficits can prove very valuable, giv-
ing the rehabilitation nurse a snapshot of what to expect (Table 1).
The rehabilitation nurse will have experience correlating the brain injury as a result of
a stroke and associated deficits along with what to expect with regards to function and
behavior. The cerebral vessel(s) occluded and subsequent area of infarct will give a
more complete understanding of the clinical symptom manifestations the nurse would
expect to see.4
Behaviorally, a patient with a left-sided stroke demonstrates an awareness of their
deficits, tends to be slow or cautious with tasks, and can be easily frustrated. Patients
with a right-sided stroke demonstrate distracted and impulsive behavior, poor mem-
ory, and diminished concentration.

SCENARIO
 59 M transferred to a rehabilitation unit after a (right middle cerebral artery stroke)
stroke. He was noted lethargic (sleepy), requiring the team to wake him to eat,
turn, and participate in therapies.
 He was dysphasic (difficulty swallowing), and had difficulty maintaining his oral
secretions. A modified barium swallow revealed a moderate risk for aspiration.

Table 1
Left versus right hemispheric strokes

Left Hemispheric Strokes Right Hemispheric Strokes

Language deficits—expressive or receptive Visual and spatial deficits
Right hemiplegia or hemiparesis Left hemiplegia or hemiparesis
Confuses L and R Gets lost, misjudges distance
Difficulty reading or writing Distorted body image
Aware of deficits, easily frustrated Poor judgment, unrealistic thoughts
Tends to be slow and cautious Poor memory and concentration
Right homonymous hemianopia Left homonymous hemianopia
(see glossary of terms) (see glossary of terms)
Quick and impulsive (needs supervision)
Distractible

Data from Lehman C, Association of Rehabilitation Nurses. The specialty practice of rehabilitation
nursing: a core curriculum. Association of Rehabilitation Nurses, 2015, pp 471-510.
 Stroke Rehabilitation 3

He was placed on a pureed diet with moderately thickened liquids, and required
supervision at meal time. A nursing assistant, nurse, or speech therapist can pro-
vide this supervision.
 He was demonstrating dysarthria (slurred speech), compromising his ability to
communicate. A language board was implemented to assist with communicating
his basic needs. There were pictures of a plate, drinking glass, toilet, bed with
side rails, nurse, wheelchair, toothbrush, eyeglasses, stop sign, and the words
yes and no. This allowed him to point to the item that best communicated his
need or response. He was able to answer yes and no questions with 90% accu-
racy, which was another tool used to improve communication.
 Signs of a left-sided visual field deficit were evident. When he received his meal,
he only ate items on the right side of the tray. This prompted the team to guide
him to turn his head, and to scan his environment while eating and ambulating.
This measure significantly improved his safety and awareness. A move to a
different room where the layout had his family sitting on his left side during their
visits increased his need to continue scanning to the left.
 He was also experiencing bladder incontinence, this was not a problem before
his stroke. A timed voiding program was initiated. Patients are toileted every
2 hours during the day and every 4 hours at night. This continuity helps to retrain
the brain to respond to bladder fullness by going to the restroom.5
As he improved and became more alert, he began to exhibit impulsive behavior.
This behavior included getting out of bed without calling for assistance, setting off
his bed alarm, and attempting to remove his wheelchair seat belt, all actions making
him at higher risk for falls. The nursing plan of care included problems addressing
swallow, communication, fall risk, and bladder incontinence.

REHABILITATION NURSING

Rehabilitation is “the process of helping a person who has suffered an illness or injury
restore lost skills and regain maximum self-sufficiency.”6 The rehabilitation nurse is a
necessary part of the coordinated interdisciplinary team, assisting patients and fam-
ilies to develop an altered lifestyle within a safe environment. The rehabilitation nursing
specialty requires a focus on goals, outcomes, the attainment or maintenance of func-
tional capacity, the ability to understand long-range patient needs, and a focus on
wellness.
“A person with a disability has intrinsic values that transcend the disability; each
person is a unique holistic being who has the right and responsibility to make informed
personal choices regarding health and lifestyle.”7 The Self-Care Deficit Theory by
Dorothy Orem is based on the premise that it is the responsibility of the rehabilitation
nurse to assist patients in compensating for and overcoming their deficits. Functioning
independently helps us to preserve and foster self-esteem. This theory is part of the
foundation of rehabilitation nursing.8
Sam experienced a left hemispheric stroke, leaving him with a right hemiplegia and
aphasia. One morning, Sam was talking on the phone with his family. The occupational
therapist had placed a strap over the receiver of his landline phone to assist him with
picking up, holding, and hanging up the phone. As the rehabilitation nurse appeared,
Sam decided to terminate the call. After doing so, he attempted to hang up the phone
but missed the phone base. He tried again but was unsuccessful. At this point, he
looked at the rehabilitation nurse and said, “Aren’t you going to help me?” To which
she replied, “I know you would like me to help you with this, but you are here to relearn
how to do these types of tasks. Will you try it again?” He did. As the receiver dropped
4 Le Danseur

into the cradle, his whole face lit up. He was so proud of his accomplishment. It was
another step toward self-care independence. As the rehabilitation nurse, it would have
been easy to replace the receiver for him, but that would have denied him this victory.
This is rehabilitation nursing.

GOAL SETTING

Upon admission, with the help of physical medicine and rehabilitation (PM&R) physi-
cian, in collaboration with PT, OT, SLP, neuropsychology, and the rehabilitation nurse,
a comprehensive assessment of the patient’s deficits and subsequent challenges is
documented. The next step is to create a person-centered plan of care, so that pa-
tients, families, and staff agree on the same goals of care. This measure facilitates a
mutual understanding of the plan and an increased willingness on the part of the pa-
tient to participate.

REHABILITATION NURSING FOCUS

Skin Assessment
Implementing strategies to keep skin intact, heal any current wounds, and alleviate
pressure areas is a priority. Educational opportunities involving patients and families
while turning the patient in bed, transitioning in and out of a wheelchair, and how to
perform a skin assessment at home are used.
Goal
To prevent pressure ulcer formation during their hospital stay and provide education to
the patient and family to encourage habitual position changes for skin protection at
home.5
Bladder Incontinence
Post-stroke patients will fall into 1 of the following 3 categories. Some will never expe-
rience incontinence, some will experience incontinence and will not be able to regain
continence, and the majority are incontinent at first, but with retraining are able to
become continent again. Timed voiding is used to retrain their brain to recognize
the sensation to void and the appropriate response of going to the restroom.5 Per-
forming a urinary history will assist you in determining if complete continence is
feasible. If a 70-year-old woman has a history of urinary urge and stress incontinence
for 15 years, the goal should be to return her to her prestroke continence level. Diapers
or adult briefs are used for patients experiencing incontinence.
Goal
Help return the patient to bladder continence or teach the family how to manage in-
continence at home.
Bowel
Post-stroke patients will fall into categories similar to bladder. The majority of stroke
patients will regain continence with retraining; however, for some bowel continence
may not be possible. Retraining involves timed toileting using their prestroke bowel
patterns. Often time’s patients present to rehabilitation who have not had a bowel
movement in several days. The initial challenge is to get their bowels moving again.
As the intensive or acute care nurse, you can help by letting the provider know each
day that the patient has or has not had a bowel movement. Providers tend to have their
own preferred medications for constipation. Use of standing and as-needed laxatives
and stool softeners should be incorporated into the daily bowel regimen if indicated.
 Stroke Rehabilitation 5

Goal
To facilitate the return of continence, retrain patients in bowel control, and limit incon-
tinent episodes.

Pain
Pain assessment will help to drive a successful plan of care. There are patients who do
not have complaints of pain after stroke. Others may find the rehabilitation process
causes discomfort owing to increased activity, overuse of the intact side of their
body, and muscle spasms. Pain caused by preexisting comorbidities such, as arthritis,
gout, or chronic back pain, may also be an issue.5
After a stroke, shoulder subluxation can occur. This is a partial dislocation of the
shoulder joint caused by the weakened supraspinatus and deltoid muscles. This con-
dition in and of itself is not usually painful, but our manipulation and improper posi-
tioning of the joint can cause pain. The primary intervention used to alleviate this
pain should be supporting the shoulder, proper positioning, using a lapboard when
sitting in a wheelchair, and range of motion exercises.5,9
Two years ago, all of our patients were using some type of opioid for pain relief.
Today, the majority of our stroke patients are finding that acetaminophen is adequate,
especially if they use it in conjunction with some nonpharmacologic modalities.
Nonpharmacologic pain modalities for the stroke population might include:
 Positioning—decrease muscle spasms and relieve pressure
 Meditation—engaging in reflection and controlled breathing with a focus on
relaxation of mind and body
 Music therapy—used to decrease stress and anxiety10
 Reiki—a gentle hands-on technique that harmonizes a person’s life force11
 Hand massage—to stimulate nerves, increase blood flow, and decrease stress
 Aromatherapy—using essential oils or scents to increase relaxation can be bene-
ficial (use caution because people with fragrance sensitivities may have a reac-
tion if they are in the immediate vicinity)
 Pet therapy—a pet visit by a certified therapy pet is used to reduce stress12 (fam-
ily pets may visit, but need to remain outside unless they are an Emotional Sup-
port Animal)

Goal
Control pain to enhance participation in rehabilitation therapies and if possible avoid or
limit narcotic use.

Hydration, Nutrition, and Swallowing

Nutrition and hydration are the foundation building blocks for post-stroke recovery.
There is a risk for malnutrition, dehydration and weight loss due to dysphagia, depres-
sion and perceptual deficits. There is a risk for malnutrition, dehydration and weight
loss. This affects 35% to 50% of post-stroke patients and is an indicator of poor
outcome.5 After a modified barium swallow, modified texture meals may be required
and swallow strategies implemented. This may include 100% supervision during a
meal by nursing, turning head toward the weaker side before swallowing in an attempt
to decrease aspiration risk, chin tuck, small bites, small sips, and/or no straws. Based
on their assessment, the SLP will determine the need for precautions and communi-
cate recommendations with the nursing team.
If mildly or moderately thickened liquids are ordered, consider using a gum-
containing thickener over a starch-based thickener. The reason for this is, that over
6 Le Danseur

time, the starch-based products become significantly thinner (increasing aspiration

risk) compared with the gum-based drink.13 Many patients find it difficult to drink
something with a thickened consistency, and therefore limits their fluid intake. This
is where working with the rehabilitation team, including the family, to encourage intake
becomes important.

Goal
Prevent aspiration and provide adequate nutrition measured by percentage eaten or
calorie count and hydration demonstrated by adequate fluid intake.

Communication
With certain types of stroke, communication deficits can be very challenging. SLP will
identify barriers and potential solutions to opening lines of communication between
the rehabilitation team and patient. Tools often used are:
 An interpreter if there is a language barrier
 Ensure the patient has eyeglasses and hearing aids used before the stroke
 Communication boards allow the patient to point to a picture to communicate
their needs
 Some patients can speak but they need time to form and articulate words, it is
prudent to give them time to comprehend and respond
 Minimize background noise, get patient’s attention, and use simple statements
to communicate when receptive (understanding) aphasia is present
 Educating the family to use these interventions will improve patient and family
satisfaction

Goals
Assist the patient in improving their communication abilities. Minimize patient frustra-
tion related to their inability to communicate clearly. Arrange outpatient or home health
SLP as needed at discharge.

Table 2
Glossary of terms

Terms Meaning Treatment/Team Members

Acalculia Inability to perform basic Speech therapy
math skills following a
stroke
Apraxia Problem finding words or Speech therapy or OT
inability to remember the
steps in a task such as
brushing hair
Ataxia Lack of coordination of Any or all of the therapists
voluntary movement depending on affected
area
Broca’s aphasia Partial loss of ability to Speech therapy
(expressive aphasia) produce language but May need communication
understanding language is board to express basic
intact needs

(continued on next page)

 Stroke Rehabilitation 7

Table 2
(continued )
Terms Meaning Treatment/Team Members
Dysarthria Trouble forming words, Speech therapy
slurred or slow speech
Dysgraphia Trouble writing Speech therapy
Dyslexia Trouble reading Speech therapy
Dysphagia Inability to swallow safely; Swallow study, modified
aspiration risk barium swallow, speech
therapy
Hemiplegia Muscle weakness on one side, Physical therapy or OT,
may include numbness proper positioning
Homonymous Visual field loss in the same Usually resolves on its own or
hemianopsia side of both eyes may need neuro-
ophthalmology
Use scanning technique to
help patient see the whole
picture

Jargon Speech incomprehensible Speech therapy

but seems to make sense to
patient
Labile emotions Exaggerated changes in Distraction can be helpful,
mood that can even be introduce an activity
inappropriate Awareness of what is
happening
Memory changes Affects short-term memory Speech therapy, use of
more than long term memory books, timers on a
phone or watch can be
helpful
Neglect To totally ignore 1 side of Speech will teach patient to
their body, the room, a scan to the neglected side
page, or their meal tray Nursing will provide
reminders
Perseveration Keeps repeating the same The team uses distraction by
phrase or word starting a new
conversation
Educate family
Uninhibited bladder A disconnect between the Nursing will use timed
sense to void and knowing voiding will help to
when and how to use the reestablish this connection
restroom and usually correct the
incontinence
Uninhibited bowel A disconnect between the Nursing will use timed
sense to empty bowel and voiding will help to
knowing when and how to reestablish this connection
use the restroom and usually correct the
incontinence
Wernicke’s aphasia Will have trouble Speech therapy
(receptive aphasia) understanding what is
being said or written
8 Le Danseur

Fall Risk
The fall rate for stroke patients during the rehabilitative phase of care can be as low as
10% or as high as 47%.14 Falls can occur with nursing or with the therapist during a
therapy session. Some common causes are knee buckling during ambulation, forget-
ting to call for help owing to poor memory, they had a good therapy session and are
sure they can go to the bathroom independently, impulsivity, or medication side ef-
fects. Fall prevention strategies used include, bed and wheelchair alarms, pelvic re-
straints, bed enclosures, and a sitter as needed. High-risk patients are placed close
to the nurse’s station, rooms are kept clutter free, and family members may spend
the night. Staying with the patient during toileting is recommended owing to the
high risk for falls. Attempts are made to turn away to provide privacy while toileting,
although one hand must be on the patient’s shoulder for safety.5

Goals
Fall and injury prevention. Educating patients and families on fall prevention strategies
that can be used during the IRF stay and at home.

AN INTERPROFESSIONAL APPROACH: “IT TAKES A VILLAGE”

An interdisciplinary team dynamic is essential to the successful rehabilitation patient

experience. Each member of the team brings his or her own expertise and is aware
that success necessitates working together toward common goal completion. The
rehabilitation interdisciplinary team is required to meet weekly to discuss each pa-
tient’s plan of care. The Commission on Accreditation of Rehabilitation Facilities
(CARF) recommends that patients and families participate in this process. These
meetings facilitate the dissemination of current information; helps remove barriers,
celebrates progress, and facilitates discharge planning.
Rehabilitation centers use the Functional Independence Measures (FIM)15,16 to
quantify patient’s progress and outcomes. The following 18 items—eating, grooming,
bathing, upper body dressing, lower body dressing, toileting, bladder management,
bowel management, bed to chair transfer, toilet transfer, shower transfer, locomotion,
stairs, cognitive comprehension, expression, social interaction, problem solving, and
memory—are scored from 1 to 7 to indicate the patient’s level of assistance needed.
 1 5 total assistance (staff assist 100%)
 2 5 Maximum assistance (patient does 25% and staff assist with 75%)
 3 5 Moderate assistance (patient does 50% and staff assist with 50%)
 4 5 Minimal assistance (patient does 75% and staff assist with 25%)
 5 5 Set up with no physical contact (staff gathers equipment or opens
containers)
 6 5 Modified independence (patient independent but uses equipment)
 7 5 Independent
Uniform Data System (UDS) collect this data from rehabilitation facilities around the
country. This enables rehabilitation facilities to benchmark and compare gains with
other similar rehabilitation centers. Beginning October 1, 2019, FIM scoring will no
longer be used to determine the Case Mix Grouping, which is similar to a diagnosis-
related group (DRG) used in the acute care setting and determines the patient’s
approved length of stay. CMS is transitioning Rehabilitation Facilities to the Standard-
ized Patient Assessment Data Elements (SPADE) tool. SPADE will be completed by
rehabilitation centers, skilled nursing facilities, long-term acute care centers, and
home health agencies to facilitate standardization of information being reported to
 Stroke Rehabilitation 9

CMS. SPADE will classify level of assistance, but the definitions will be different and
the items covered expanded.

REHABILITATION 5 RELEARNING

On admission, the rehabilitation team completes an assessment of patient and fam-

ilies readiness to learn. Nationally, the average length of stay in an IRF for stroke pa-
tients is 15 days. Relearning will include activities of daily living; bed, wheelchair, and
car transfers; walking alone or with a device; communicating; swallowing; problem
solving; bladder and bowel control; pressure reliefs; blood pressure control; stroke
prevention; medication administration; and fall prevention, just to name a few. Almost
every nursing and therapy contact should include education.

NEUROPSYCHOLOGY

A specialist used primarily in the rehabilitation setting is the neuropsychologist. Neu-

ropsychologists study the relationship between behavior, emotions, cognition, and
brain function. They individualize stroke education, helping the patient and family to
understand what their challenges might be, taking into account their stroke type
and location. They also perform testing for various purposes, including the ability to
return to work. They work with staff on behavior management plans and provide
emotional support for patients and staff throughout the rehabilitation process.

EMOTIONAL SUPPORT

Once patients are medically stable and recognize life will be different, their coping
skills are tested. There are many unknowns. Will I be able to go back to work? Will I
be able to communicate? Will I be able to climb the stairs to get into my house?
How will my friends and family see me now? How do I adjust to my new self-image?
Listening to the patient’s story and allowing them to grieve is important, helping
them to work through how different their life is now, hoping for the best but dealing
with the present. The team works to decrease stress by allowing the patient and family
to have control over their care choices. The nurse, neuropsychologist, social worker,
and chaplain all play an important role in this process.5,17

FAMILY AND CAREGIVERS

The rehabilitation goal is to enable patients to return home upon discharge. This
will involve family and/or caregiver support. Strokes have the most impact on the
patient, but also have significant life-altering effects on the family. The family mem-
ber is now transitioning into the role of caregiver and may need to learn other roles
as well. For this reason, all rehabilitation patients and their families interact with a
social worker.
The social worker is available for providing community resources, support groups,
help caregivers to tap into unrecognized resources such as friends, neighbors, church
groups, and family for help and respite. The social worker is an integral part of the
discharge process, working with case management to set a plan in motion as early
as possible during the IRF stay. The social worker will assess for available community
resources, educate caregivers in the importance of self-care, arrange for department
of motor vehicles (DMV) handicap parking, disability paperwork completion, and
assist with identifying other medical insurance resources that might be available.
Engaging family members or caregivers early in the rehabilitation process is vital.
The team can assist with teaching the patient and caregivers coping skills. Helping
10 Le Danseur

them to learn from both positive and negative experiences associated with care-
giving. Due to the high risk of post-stroke depression, supporting the patient and
family’s ability to problem solve will potentially translate into an improved quality of
life.18,19

SEXUAL FUNCTIONING AFTER A STROKE

Recent research shows that couples want information about their future sexual rela-
tionships.5,20 Occasionally, patients are curious and may ask questions about sex
early in their rehabilitation stay, whereas others want to know but are too embarrassed
to ask. We have integrated this education into our process for all patient who are open
to receive it.
There are multiple factors that will affect their sexual abilities moving forward.
Sensation will affect their erogenous zones. Mobility will affect their ability to sustain
certain positions during sex. The ability to communicate can interfere with picking
up your partners subtle cues that they are interested in engaging in sex. Initially, fa-
tigue can become a large barrier. Medications for blood pressure, depression, and sei-
zures can cause erectile dysfunction. What should they do if this occurs? When is it
safe to start having sex again? Will having sex cause another stroke? If you had a
stroke, would you like to have the answers to these questions?

COMMUNITY REENTRY

A part of any rehabilitation program should include working with a recreational thera-
pists, who engages with patients and encourages them to return to their previous
hobbies or activities.. By incorporating their previous recreational activities into their
rehab program, creates an opportunity for them to practice their therapy in a fun
and enjoyable way. A recent study evaluated 24 participants in an art-based creative
engagement experience. The findings showed that the patients fell into 1 of 4 cate-
gories: they had an appreciation of the opportunity, an appreciation of self, an appre-
ciation of others, or a renewed appreciation of life, all of which were beneficial.21
Available activities can include card games, art class, music, knitting, crocheting,
yoga classes, gardening, golf, and interactions with pets. Opportunities to take
each patient on an outing prior to discharge, such as to a restaurant, shopping excur-
sion, movie or fishing can be beneficial. This allows them to adjust to being in public
and helps them start to adjust to different responses to their new body, changes to
their mobility, or communication abilities.

DRIVING

“In approximately 30% of stroke survivors, it is clear from the onset that driving will no
longer be possible. Approximately 33% of survivors will be able to return to driving
with little or no retraining, and 35% will require driving-related rehabilitation before
they can resume safe driving again.”22 At the time of discharge, patients are usually
instructed not to drive initially. The topic is then discussed between patient and physi-
cian in the outpatient setting. Some rehabilitation centers have driving simulation pro-
grams that address motor, visual, cognitive and perceptive skills. Once cleared by OT
they would be able to retest at the DMV if required by their state.

SUMMARY

Your patients have survived thanks to you, but they still have a challenging journey
ahead. Ultimately, all short-term goals will lead to successful long-term goal
 Stroke Rehabilitation 11

achievements and a safe transition home. Upon discharge, referrals are made to either
outpatient or home health services, to continue the rehabilitation process. Rehabilita-
tion should begin the moment health care is initiated, to incorporate wellness and self-
reliance into their care. “A major goal in educating all health care providers is to pre-
pare them to ‘think rehab’ from the moment of initial contact with the stroke patient.”7
We are all part of the rehabilitation process, a link in the chain toward improved quality
of life.

STROKE REHABILITATION TERMINOLOGY

Table 2 lists terms commonly used by the rehabilitation team.5

DISCLOSURE

The author has nothing to disclose.

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