eriatric c ursing Classic An Anniversary Selection from 10 Years o f Excellence

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

y our 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 fight hemiplegia?

Left hemiplegia might seem to be the better choice because his ability to understand and express language probably would be retained.

However, speech and language are only two of the many functions that a stroke can damage. You may change your mind if you consider the proba- ble effects that a fight or left CVA can

Geraldine Hart, RN, MSN, is an assistant pro- fessor in the School of Nursing at Dalhousie University, Halifax, Nova Scotia, Canada.

have on seven functions: • language • speech • sensation (specifically, pain, vi- sion, and position sense) • perception (of both self and envi- ronment) • movement (specifically, hemiple- gia and apraxia) • behavioral style • memory.

Function and Effect

Language. The patient with left hemiplegia usually has intact lan- guage abilities.

The right hemiplegic may have varying degrees ofaphasia, including difficulty understanding the spoken or written words of others (receptive

aphasia) or difficulty expressing his or her own thoughts in speech or writing (expressive aphasia).

Speech, as separate from language, can be affected by a stroke causing ei- ther left or right hemiplegia. Speech dysfunction, or dysarthria, is due to impaired coordination of the vocal apparatus in the throat.

The left hemiplegic patient with dysarthria will have trouble speaking clearIy but no trouble choosing the proper words or understanding the speech of others.

The right hemiplegic patient may have difficulty, finding the correct words and difficulty pronouncing them clearly.

The implications of language and speech dysfunction arc clinically im-

Originally published in Geriatric Nursing © AJN Co...)anuarylFebruary 1983.

Geriatric Nursing March/April 1990 67

eriatric c ursing Classic portant. First, determine whether the patient--your uncle, for instancem has language problems, speech prob- lems, or both. Ifhe shows any lack of understanding or inability to express himself, find out the reason. A hear- ing loss, common among older people, may explain why he does not always respond appropriately. The cause may be as simple aswax in the auditory canal.

Rarely does a patient have pure re- ceptive or expressive aphasia; more commonly, there is a mixture. There- fore, when you note difficulty in ei- ther area, check for problems in the other. To test for comprehension, make simple requests such as "grasp the bed rail" or "pick up your comb." If the patient can follow these direc- tions with no help from your ges- tures, this shows basic verbal com- prehension.

Language functions are written as well as verbal. Their control, though located in the same hemisphere, lies in different areas. Sometimes, the pa- tient can function better in either ver- bal or written language. Try both.

Sensation can be diminished on ei- ther paralyzed side. Typically, the oatient has decreased awareness of painful stimuli (for example, a pin- prick or lying on a catheter clamp) and temperature (inability to tell that a heating pad is too hot). Deep pain sensation usually remains, so the pa- tient may have pain if not positioned correctly 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 herrlianop- sia on the side of the hemiplegia, or inability to see out ofeithe r eye in the direction of the paralyzed side. The effect is to block out that half of the visual field.

Perception. The left hemii31egic pa- tient usually is unaware of his body and environment on the left. This

cannot be explained solely on the ba- sis of a visual field defect. In fact, vi- sual testing sometimes shows no .sen- sory defect even though the patient has a unilateral neglect of his left side.

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

The left hemiplegic patient often has difficulty in correctly judging depth as well as vertical/horizontal orientation in t h e environment. Judgment of the passage oftime also may be distorted.

Sensory and perceptual dysfunc- tion has specific implications for nursing care. Hemiplegic stroke pa- tients may experience general pain in the affected side as spasticity in- creases. To prevent this type of pain, start regularpassive 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 paralyzed shoulder joint. That is, do not lift or pull a patient by grasping under the a r m s .

Ordinarily, a visual field defect is not a grave handicap unless the pa- tient also has a perceptual neglect of the same side, as the left hempiplegic often does. Depending on the site of the cerebral lesion, this neglect can range from "forgetting" (to wash the left side of the face or eat food on the left side of a meal tray) to completely denying that his left side belongs to him (asking "What is someone else's hand doing in my bed?" or looking to his fight to converse with a person speaking from his left).

Nursing interventions for unilater- al neglect and for distortions of depth and vertical/horizontal orientation include physical assistance and close supervision to protect the patient from harm--burns, bruises, cuts,

and falls. Dependable assistance from nurses also can relieve the psy- chological insecurity patients" dis- torted perceptions may cause them. Therefore, as you assist the left henri- plegic with such activities as wash- ing, eating, and moving about, con- sistently reinforce his awareness of the left side of his body and physical environment(l).

Hemiplegia, or paralysis of one side of the body, is the term often used to categorize stroke patients. However, not all strokes produce pa- ralysis. Disturbances of language and speech, sensation, perception, be- havioral style, and memory can re- sult from stroke whether or not it causes hemiplegia.

Immediately after a stroke, the af- fected side may be flaccid, or limp. If the dysfunction does not resolve, that side gradually becomes spastic, or stiff. The limbs may be equally in- volved, but the arm is typically more severely affected than the leg.

During the ongoing spastic stage of hemiplegia resulting from a stroke, abnormal nerve stimulation leads to abnormal postures and movements. These, in turn, interfere with the abil- ity to move in the usual functional ways.

Head and neck muscles also can be involved, with some patients show- ing facial asymmetry. Dysfunction of the muscles of vocalization may lead to unclear speech and swallowing dif- ficulty (dysphagia).

Apraxia, the inability to carry out purposeful learned motor activities, can exist even without paralysis or lack of sensation; therefore it cannot be explained by these deficits.

In the left hemiplegic patient, apraxia probably is related to percep- tual distortions. The pathophysiolo- gy is complex, however, and not yet completely understood, especially in the person with fight hemiplegia.

The left hemiplegic patient who has apraxia typically develops prob- lems 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

68 Geriatric Nursing March/April 1990

to put his left arm in the neck of a sweater or hold the comb upside down.

The fight .hemiplegie patient less often has apraxia, but when it occurs it typically is bilateral. The apraxic patient usually can describe how to perform a complex task, such as how to light a cigarette, but cannot.per- form it.

There are various implications of movement disorders. Correct body positioning and ROM exercises will help prevent trauma to the skin and joints of 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. They are devel- oped best in coordination with physi- cal and occupational therapists or from clearly illustrated, written pro- cedures(2).

Whenever possible, involve the patient in positioning and exercising the hemiplegic limbs. This increases independence and reinforces the pa- tient's awareness of the hemiplegic side if his sensation or perception of that side is impaired.

Dysphagic patients swallow most effectively when sitting upright in a symmetrica! position with external support if necessary. They should be guided to feed themselves or be cued when food is being placed in their mouth. Such measures, together with the use of foods of varying textures and temperatures, helps to initiate swallowing in time to prevent aspira- tion and coughing(3).

Managing the various types of apraxia can be as complicated as its cause. One patient (usually the left hemiplegic) may do better if you guide comple x actions, such as get- ting out of bed, with step-by-step di- rections such as "turn your head to me," "now bring your far arm to me," and so on. Another patient (usually the right hemiplegic) might respond to gestures, such as lowering

Prefrontal area intellect, pars( elaboration of I

Broca's ar (motor sp(

T H E C E R E B R U M

Parietal lobe Precentral gyms (major area (major motor area) of perception)

I =tative

(word selection, integration)

Cerebellum

I area

POSSIBLE E F F E C T S OF STROKE ON SEVEN F U N C T I O N S

Function Person with Left Hernlplegla Person with Right Hemiplegla

Language Usually retains language 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

Sensation

Occiptal lobe

Perception

Movement

Behavioral Style

Memory

Difficulty in speaking (dyssrthria), but no difficulty in Choosing words or understanding speech of others.

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

Decreased awareness of superficial pain. but feels deep pain. Decreased position sense (proprio- ception). Defect of both eyes (homonymous hemlanopsia) in left visual field.

Same effects but on right side of body.

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.

Varying degrees of paralysis ] (hemiplegla) 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 (apraxla).

Same effects on right side of body.

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

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 concem about physical disability. Increased emotional lability.

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.

eriatric c ursing Classic the bed rail and standing back while holding out the patient's dressing gown.

Behavioral style. The individual's prestroke personality is an obvious factor in differences after stroke. Nevertheless, some useful generali- zations can be made about the left compared to the right hemiplegic.

The person with left hemiplegia tends to have poor judgment and to overestimate his physical abilities. This, together with a tendency to react quickly and impulsively, puts him at high risk for physical injury. The right hemiplegic patient does not have impaired judgment. However, he tends to be cautious to the point of underestimating his physical ability.

The left hemiplegic patient often has a short attention span and there- fore concentrates poorly on the learn- ing tasks necessary for successful re- habilitation.

The right hemiplegic patient's at- tention span is not impaired unless overall brain damage is severe enough to decrease his level of con- sciousness substantially. Hence he can concentrate on the learning nec- essary for rehabilitation.

Factors in the poor concentration of the left hemiplegic patient may be decreased awareness of and concern for the negative impact that his disa- bilities will have on future function- ing as an independent person.

Conversely, the right hemiplegic patient tends to be highly concerned about his disabilities and their effect on his future. Fatigue, frustration, and depression are the principal fac- tors limiting his application to reha- bilitation tasks.

Both left and right hemiplegic pa- tients may be more emotionally la- bile than before their stroke. Some- times their positive or negative reac- tions seem related to their immediate environment--frustration, for ex- ample, at the inability to Complete a task they found simple before the stroke. At other times, the nurse can see no relationship between the ex- pressed emotion and the environ- ment. Patients may laugh one mo-

ment and cry the next, or indicate that they don't know why they are laughing or crying.

Memory. Any memory deficitsthe left hemiplegic patient has will be most obvious in relation to new in- formation about space. This patient has difficulty remembering how to get to the bathroom or that a call bell is always attached to his bed.

Memory deficits that a fight hemi- plegic patient may have tend to relate to new language information. This patient may be unable to remember the name of the nurse assigned to him for the last two weeks or what to call a urinal.

Deep pain sensation usually remains, so hemiplegic patients may have pain if not

positioned correctly or turned frequently.

The nursing implications of typi- cal behavioral styles and memory de- fects resulting from strokes are use- fully considered together. The priori- ty for the left hemiplegic patient is protection from injury. This pa- tient's overestimation of physical abilities, together with a usually in- tact verbal function, may lead health care workers, family, and friends to think he is more able to care for him- self safely than is actually the case.

Continually assess the actual abili- ty of the left hemiplegic patient to function safely, and communicate your observations to everyone in- volved in his care. Provide the left hemiplegic patient with a structured, consistent environment--the same physical surroundings, a regular schedule for eating, sleeping, taking medication, exercising, and so forth. I fa marked memory deficit persists, the patient may need such an envi- ronment permanently, with external protection by care providers and family.

The right hemiplegic patient is less susceptible to injury because judg- ment of physical capability and per- ception of body and environment are not impaired. But this patient may be so overcautious about attempting physical activities that it hampers re- covery. Even if he is unable to ex- press doubts and fears in words, he probably will communicate them by nonverbal means. As a result, every- one may overprotect him or do for him those tasks that he can learn to do for himself.

Ongoing assessment of the ability to function safely is essential. How- ever, the main purpose of assessing the person with right-sided paralysis is to collect objective data on which to base realistic, progressive, rehabil- itation goals that will lead to achiev- ing independence.

The right hemiplegic patient also copes better in a structured, consis- tent environment, especially in the early stages of rehabilitation. Later, often after returning home, the right hemiplegic may need encourage- ment to break out of previous behav- iors that are now limiting progress.

For example, a woman learned in the hospital to transfer from one seat to another with a helper available for standby assistance. Although her strength and balance developed to the point where she could transfer safely on her own by the date of dis- charge, she required considerable en- couragement to do so at home.

You were asked two questions at the beginning of this article. The overall potential of persons with right hemiplegia, even though they may have language difficulties, is greater than the potential of left hem- iplegics in terms of independent function and a return to previous Iife-style(3).

References I. Hart, Geraldine. Perceptualdistortion. Can.Nurse

76:44---47, May 1980. 2. Ge¢, Zena, and Passarella, Phyllis. Nursing Care of

IheStrokePalient. Arch-Publications, Pittsburgh, 1985.

3. GIaser, Suzanne. How to improve the first stage of digestion. Geriatr.Nurs. 2:350--353. Sept.-Ocl. 1981.

70 Geriatric Nursing March/April 1990