Strokes Causing Left vs. Right Hemiplegia: Different Effects and Nursing Implications

Here, in concise, clear form is the basis for intelligent care of the poststroke patient.

GERALDINE HART

Your uncle has just suffered a stroke and one side of his body is paralyzed. If it were in your power, would you prefer him to have left or right hemiplegia? Why?

Left hemiplegia might seem to be the better choice because his ability to understand and express lan- guage probably would be retained. Most people, both right- and left- handed, have language centers sit- uated in the left cerebral hemi- sphere. Therefore, a cerebrovascu- lar accident in the left hemisphere,. which may cause right-sided para- lysis, is more_likely to_leave-a-per- son with a language dysfunction than is a stroke in the right_hemi.- sphere,_which may cause left hemi- plegia.

However, motor power and lan- guage are only two of the many functions that a stroke can damage. Perhaps comparing other effects of stroke causing right or left hemi-

Geraldine Hart, RN, MSN, is an assistant professor in the School of Nursing at Dal- housie University, Halifax, Nova Scotia.

plegia might lead you to change your mind. You will want to con- sider the nursing implications of the probable different effects that a right or left CVA has on the follow- ing seven functions:

�9 language �9 speech �9 sensation (specifically, vision,

pain, and position sense) �9 perception (of self and envi-

ronment) �9 movement (hemiplegia and

apraxia) �9 behavioral style �9 memory

Function, Effect, and Nursing Implications

LANGUAGE The patient with left hemiplegia usually has intact_lan- guage abilities.

The right hemiplegic may have varying degrees of aphasia, which includes difficulty understanding the spoken or written words of oth- ers (receptive aphasia) or difficulty expressing his or her own thoughts in speech or writing (expressive aphasia)."

SPEECtt, as separate from lan- guage, can be affected by a" stroke causing either left or right hemiple- gia. Speech dysfunction, or dysar- thria, is due to impaired coordina- tion of the vocal apparatus in the throat.

The left hemiplegic patient with dysarthria will have trouble speak- ing clearly and understandably but no trouble choosing the proper words or understanding the speech of others.

The right hemiplegic patient may have speech difficulties com- pounding language problems. He will have difficulty finding the cor- rect words and difficulty pronounc- ing them clearly.

The implications of language and speech dysfunction are clinically important. First, you need to deter- mine whether the patient--your uncle, for instance--has language problems, speech problems, or both. If he shows any lack of under- standing or inability to express himself, assess in more depth to find out the reason. A hearing loss, common among older people, may explain why he does not always re- spond appropriately. The cause may be as simple as wax in the au- ditory canal.

Rarely does a patient have pure receptive or expressive aphasia; more commonly, there is a mixture. Therefore, when you note difficulty in either area, check for problems in the other. To test for comprehen-

"The masculine pronoun is used most con- sistently throughout this article to enhance readability: no sexual bias is intended.

Geriatric Nursing January/February 1983 39

sion, make simple requests such as "grasp the bed rail" or "pick up your comb." I f the patient can fol- low these directions with no help from your gestures, this shows ba- sic verbal comprehension.

Language functions are written as well as verbal. Their control, though located in the same hemi- sphere, lies in different areas. Sometimes, therefore, the patient can funct ion better in either verbal or written language. Try both as methods of communication.

Awareness of the underlying cause and a consistent approach in dealing with the stroke patient 's communicat ion difficulties are ba- sic to effective nursing interven- tion. "Ear ly referral to a speech therapist is desirable. Specific measures to alleviate communica- tion problems secondary to lan- guage or speech dysfunctions are described by Dreher and Stryk- er ( l ,2) .

SENSATION can be diminished on either paralyzed side. Typically, the patient has decreased aware- ness of painful stimuli (for exam- ple, a pinprick or lying on a cathe- ter clamp) and tempera ture (inability to tell that a heating pad is too hot). Deep pain sensation usually remains, so the patient may have pain if not positioned correct- ly or turned regularly.

Position sense (proprioception) is diminished. Consequently the pa- tient cannot tell where an affected limb is if he cannot see it (similar to the feeling that an arm or leg has "gone to sleep").

Vision is the third sense that may be affected by a stroke. The typical deficit is a homonymous hemianop- sia on the side of the hemiplegia, or inability to see out of either eye in the direction of the paralyzed side. The effect is to block out that half of the visual field, the so-called field cut. (For a sensitive descrip- tion of coping with that defect, see Schwartz 's article (3)).

PERCEPTION The left hemiplegic patient often has a lack of aware- ness of his left side and his environ- ment that cannot be explained sole- ly on the basis of a visual-field de- fect. In fact, visual testing some-

times shows no sensory defect even though the patient has a unilateral neglect of his left side.

The right hemiplegic patient, on the other hand, usually has normal awareness of his body and spatial orientation even if he lacks sensa- tion in his right side and has a right visual field cut. He usually will learn the position of his affected right limbs by feeling them with his left hand or foot and by turning his head to the right to compensate for any lack of vision to his right.

The left hemiplegic patient often has difficulty in correctly judging depth as well as ver t ical /horizontal orientation in the environment.

Ongoing assessment of ability to function safely is essential for patients who have either left or right hemiplegia.

Judgment of the passage of time also may be distorted.

Sensory and perceptual dysfunc- tion has specific implications for nursing care.

Hemiplegic stroke patients may experience general pain in the af- fected side as spastieity increases. To prevent this type of pain, start regular passive range of motion (ROM ) exercises, and position the person properly when in a bed or chair. Also, use transfer methods that-do not put tension on the para- lyzed shoulder joint. Tha t is, do not lift or pull a patient by grasping un- der the arms.

Ordinarily, a visual-field defect is not a grave handicap unless the patient also has a perceptual ne- glect of the same side, as the left hemiplegic often does. Depending on the site of the cerebral lesion, this neglect can range from "for- get t ing" (to wash the left side of the face or eat food on the left side

of a meal tray) to completely deny- ing that his left side belongs to him (asking " W h a t is someone else's hand doing in my bed?" or looking to his right to converse with a per- son speaking from his left).

Nursing interventions for unilat- eral neglect and for distortions of depth and vert ical /horizontal orientation include physical assis- tance and close supervision to pro- tect the patient from ha rm- -burns , bruises, cuts, and falls. Dependable assistance from nurses also can re- lieve the psychological insecurity patients' distorted perceptions may cause them. Therefore, as you as- sist the left hemiplegic with activi- ties of daily living, such as washing, eating, and moving about, consis- tently reinforce his awareness of the left side of his body and physi- cal environment(4).

tIEMIPLEGIA, or paralysis of one side of the body, is the term often used to categorize stroke patients. However, not all strokes produce paralysis. Disturbances of language and speech, sensation, perception, behavioral style, and memory can result from stroke whether or not it causes hemiplegia.

I f paralysis does ensue, the lack of functional movement is not ex- plained simply by absence of motor power in the affected muscles, but also by inability to direct nerve im- pulses to the muscles in the many and varied combinations needed for daily activities(5).

Immediately after a stroke, the a f fec ted side may be flaccid, or limp. If the dysfunction does not re- solve, that side gradually becomes spastic, or stiff. The limbs may be equally involved, but the arm is typically more severely affected than the leg.

Head and neck muscles also can be involved, with some patients showing facial asymmetry. Dys- function of the muscles of vocaliza- tion may lead to unclear speech and swallowing difficulty (dysphagia).

APRAXIA, the inability to carry out purposeful learned motor activ- ities even though motor power and sensation are intact, can result from a stroke causing left or right hemiplegia.

40 Gcriatric Nursing January~February 1983

Apraxia probably is related to perceptual distortions in the left hemiplegic patient. The pathophys- iology is complex, however, and not yet completely understood, espe- cially in the person with right hem- iplegia(6,7).

The left hemiplegic patient who has apraxia typically develops problems only on the affected side. Often there is difficulty putting on clothes on this side or using utensils such as a comb with the left hand. He might try to put his left arm in the neck of a sweater or hold the comb upside down.

The right hemiplegic patient, though less often apraxic, typically has bilateral apraxia. This patient usually can describe how to per- form a complex learned task, such as how to light a cigarette, but can- not perform it.

There are various nursing impli- cations of movement disorders.

Correct body positioning and ROM exercises will help prevent trauma to the skin and joints of the paralyzed limbs, as well as edema of the affected arm and hand.

Design positioning, turning, and exercise programs to promote sym- metrical posture and normal move- ment. These programs should be consistent and based on the patho- physiology involved(8). They are developed best in coordination with physical and occupational thera- pists or from clearly illustrated, written procedures(9).

Whenever possible, involve the patient in positioning and exercis- ing the hemiplegic limbs. This in- creases independence and rein- forces the patient's awareness of the hemiplegic side if his sensation or perception of that side is im- paired.

Dysphagic patients, who cannot hold their head up without assis- tance during the early stages of re- covery, usually swallow with the least difficulty when turned toward the unaffected side and when the head of the bed is elevated at least 45 degrees. Semisolids such as yo- gurt and Jell-O may be swallowed more easily than clear fluids, espe- cially acid ones. These measures help patients to sense the presence

Prefrontal area (intellect, pets0 elaboration of tl

THE CEREBRUM

Parietal 10be Precentral gyrus (major area (maior motor areal of perception)

~tative

Occiptal lobe

Broca's are (motor spe~

(word selection, integration)

Cerebellum

try I area

P O S S I B L E E F F E C T S OF S T R O K E ON S E V E N F U N C T I O N S

Function Person with Left Herniplegia Person with Right Hemiplegia

Language Usually retains !anguage ability. Varying degrees of difficulty in understanding written or oral words (receptive aphasia) and/or difficulty in expressing thoughts in speech or writing (expressive aphasia).

Speech Difficulty in speaking (dysarthria), but no difficulty in choosing words or understanding speech of others.

Difficulty in choosing correct words and in pronouncing them (dysarthria).

Sensation Decreased awareness of superficial pain, but feels deep pain. Decreased position sense (proprio- caption). Defect of both eyes (homonymous hemisnopsia) in left visual field.

Same effects but on right side of body.

Perception Decreased awareness of left side of body and environment, with or without visual-field defect. Difficulty in judging depth, vertical/horizontal orientation, and the passage of time.

Normal awareness of body and spatial orientation despite possible lack of sensation on right and right visual-field defect.

Movement Varying degrees of paralysis (hemiplegie) of left side, Pos- sible difficulty in swallowing (dysphagia), left facial asymmetry, and unclear speech. Inability to carry out learned motor activity on left .side (apraxia).

Same effects on right side of body.

Less often apraxic. When affected, typically has bilateral apraxia.

Behavioral Style

Impaired judgment. Tends to over- estimate physical ability, reacts quickly, short attention span, and appears unconcerned about physical disability. Increased emotional lability.

Judgment intact. Underestimates physical ability, reacts slowly, has normal attention span and increased concern about physical disability. Increased emotional lability.

Memory Most deficits are related to new spatial information, e.g., location of call bell, toilet.

Most deficits are related to new language information, e.g., remem- bering names.

of food and beg in swal lowing in t ime to p reven t asp i ra t ion and cough ing(10) .

M a n a g i n g the var ious types of ap rax ia can be as compl ica ted as its cause. R e h a b i l i t a t i o n depends on assessment of each pa t ien t ' s u n i q u e difficulties and consu l t a t ion a m o n g

migh t respond to gestures, such as lowering the bed rail and s t a n d i n g back while hold ing out the pa t i en t ' s dress ing gown.

B E H A V I O R A L S T Y L E , o r the indi- v idua l ' s pres t roke personal i ty , is an obvious factor in differences af ter stroke. Never the less , some useful

The r ight hemip leg ic pa t i en t does not have impa i r ed j u d g m e n t . How- ever, he tends to be cau t ious ko the point of u n d e r e s t i m a t i n g his physi- cal abi l i ty .

T h e left hemip leg ic pa t i en t of ten has a short a t t en t ion span and therefore concen t ra t e s poorly on

I i

In 1978 I entered a Boston hospital and had an emergency cholecystectomy. In the recovery room it was discovered that I'd had a stroke that completely paralyzed my left side. Teliing me what had happened must have been the most difficult task that Muriel, my wife of 40 years, had ever faced�9 I had been a very active person and I know that this stroke hurt her as much as it did me.

For physical therapy and occupational therapy, I was admitted to a rehabilitation hospital. My PT was Gall and my OT was Molly. She taught me to feed myself, take a bed bath, and dress the best I could with one hand.

Molly would come to my room early, toss me a pair of shorts and stockings, and say, "Please put them on." Later she'd return to check on my progress�9 If she said "Norm" in a peculiar voice, I knew I had goofed---either my shorts were on backward, the heels of the stockings were on the instep, my left leg was in the right hole, or sometimes my leg would be through the fly. Molly never lost her

- temper--we just laughed about my mistakes. In physical therapy I was fitted with a brace, and soon I

could take short steps with the aid of a four-legged cane. With a wheelchair, I propelled myself around, using one arm and one leg. I exercised faithfully to keep the joints loose and help strengthen the muscles�9 I learned to transfer to the wheelchair from the bed and from chair to bed.

Later I transferred from chair to car. Then a new world opened up--r ides in the country, visits to restaurants, but only those with ramps or no steps. My wife often took me out on weekends�9 She took me home and I could transfer without any help.

I had lost my balance so at first I had to sit to use the toilet and I needed help to have my pants pulled up and zipped. This was depressing and degrading, but after much effort I eventually managed alone and felt quite proud---even if I did seem like a stork standing 9n one leg

and holding the grab bars. After several meetings with my wife, the hospital staff,

and interested friends, we decided I was strong enough to live at home if I could get the wheelchair in and out of the house. Unfortunately, the house had front steps�9 One weekend my wife announced that my wonderful friends Bill and Stan, a carpenter, had built a ramp from the driveway to our front door. This was my ticket home!

Now I had to face a difficult decision�9 Not able to walk and having the use of only one hand, I knew I could no longer teach industrial arts, as I had done for 32 years at the Cotting School:for Handicapped children�9 In fairness to my employer I would have to retire. Afterward, I was discouraged and full of self-pity. I knew I would be a terrific burden to my wife. My situation reminded me of a game we played as kids. We would tie a rope to a tree branch and hang on until finally our hands would slip and we knew we'd have to let go. Many times after my stroke I wished I could let go, but thoughts of my loving family, my good friends, and the staff who worked so hard with me and believed that I could make it made me hold on tight.

It was necessary for my wife to work and impossible to find someone to care for me, so I an now living at Rogerson House, a home for retired men located across from Jamaica Pond in Jamaica Plain, Massachusetts. The setting was beautiful--well-trimmed lawns, large shade trees, and beautiful flowers tended by Bernie, a resident with two green thumbs�9

My advice to anyone who has a stroke is this: Work hard, set goals to accomplish, be encouraged by any progress you make, and above all don't get depressed. Replace your depressed thoughts with accomplishments�9

- - N O R M A N INGRAM

all t eam m e m b e r s to develop an ap- propr ia te and cons is ten t approach.

O n e pa t i en t (usua l ly the left hemiplegic) m a y do be t te r if you guide complex act ions, such as get- t ing out of bed, with s tep-by-s tep d i r e c t i o n s - - " t u r n your head to me," "now b r ing your far a r m to me," and so on. A n o t h e r pa t ien t (usua l ly the r ight hemiplegic)

genera l i za t ions can be m a d e abou t the differences in behaviora l style of the left compared to the r ight hemiplegic .

The person with left hemipleg ia tends to have poor j u d g m e n t and to overes t imate his physical abil i t ies. This , together w i t h a t endency to react quickly and impuls ively , puts h im at high risk for physical in jury .

the l e a rn ing tasks necessary for successful rehabi l i t a t ion .

T h e r ight hemiplegic pa t i en t ' s a t t en t i on span is not impa i red un- less overall b ra in d a m a g e is severe enough to decrease his level of con- sciousness subs tan t ia l ly . Hence he can c onc e n t r a t e on the l ea rn ing necessary for rehab i l i t a t ion .

Factors in the poor concen t r a t i on

42 Geriatr ic Nursing January /Februa ry 1983

of the left hemiplegic patient may be apparent decreased awareness of and concern for the negative im- pact that his disabilities will have on future functioning as an inde- pendent person.

Conversely, the right hemiplegic patient tends to be highly con- cerned about his disabilities and their effect on his future. Fatigue, frustration, and depression are the principal factors limiting his appli- cation to rehabilitation tasks.

Both left and right hemiplegic patients may be more emotionally labile than before their stroke. Sometimes their positive or nega- tive reactions seem related to their immediate envi ronment - - f rus t ra - tion, for example, at the inability to complete a task they found simple

�9 before the stroke. At other times, the nurse can see no relationship between the expressed emotion and the environment. Patients may laugh one moment and cry the next, or indicate that they don' t know why they are laughing or cry- ing.

MEMORY Any memory deficits the left hemiplegic patient has will be most obvious in relation to new information about space. This pa- tient has difficulty remembering how to get to the bathroom or that a call bell is always at tached to his bed.

Memory deficits that a right hemiplegic patient may have tend to relate to new language informa- tion. This patient may be unable to remember the name of~ th-e-fiurse assigned to him for the last two weeks or what to call a urinal.

The nursing implications of typi- cal behavioral styles and memory defects resulting from strokes are usefully considered together.

The priority for the left hemi- plegic patient is protection from in- jury. This patient 's overestimation of physical abilities, together with a usually intact verbal function, may lead health care workers, family, and friends to think he is more able to care for himself safely than is ac- tually the case.

Continually assess the actual ability of the left hemiplegic pa- tient to function safely, and corn-

municate your observations to everyone involved in his care. Pro- vide the left hemiplegic patient with a structured, consistent envi- r o n m e n t - t h e same physical sur- roundings, a regular schedule for eating, sleeping, taking medication, exercising, and so fo~'th. I f a marked memory deficit persists, the patient may need such an envi- ronment permanently, with exter- nal protection by care providers and family.

The right hemiplegie patient is less susceptible to injury because

Deep pain sensation usually remains, so hemiplegic patients Ilia3' have pain if not positioned correctly or turned frequently.

judgment of physical capabili ty and perception of body and envi- ronment are not impaired. But this patient may be so overcautious about at tempting physical activi- ties that it hampers recovery. Even if he is unable to express doubts and fears in words, he probably will communicate them by nonverbal means. As a result, everyone may overprotect him or do for him those tasks that he c a n learn to do for himself.

Ongoing assessment of the abili- ty to function safely is essential for both the right and left hemiplegic patient-. However, the main pur- pose of assessing the person with right-sided paralysis is to collect objective data on which to base re- alistic, progressive, rehabilitation goals that will lead to achieving full potential for independence.

The right hemiplegic patient also copes better in a structured, con- sistent environment, especially in the early stages of rehabilitation. Later, often after returning home, the right hemiplegic may need en-

couragement to break out of pre- vious behaviors that are now limit- ing progess.

For example, a woman learned in the2hospital to transfer from one seat to another with a helper avail- able for standby assistance. Al- though her strength and balance developed to the point where she could transfer safely on her own by the date of discharge, she required considerable encouragement to do so at home.

You were asked two questions at the beginning of this article. The information supplied indicates that the overall potential of persons with right hemiplegia, even though they may have language difficulties, is greater than the potential of left hemiplegics in terms of indepen- dent function and a return to pre- vious life-style(9,11). The probable differences between the impact of a stroke causing left versus right hemiplegia have strong implica- tions for assessment, planning, di- rect nursing care, and guidance to patients and their families.

References I. Dreher, Barbara. Overcoming speech and lan-

guage disorders. Geriatr.Nurs., 2:345-349. Sept.-Oct. 1981.

2. Stryker, Stephanie. Speech After Stroke: .4 Manual for the Speech Pathologist and the Family Member. 2nd ed. Springfield, 111. Charles C Thomas, Publishers, 1981.

3. Schwartz, Doris. Catastrophic illness: how it feels. Geriatr.Nurs. 3:302-306, Sept.-Oct. 1982.

4. Hart, Geraldine. Perceptual distortion. Can.Nurse 76:44-47, May 1980.

5. Parry, Anne. and Eales, Carole. Hemiplegia- 3. Handling the early stroke patient at home and in the ward. Nurs.Times 72:1680-1683, Oct. 28, 1976.

6. Siev. Ellen, and Freishtat, Brenda. Perceptual Dysfunction in the Adult Stroke Patient: A Manual for Evaluation and Treatment. Thor- orate, N.J., Charles B. Slack, 1976, pp. 59- 73.

7. Taylor, J.W., and Ballenger, Sally. Neurolog- ical Dysfunctions and Nursing Intervention, New York, McGraw-l'till Book Co., 1980, pp. 176, 186-187.

8. Parry, Anne, and Eales, Carole. Hemiplegia- 2. Damage to nervous pathways. Nurs.Times 72:1640-1641, Oct. 21, 1976.

9. Guentz, Sara, and Navales, R.D. New ap- proaches to the nursing care of the stroke pa- tient. Clin.Orthop. 131:90-96, Mar.-Apr. 1978.

10. Glaser, Suzanne. How to improve the first stage of digestion. Geriatr.Nurs. 2:350-353, Sept.-Oct. 1981.

11. Anderson, E.K. The significance of the parie- tal lobes in hemiplegia, llawaii Med.J. 27:141-145, Nov.-Dec. 1967.

Geriatr ic Nursing January /Februa ry 1983 43