The person with significant impairment of strength on one side of the body or
with total absence of movement on the arm and leg on the same side needs
assistance above all to prevent any complications arising from possible
prolonged immobility (see bedsores, skin lesions) ). The interventions that are
shown below are therefore fundamental, dedicated to the "lured" person.
The skin serves the human body to provide protection to the internal organs from possible germs, but also to free the body from waste through sweat; provides the sense of touch and regulates body temperature. It is therefore essential to keep it clean and dry to keep it from remaining healthy. In the case of a person affected by a stroke, it may be necessary to have one or more people intervene to provide for their hygiene. If the person is in a wheelchair, it is advisable to bring it to the bathroom and place it in front of the sink; if the bathroom is too small, place the person in front of a table on which a basin of water will be placed by providing a knob or a sponge and liquid soap to allow it to clean itself of the face and upper body, helping it for the areas it can not reach. In the event that the person is unable to perform, even aided, intimate hygiene in the bathroom, it will be necessary to perform the bidet in bed. If the person is completely dependent, it will be necessary to perform hygiene in bed. In this case you need to place everything you need near the bed, on a convenient shelf: two knobs or sponges, one for the face and one for the intimate parts, neutral soap or Marseilles, towels: one for the face and one for the genital area, spare linens, frying pan, jug and washbowl with warm water, and possibly waxed diapers and / or disposable overhead towels. These devices (diapers and transverse) can be obtained through the prescription of the doctor who resigns from the hospital ward, for example from medicine or neurology etc. Uncover the person to the waist and undress her. Then proceed to the hygiene of the face, chest and arms, paying particular attention to the underarm, submammary and umbilical area, especially in obese people, in order to prevent cutaneous candidiasis. Proceed in order to wash, rinse and dry. Rotate the person on the side and proceed to wash the back and the lumbosacral region. Have the person wear the underwear shirt. Completely discover the person and perform the washing of the lower limbs, then proceed with intimate hygiene. If possible, use the bed-bidet technique; in the event that it is not possible to place the pan, proceed with artillery using a sponge or knob not too moistened with water.
Proceed to change the bed linen: unfasten the sheets and replace them by
rotating the patient first on one side and then on the other. As for oral
hygiene, it is important that it be done after each meal. If the person is able
to brush his teeth with a toothbrush and toothpaste; alternatively rinse with a
mouthwash. In case the person is not able to provide oral hygiene with gauze
soaked in water and mouthwash: bandage the index and middle finger with a gauze
soaked in water and mouthwash and proceed to clean the tongue, palate, holes and
teeth walls . It is important to remove and perform the daily cleaning of the
denture. Proper hygiene of the oral cavity allows the oral mucosa and the tongue
to be kept intact, avoiding the onset of ulcers and infections. It is necessary
to help the person or to replace it in the care of hands and nails in order to
keep them clean. As far as the cutting of nails is concerned, it is advisable to
soak the hands in soapy water and proceed with cutting using a cutter. To clean
the nails you can use the special toothbrush.
It is recommended, for people who are enticed or who stay at home, the use of cotton garments comfortable and tied on the front. First insert the sleeve from the hemiplegic limb and then the one from the healthy limb; to undress proceed with the opposite maneuver: first the healthy limb then the plegic one (see also muscular flaccidity). Footwear must be worn when the person is sitting in bed; they must be in leather and with a non-slip sole. Slippers are not recommended.
It is important that the person urinates several times a day and discharges
regularly. If the person feels the urge to accompany her in the bathroom when
she wishes or, if this is not possible, place her on the comfortable. If the
person is enticed, place the pan (as for the bidet in bed) or the
urinary pot. In the
case of defecation the pot will be used for both men and women. Faecal
incontinence rarely occurs while urinary incontinence is common. For the woman
the diaper is used, while for the man the condom device can also be used. There
are several sizes of diapers that vary according to weight.
They must be checked every 2 hours and changed if wet. To carry out this
operation, let the person assume the gynecological position, possibly keeping
the hemiplegic limb in position with his / her own leg and replace the garrison;
alternatively it is possible to rotate the person on the side and carry out the
same maneuver. The condom device is made like a condom to which a straw is
attached with a bag collecting urine; it must therefore be positioned after
performing an accurate intimate hygiene. Secure the condom to the skin through
the appropriate adhesive strip and connect it to the bag. It is advisable to use
this device only during the night as it must not remain in place for more than
8-12 hours; alternatively, the use of the diaper is suggested, taking into
account, however, that the diaper can favor the maceration of the skin,
especially if stool and urine, and left in situ, when there are already bedsores
(!) . If the person has a bladder catheter, more attention should be paid to
performing intimate hygiene at least twice a day with water (see risk of urinary
infections); the connection tube must rest above the lower limb to prevent the
formation of pressure sores, the urine collection bag must fall. Depending on
the type of catheter, consult the primary care physician or home nursing
professional for replacement. If the person is constipated it may be necessary
to administer herbal teas or laxative drugs or to perform an evacuating enema,
after medical consultation. Constipation should not last longer than three days
(see Constipation Therapy, Constipation Diet).
The prevention of bedsores is based on proper nutrition, with a balanced intake
of proteins, sugars and fats; on adequate hygiene, especially in the
genito-peritoneal area to avoid maceration and / or abrasion; on the prevention
of compression of areas such as shoulder blades, sacrum, heels, notoriously more
at risk of developing sores. We recommend using the appropriate aids (mat, bow).
On the other hand, it is essential to practice regular postural changes.
Basically the patient must be rotate every two hours; the paralyzed limb placed
in the drain and placed on a soft pillow.
Nutrition
Proper nutrition is the necessary basis to avoid the occurrence of complications
such as bedsores, but also of concomitant diseases that can worsen the state of
health of the person already affected by stroke. It is therefore useful to
follow a balanced diet low in fat and, in the case of diabetes, also of sugars.
Equally important is hydration: it is advisable to drink at least 1 liter of
water, better oligomineral (see the waters); if the person is not able to drink
alone, let them drink at least 5 glasses of water during the day. However
attention should be paid to patients with water restriction, for example cardiac
patients with congestive heart failure and liver disease. In the event that the
person presents dysphagia, ie a defect in the transit of food from the mouth to
the stomach, it is advisable to maintain a sitting or semi-sitting position for
feeding; the consistency of food must be semi-solid and homogeneous; it is
useful to ask the person to hold the breath before swallowing and to finish it
with a cough to facilitate the defense mechanisms of the airways.
Parenteral nutrition is a nutrition technique that involves infusion through a
venous catheter of nutrients directly into the bloodstream. It is therefore
necessary to keep the catheter insertion site well clean and to make this type
of therapy modulated by a competent doctor or nurse. Enteral nutrition is a
feeding technique that uses the use of probes through which food in liquid or
semi-liquid form goes directly to the stomach. The probes can reach the stomach
through the nose - in this case the nasogastric tube (SNG) - or through a hole
in the skin they arrive directly in the seat. percutaneous gastrostomy (PEG).
The person affected by stroke will have to follow an antihypertensive therapy at
home: it is important that doses and times of administration are established by
the doctor and that they are not changed for any reason other than the doctor
himself. With regard to anticoagulant therapy it may be necessary to perform
subcutaneous injections (see prophylaxis of the thromboembolic thrombus risk):
these injections can also be carried out by the person himself or if he is not
able to give a family member: such injections of heparin (cf.
prophylaxis_trombosis) perform on the belly in the periumbilical area by
pinching and injecting the drug. It is advisable to be shown by a nurse how to
perform such injections before performing them independently. If anticoagulant
therapy is followed, it is necessary to periodically check the coagulation
values, avoid intramuscular injections and verify the appearance and the nature
of any hematomas.
By "positioning" we mean the set of all the positions or postures that are
assumed by the head, the upper limbs, the trunk and the lower limbs, both in the
bed and in the wheelchair. The correct positioning of the hemiplegic patient is
an assistive modality and an extremely useful and necessary therapeutic action
for the prevention of so-called "tertiary damages" (among which decubitus sores,
muscular-tendon and articular limitations, respiratory and bladder problems),
and for eliminate those spoiled attitudes that tend to facilitate the increase
of muscle tone, for example the push of the foot against the bed.
For the implementation of an effective positioning it may be necessary to use
aids, such as for example:
- anti-decubitus mattress, (water or alternating pressure air)
- Anti-decubitus cushions (silicone gel, silicone, communicating air bubbles,
normal cushions
- sandbags of various sizes, bow, for the weight of the blankets, cushions of
particular shapes, ex. wedge.
It can often happen that due to the injury, the patient loses consciousness not
only of the injured body, but also of all the space on that side (eminattention).
The patient with this disorder is unable to explore the contralateral space to
the lesion, ignores the people who turn to him on the affected side, leaves
portions of the food on the plate, ignores the obstacles on the left and reads
only part of a text, losing the ability to understand it. Precisely for this
reason also the room should be arranged so that the hemiplegic side receives the
greatest stimulation possible: the bed should be arranged so that the affected
side is not towards the wall, but so that all activities take place from that
side; also the bedside table and the television should be on the side of the
injured side to encourage the patient to turn his head and explore that space as
well. Similarly, the family members or friends who assist him should stimulate
the patient by always standing on the side of the hemiplegic side, inviting him
to turn his gaze to them during assistance maneuvers or conversation.
The main postures for bed and wheelchair are described and illustrated below; it
should be kept in mind, however, that for each patient different specialized
indications will be given by the specialized staff, based on the clinical
condition, considering the patient's vigilance, collaboration, and deficit.
motor, muscle tone, presence of pain, skin conditions, circulatory problems,
etc. In order for the positioning of the patient to be truly effective, the
variation of the same postures during the 24 hours is of fundamental importance,
with regular changes every 2 hours, especially in the initial stages or in cases
of prolonged entrapment. This posture is the least indicated compared to the
others because it involves a greater risk of forming bedsores at the heel and
the sacrum. The head must be well supported by a cushion avoiding excessive
flexion of the cervical spine. a pillow that maintains the upper limb of the
antideclive hemiplegic laying a small pillow under the pelvis and one at the
level of the foot laterally, to prevent the plegic limb from rotating out, place
a soft pad under the sole of the foot, keeping it in position avoiding the push
against the footboard of the bed, which would be negative, the head is supported
by a single cushion the trunk is supported by a pillow and slightly rotated
backwards the hemiplegic upper limb is moved forward about 90 ', with the elbow
and the palm relaxed and relaxed; the lower limbic limb is stretched and the
lower limb is flexed, supported by a pillow
Positioning on the healthy side
the head is supported by a single pillow
the trunk is perpendicular to the bed surface
the hemiplegic upper limb is supported by a single pillow placed at the side, at
the same height of the shoulder
the lower limbic limb is supported by a cushion, with a hip and knee bent
the healthy lower limb is positioned with extended hip and slightly flexed kneeSpostamenti e
trasferimenti
To move the patient to the head of the bed, if he is able to collaborate, the lower limbs are flexed (resting the sole of the foot on the bed) helping him and supporting him from the hemiplegic side and asking, grasping with the healthy upper limb the head of the bed or any handle (giraffe), to pull upwards pushing with the legs. To carry out this shift it is important to check and maintain, by the person assisting him, the flexion of the hemiplegic limb, either this flaccid or hypertonic, to avoid pathological movements or, due to the fall of the limb due to weakness, that joint microtrauma occurs. Moving is best done with two people; sometimes the patient moves from a bed to the stretcher, lifting it with a transverse in four people, being careful to give blows or slam the pelvis which is at risk of skin lesions.