A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
A. Application of elastic stockings to prevent flaccid by muscle
B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
C. Use a bed cradle to prevent dorsiflexion of feet
D. Do passive range of motion exercise
Correct Answer: B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
The left side of the body will be affected in a right-sided brain attack. Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/glutes exercise, squeezing rubber ball, extension of fingers and legs/feet. Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if the underlying problem is hemorrhage.
Option A: The left upper extremity will be affected, application of elastic stockings is unnecessary. Assist the patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage the patient to use his unaffected side to exercise his affected side. ROM exercise helps in reducing muscle stiffness and spasticity. It can also help prevent contractures.
Option C: There is no dorsiflexion of foot in a right-sided brain attack. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain a neutral position of the head. Prevents contractures and foot drop and facilitates use when function returns. Flaccid paralysis may interfere with ability to support the head, whereas spastic paralysis may lead to deviation of the head to one side.
Option D: Active-assistive range of motion exercises would be recommended for the client. Encourage the patient to assist with movement and exercises using unaffected extremity to support and move the weaker side. May respond as if the affected side is no longer part of the body and needs encouragement and active training to “reincorporate” it as a part of own body.