Using elements of the stimulation perception in patients with stroke.
Introduction
The cause of restlessness in patients with cerebrovascular accident (CMP) is not only the medical diagnosis itself, but also other subjects, such as staying in a foreign environment (neurology department), strangers (neurology department staff), age of the patient, psychological changes - anxiety, fear, fear for life, erroneous perception of reality, disorders of memory, speech, sleep, failure to satisfy the patient's needs. Manifestations of restlessness are often reflected in the patient's refusal to accept any help and care from the staff - fluids, food, medicines, non-cooperation in routine tasks (positioning, rehabilitation, hygiene). He removes catheters, cannulae, probes himself. If the staff is not attentive, physical attacks occur, for example, grabbing the hair, pinching, spitting. The patient voluntarily leaving the bed, which very often leads to falls and subsequently to patient injuries. The task of the entire nursing team is always to ensure the patient's safety and to try to obtain the necessary information from the patient's family and surroundings. We always prefer a sensitive approach to the patient and in no case prevent the visits of these patients. We always ensure the safety of the patient after consultation with the doctor, mainly by fixation of the upper limbs, lower limbs, possibly through the chest, proper fixation of intravenous cannulas or other inputs. With these patients, we have proven to use stimulation of perception, which will allow patients to perceive and feel their body again, learn to communicate with the environment without words, help them orient themselves in space and time. This care is professionally called basal stimulation and its goal is to help the patient cope with the difficult period of hospitalization as best as possible.
If we want this care to be successful, it is necessary to know as much as possible about the patient's personality, his habits, character, interests, what he likes, but also what he can't tolerate. If the concept of perceptual stimulation is used, it is necessary for the patient to have familiar things around him, such as toiletries that he is used to using (brush and toothpaste, mouthwash, body lotion, shaving equipment, perfume), watches, alarm clock, glasses, favorite objects (photos, children's paintings, pillow, socks, scarf), books, magazines, radio, players.
Stimulation of perception
The author of the concept is Professor Dr. Andreas Fröhlich, special pedagogue, who worked since 1970 at the Rehabilitation Center in Germany with children who were born with severe combined somatic and intellectual changes. Professor Christel Bienstein, a nurse, brought the concept of basal stimulation into nursing care in the 1980s. She worked for many years at the Education Center of the German Professional Association for Nursing Professions in Essen, Germany, and also in the field of intensive care medicine. Basal stimulation is a concept that supports human perception at the most basic (basal) level. Every person perceives with the help of senses, sensory organs that arise and develop already in the embryonic phase and have an irreplaceable meaning from birth to death. The basic elements of the concept of basal stimulation are movement, communication and perception and their close connection. Targeted stimulation of stored memories can reactivate brain activity and thereby support clients' perception, communication and momentum (Friedlová, 2007, p. 13).
Elements of basic stimulation include somatic, vestibular, vibrational. We include optical (visual), auditory (auditory), tactile-haptic (tactile) stimulation, olfactory (auditory), oral (taste) stimulation (Friedlová, 2007, p.24).
Touch
The concept of basal stimulation is not touch therapy and cannot be confused with this term. But the concept of basal stimulation works with touch and places great emphasis on the quality of touch. Another factor that affects the quality of touches is the number of hands on the patient's body.
A prerequisite for quality touch is calmness, the manner and meaning of the contact, the force and pressure developed, the rhythm, which involves repetition, rhythm and sequence. The touch must be made with the entire surface of the palm and fingers, we should apply the same pressure all the time, we are not in a hurry, but we work calmly. In the room in which we work, we try to eliminate noise and stimuli that would distract the patient. Our hands should not be cold. Unexpected and untargeted touches in patients with a reduced degree of perception cause a feeling of uncertainty, fear and can startle. Therefore, we should always let the patient know when our presence with him begins and ends. We can provide him with information using a targeted touch, the so-called initial touch. We will choose a suitable place for the initial touch, according to the biographical history taken from relatives or closest friends. We write the chosen place for the initial touch on the table by the patient's bed and inform everyone who works with the client to respect and use this chosen initial touch. (Friedlová, 2007, p.72)
Somatic stimulation
Somatic stimulation enables the patient to convey sensations from his body and stimulate the perception of the body schema and subsequently the surrounding world. Immobility and inactivity, for example due to injury, illness or combined disability, results in the loss of memories of movement and changes in the perception of body schema.
Soothing somatic stimulation (bath)
The soothing bath is performed in the direction of hair growth and thus creates relaxation in the patient, because each hair is surrounded by nervous tissue. It reacts to movement and transmits this information to the brain, the patient relaxes.
Invigorating somatic stimulation (bath)
We perform an invigorating bath against hair growth and thereby increase the patient's attention, muscle tone, heart rate and blood pressure, as well as the client's activity. We do not apply it to patients who are disoriented, restless, with fresh bleeding into the brain and increased intracranial pressure.
Positioning
Changing body position supports a sufficient supply of stimuli, provides somatic and vestibular stimulation. After half an hour of lying quietly, the perception of one's own body changes, there is a loss of the feeling of one's own bodily boundaries. A patient who does not have enough stimuli can be confused, restless, loses his orientation and does not communicate. When positioning, we always ask the patient whether he feels good, has no pain and whether the selected position suits him. If the patient is unable to answer, we are guided by the biographical anamnesis, which position the patient liked to occupy or in which position he used to fall asleep. The so-called the position of the mummy, which helps the patient perceive the sensations of his own body and feel the boundaries of his body. It is used in patients who are restless, aggressive, confused, bedridden for a long time. Before positioning, a soothing bath can be taken. Aids are used - blankets, towels, pillows, sheets, positioning aids (roller, snake).
Case report
A 70-year-old female patient was brought by the emergency medical service (RZP) to the neurological department in the evening with suspected CMP. The basic information provided by the daughter to the RZP crew - until this afternoon the patient was self-sufficient, oriented - in time and place, without movement disorders, sometimes she has back pain. The patient was found by her family on the floor in the kitchen, uncommunicative, unresponsive to being addressed and with impaired mobility of the right limbs. In this state, the staff performed basic prescribed examinations with the established conclusion of acute left hemispheric CMP with right-sided severe hemiparesis and with mixed aphasia and right-sided hemianopia.
During the objective assessment by the nurse, severe right-sided limb impairment was noted, mostly the right upper limb (RHM), non-communicating, emitting only screams, not swallowing liquids or food. Fluctuating state of consciousness, frequent somnolence, restless, uncooperative, negativistic, urinary incontinence, later stool. The attending nurse obtained the following information from the daughter: the patient was non-conflictual, talkative, liked to seek the company of other people. She liked listening to the radio, reading. An important warning from the daughter that the patient has a hard time enduring hospitalization in a hospital facility. Due to the severe disability of the right limbs, the patient was referred to the nursing staff in the care of bio-psycho-social needs. Unfortunately, from the beginning of hospitalization, the patient's restlessness was evident, there was a negative attitude towards everything we did around her. In addition, verbal contact was impossible for aphasia, which was certainly very stressful. During any manipulation with the patient, there was pinching of the staff, sometimes even spitting.
Due to the severe disability of the right half of the body, the patient was unable to leave the bed, which minimized the risk of possible injury due to a fall to a certain extent. Fixation of the left upper limb (LHK) was necessary for repeated tearing of the peripheral cannula, which led to further restlessness and a negative attitude. Due to the increasing restlessness of the patient, the attending physician prescribed a neuroleptic to calm her down. It was obvious that it is absolutely necessary to get the patient to cooperate both in treatment and in routine activities and to try to use all the acquired knowledge about the patient. The priority was the involvement of the family, in this case the daughter, in the care process. The daughter cooperated very willingly, visited her mother regularly, read the daily newspaper to her, performed, according to previous training by the staff, massages of affected limbs. She brought her favorite things from home, such as a pillow, socks, and made her favorite rosehip tea, which we administered in small doses into the oral cavity.
If the daughter was present, we could remove the LHK fixation despite the possible risk of the cannula or catheter being pulled out. We always placed all things that the patient's family brought in the field of vision (pictures from grandchildren, photographs, pillows). We put her socks on her lower legs. We tried to explain all procedures to the patient. Around the 16th day of hospitalization, we managed to manage the initial restlessness and negativism, even with the significant help of the patient's daughter.
Conclusion
Stimulation of perception in patients with cerebrovascular accident helps the nursing staff to satisfy their physical, psychological and social needs. It also helps to actively involve patients' families and closest friends in medical and nursing care.
Authors: PhDr. Lada Cetlová, PhD., B.Sc. Lada Nováková List of bibliographic references [1] FRIEDLOVÁ, K., 2007. Basal stimulation in basic nursing care. 1 ed. Prague, Grada, 2007, 31. p. ISBN 978-80-247-1314-4.