affected arm or shoulder. If the arm is paralyzed, subluxation (incomplete dislocation)
at the shoulder can occur as a result of overstretching of the joint capsule and
musculature by the force of gravity when the patient sits or stands in the early stages
after a stroke. This results in severe pain. Shoulder–hand syndrome (painful shoulder
and generalized swelling of the hand) can cause a frozen shoulder and ultimately
atrophy of subcutaneous tissues. When a shoulder becomes stiff, it is usually painful.
Many shoulder problems can be prevented by proper patient movement and
positioning. The flaccid arm is positioned on a table or with pillows while the patient is
seated. Some clinicians advocate the use of a properly worn sling when the patient first
becomes ambulatory, to prevent the paralyzed upper extremity from dangling without
support. Range-of-motion exercises are important in preventing painful shoulder.
Overstrenuous arm movements are avoided. The patient is instructed to interlace the
fingers, place the palms together, and push the clasped hands slowly forward to bring
the scapulae forward; he or she then raises both hands above the head. This is repeated
throughout the day. The patient is instructed to flex the affected wrist at intervals and
move all the joints of the affected fingers. He or she is encouraged to touch, stroke, rub,
and look at both hands. Pushing the heel of the hand firmly down on a surface is useful.
Elevation of the arm and hand is also important in preventing dependent edema of the
hand. Patients with continuing pain after attempted movement and positioning may
require the addition of analgesia to their treatment program.
Medications are helpful in the management of poststroke pain. Amitriptyline
hydrochloride (Elavil) has been used, but it can cause cognitive problems, has a
sedating effect, and is not effective in all patients. The antiseizure medication
lamotrigine (Lamictal) has been found to be effective for poststroke pain, and it may
serve as an alternative for patients who cannot tolerate amitriptyline (Nicholson, 2004).
Enhancing Self-Care
As soon as the patient can sit up, personal hygiene activities are encouraged. The
patient is helped to set realistic goals; if feasible, a new task is added daily. The first
step is to carry out all self-care activities on the unaffected side. Such activities as
combing the hair, brushing the teeth, shaving with an electric razor, bathing, and eating
can be carried out with one hand and are suitable for self-care. Although the patient
may feel awkward at first, the various motor skills can be learned by repetition, and the
unaffected side will become stronger with use. The nurse must be sure that the patient
does not neglect the affected side. Assistive devices will help make up for some of the
patient's deficits (Chart 62-3). A small towel is easier to control while drying after
bathing, and boxed paper tissues are easier to use than a roll of toilet tissue.
Return of functional ability is important to the patient recovering after a stroke. An
early baseline assessment of functional ability with an instrument such as the
Functional Independence Measure (FIMTM) is important in team planning and goal
setting for the patient. The FIMTM is a widely used instrument in stroke rehabilitation
and provides valuable information about motor, social, and cognitive function (Kelly-
Hayes, 2004). The patient's morale will improve if ambulatory activities are carried out
in street clothes. The family is instructed to bring in clothing that is preferably a size
larger than that normally worn. Clothing fitted with front or side fasteners or Velcro
closures is the most suitable. The patient has better balance if most of the dressing
activities are carried out while seated.