Abstract
Introduction: population aging increases the risk of several acute and chronic diseases. Of these, stroke is one of the most prevalent in Portugal, resulting in neurological and motor deficits in the individual, with serious implications for their mobility, functionality and quality of life. Objective: to describe the gains in body balance, muscle movement and gait with the intervention of Rehabilitation Nursing in a person after a Stroke. Case report: descriptive study, case report type, in which CARE recommendations were followed, of an individual with impaired body balance, muscle strength and walking with a walking aid after a stroke. An initial assessment was carried out with the development of a rehabilitation nursing care plan, and the respective health gains were demonstrated. The importance of training the individual in relation to body balance, muscle strength, walking with a walking aid and their relationship with the level of independence and functionality of the individual, in their home context, is highlighted. Conclusions: after intervention by a specialist nurse in rehabilitation nursing, there was an improvement in body balance, muscle strength and walking with a walking aid, with an increase in the level of independence and functionality of the person.
Keywords
Rehabilitation Nursing, Stroke, Postural Balance, Gait, Functional Status
INTRODUCTION
Population aging and changing lifestyle habits favor an increase in acute and chronic diseases; resulting in an increase in morbidity; functional dependence and mortality.(1) Among cardiovascular diseases; stroke is one of the main causes of death and disability in Portugal; as in the rest of Europe.(2)
Stroke is a clinical syndrome with an abrupt and insidious onset; characterized by focal or global vascular alterations; resulting in neurological and motor deficits. It mainly affects people over 65 and is associated with modifiable and non-modifiable risk factors. Hemiparesis is one of the most common sequelae; compromising balance and gait.(3)
It is a major public health issue and one of the main causes of death and disability in Portugal.(4) Balance and gait are the most affected areas; interfering with movements such as standing; sitting and transferring; increasing the risk of falls and worsening functional independence.(5)
Limitation of mobility seriously compromises a person's quality of life; making it essential for rehabilitation nurses to intervene to restore functional independence; whether in an acute or chronic situation; in hospital or at home.(5;6)
This case study analyzes the health gains in balance; muscle movement and gait with a walking aid; promoting the person's functional independence; through the implementation of a rehabilitation nursing (RN) plan.
CASE REPORT
This case report was prepared according to the CARE recommendations and refers to a person with impaired body balance; muscle strength and gait with a walking aid; as a result of stroke sequelae. The functional motor re-education and training plan for the person and their caregiver; in a home setting; was outlined.
Data was collected through anamnesis and consultation of the clinical file; after obtaining free and informed consent; in accordance with the General Data Protection Regime; safeguarding the confidentiality and anonymity of the data.
Mr. C.; 84; lived with his 82-year-old wife; both suffering from multiple chronic illnesses; but capable of self-management and controlling their health conditions; maintaining independence in their activities of daily living (ADLs). They had the support of their two daughters in managing purchases; appointments and therapy.
He presented with mild dysarthria; difficulty walking; decreased strength in the lower limbs and body imbalance to the left. He went to the hospital emergency department; where he was diagnosed with an ischemic stroke of the right middle cerebral artery; of cardioembolic etiology secondary to atrial fibrillation; identified during hospitalization.
During hospitalization; neurological and motor deficits were identified; including hemiparesis on the left; deviation of the labial commissure on the right; dysphagia and moderate dysarthria. Although he had a favorable evolution; he remained with reduced mobility and functionality; resulting in a high level of dependence; incompatible with an immediate return home.
He was referred to the Medium Duration Rehabilitation Unit; where he stayed for four months; with an indication to continue with the rehabilitation program. He was admitted to the Integrated Continued Care Team to continue his rehabilitation at home.
On initial assessment; he had a slight deviation of the labial commissure to the right; with no changes in language or swallowing. He maintained a slight left hemiparesis; with brachial predominance; and walked with the support of a walker and a third person; unable to go up and down stairs. Partially dependent on ADLs; requiring support from the caregiver throughout the 24-hour period.
On his return home; Mr. C. identified the main objective as regaining the ability to leave the house; despite the existing architectural barrier (the house is on the second floor with no elevator).
For a comprehensive assessment of its functionality; a set of specific instruments was used. Regarding muscle strength (Medical Research Council); body balance (balance assessment and Tinetti Index); gait (Tinetti Index; Holden Functional Gait Classification); risk of falling (Morse Falls Scale); ADL (Barthel Index) and functionality (National Functionality Table) (Table 1).
Evaluation instruments | Evaluation instruments | Initial assessment | Final assessment |
|---|---|---|---|
Medical Research Council | Upper Right Limb | 4 | 4 |
Medical Research Council | Upper Left Limb | 3 | 4 |
Medical Research Council | Lower Right Limb | 5 | 5 |
Medical Research Council | Lower Left Limb | 4 | 5 |
Balance assessment | Static sitting | Present | Present |
Balance assessment | Dynamic sitting | Diminished | Present |
Balance assessment | Static orthostatic | Diminished | Present |
Balance assessment | Dynamic orthostatic | Absent | Diminished |
Tinetti Index | Static and Dynamic Balance | 6 | 15 |
Tinetti Index | Gait Assessment Scale | 4 | 11 |
Holden Functional Gait Classification | Holden Functional Gait Classification | Category 2 Dependent gait level I | Category 4 Independent walking (flat surface) |
Morse Falls Scale | Morse Falls Scale | 75 | 50 |
Índice de Barthel | Índice de Barthel | 40 | 70 |
National Functionality Table | National Functionality Table | 112 | 53 |
An individualized RN care plan was drawn up with Mr. C and his caregiver; including RN interventions and diagnoses (tables 2 and 3); implemented three times a week for 6 weeks.
The exercises were adapted to Mr. C's ability in each session; considering frequency; intensity; time; type; volume and progression. At the same time; Mr. C and his caregiver were given the knowledge; training and skills to perform them independently; once or twice a day.
Rehabilitation Nursing Diagnosis | Initial assessment | Final assessment |
|---|---|---|
Body Balance | Compromised | Improved |
Potential to improve knowledge of body balance technique | ND | D |
Potential to improve ability to use body balance technique | ND | D |
Muscle movement in the left body | Diminished | Increased |
Potential to improve knowledge of muscle and joint exercise techniques | ND | D |
Potential to improve ability to perform muscle and joint exercise techniques | ND | D |
Walking with a walking aid (walker) | Comprometido | Melhorado |
Potential to improve knowledge about getting around with walking aids (walker and cane) | ND | D |
Potential to improve the ability to walk with a walking aid (walker or cane) | D | D |
Legend: ND - Does not demonstrate; D - Demonstrates | Legend: ND - Does not demonstrate; D - Demonstrates | Legend: ND - Does not demonstrate; D - Demonstrates |
Exercise Plan | Repetitions | Material |
|---|---|---|
Body Balance | [empty cell] | [empty cell] |
Postural correction (when performing exercises) | [empty cell] | [empty cell] |
Static and dynamic balance training while sitting and standing | [empty cell] | [empty cell] |
Hip flexion and extension | 3x10 | Walker/Chair |
Hip abduction and adduction | 3x10 | Walker/Chair |
Knee extension | 3x10 | Walker/Chair |
Tibiotarsal flexion-extension | 3x10 | Walker/Chair |
Andar com auxiliar de marcha (andarilho) Sitting and standing without support | 3x10 | Chair |
Climbing up and down steps (step in each lower limb) | 3x10 | Stairs |
Load alternation Lower Limb/Unipodal support | [empty cell] | [empty cell] |
Gait training with a walker | [empty cell] | Walker |
Walking with a cane | [empty cell] | Cane |
Climbing and descending stairs | [empty cell] | Cane |
Gait training with the walking aid on the street | [empty cell] | Walker/Cane |
Obstacle avoidance | [empty cell] | [empty cell] |
Muscle movement in the left body Pedal UL and LL | 15 min | Pedalboard |
Glenohumeral flexion and extension | 3x10 | Weight 300 g |
Glenohumeral abduction adduction | 3x10 | Weight 300 g |
Ulnar flexion-extension | 3x10 | Weight 300 g |
Wrist flexion and extension | 3x10 | Weight 300 g |
Facial muscle exercises | 2xdia | [empty cell] |
Perform facial muscle massage | 2xdia | [empty cell] |
Movement coordination exercises | [empty cell] | [empty cell] |
DISCUSSION
After Mr. C's initial and final assessment; there was an improvement in muscle strength in the left hemisphere; while the level of strength in the right hemisphere remained the same. There was also progress in body balance (static and dynamic); evidenced by an increase in the Tinetti scale score; as well as progress in the gait category; according to the Holden scale. The level of independence and functionality improved; reflected in the increase in the Barthel Index score and the reduction in the National Functionality Table score. Despite maintaining a high risk of falling; there was a decrease in the Morse scale score; bringing it closer to the average risk.
This individualized RN care plan enabled Mr. C. to achieve his main goal; enabling him to get out of the house and walk on the street.
Mobility and gait are essential predictors of survival and determinants of ADL performance. Walking means independence and is only possible with muscle strength and body balance. These gains promote a better quality of life and greater participation in society.(2)
Mr. C. and his caregiver have shown an increase in knowledge and ability to perform body balance techniques; muscle and joint exercises; as well as to use walking aids; evolving from the walker to the cane; both at home and on the street. The Directorate-General for Health recommends daily mobilizations for people with mobility alterations due to stroke; 2-3 times a day; with a minimum of 10 repetitions.(7)
Health transition processes require the intervention of the rehabilitation nurse specialist; allowing the person to remain at home; with the necessary health care; promoting the greatest possible degree of independence and functionality.(8)
CONCLUSIONS
This case report highlighted the importance of functional motor re-education in the areas of body balance; muscle strength and gait; resulting in improved independence and functionality; as well as increased knowledge and training of the person and caregiver.
The conclusion is that; although it is not possible to reverse the sequelae of the disease; it is feasible to maximize functional capacity; preventing immobility and social isolation.
References
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- 2 Marques-Vieira C; Caldas AC. A relevância do andar: reabilitar a pessoa com andar comprometido. En: Marques-Vieira C; Sousa L; coordinadores. Cuidados de enfermagem de reabilitação à pessoa ao longo da vida. Lisboa: Lusodidacta; 2023. p. 547-55.
- 3 Marques DS; Veras RO; Faturi CLN; Costa FHS; Diniz AN; Mouzinho LSN; et al. Fatores de risco modificáveis e não modificáveis associados ao desenvolvimento de acidente vascular cerebral. CLCS. 2023 Oct 5;16(10):19411-25. Disponible en: https://ojs.revistacontribuciones.com/ojs/index.php/clcs/article/view/2429
- 4 Sociedade Portuguesa de Medicina Interna. O AVC é a principal causa de morte e incapacidade em Portugal. 2021. Disponible en: https://www.spmi.pt/o-avc-e-a-principal-causa-de-morte-e-incapacidade-em-portugal/
- 5 Rocha IDJ; Bravo MFM; Sousa LMM; Mesquita ACN; Pestana HCFC. Intervenção do enfermeiro de reabilitação no ganho de equilíbrio postural na pessoa após acidente vascular cerebral: estudo de caso. Rev Port Enferm Reabil. 2020 Oct 27;3(Suppl 1):5-17. Disponible en: https://rper.aper.pt/index.php/rper/article/view/91
- 6 Novo Lima AM; Salomé Martins Ferreira M; Ferreira Pereira da Silva Martins MM; Fernandes S. Influência dos cuidados de enfermagem de reabilitação na recuperação da independência funcional do doente. J Health NPEPS. 2019;4(2):28-43.
- 7 Araújo P; Soares A; Ribeiro O; Martins MM. Processo de cuidados de enfermagem de reabilitação à pessoa adulta/idosa com compromisso no sistema nervoso. En: Ribeiro O; coordenador. Enfermagem de reabilitação: conceções e práticas. Lisboa: Lidel; 2021. p. 164-233.
- 8 Oliveira C; Couto G; Silva RP. Enfermagem de reabilitação nos cuidados de saúde primários. En: Ribeiro O; coordenador. Enfermagem de reabilitação: conceções e práticas. Lisboa: Lidel; 2021. p. 654-70.
Declarations
Funding
None.
Conflict of interest
None. AUTHORSHIP CONTRIBUTION Conceptualization: Carla Raposo; Helena Pestana. Data curation: Carla Raposo. Formal analysis: Carla Raposo; Ana Rita Vilhena. Research: Carla Raposo; Ana Rita Vilhena. Methodology: Carla Raposo; Helena Pestana. Supervision: Helena Pestana; Luís Sousa. Validation: Sandy Severino; Luís Sousa. Drafting - original draft: Carla Raposo; Luís Sousa. Writing - proofreading and editing: Carla Raposo; Ana Rita Vilhena; Helena Pestana; Sandy Severino; Luís Sousa.
Authorship contributions
Drafting – original draft: Carla Raposo, Ana Rita Vilhena, Helena Pestana, Sandy Severino, Luís Sousa.
Writing–review and editing: Carla Raposo, Ana Rita Vilhena, Helena Pestana, Sandy Severino, Luís Sousa.