What are the short-term and long-term goals and interventions for a patient with cerebral infarction resulting in hemiparesis and hemiplegia?

Goals and Interventions for Cerebral Infarction with Hemiparesis/Hemiplegia

Short-Term Goals (First 24-48 Hours to 2 Weeks)

Prevent Life-Threatening Complications

The immediate priority is preventing cerebral edema, herniation, and hemorrhagic transformation, which account for most early deaths after stroke. 1, 2

• Monitor neurological status hourly for the first 24-48 hours, specifically assessing level of arousal and pupillary function to detect early cerebral swelling 2
• Watch for ipsilateral pupillary dysfunction with mydriasis, which is the most common sign of deterioration requiring urgent neurosurgical intervention 2
• Obtain early neurosurgical consultation within the first 2-5 days if the patient has frank hypodensity on CT within 6 hours, involvement of one-third or more of the MCA territory, or early midline shift 2
• Perform CT scan 24 hours post-thrombolysis (if tPA was given) before starting any antithrombotic therapy to exclude intracranial hemorrhage 3

Prevent Subacute Medical Complications

Early mobilization and prophylaxis against immobility complications are strongly recommended and can be initiated within 24 hours if the patient is medically stable. 1

• Administer subcutaneous anticoagulants (or intermittent external compression stockings if anticoagulants are contraindicated) to prevent deep vein thrombosis in immobilized patients 1
• Assess swallowing function before any oral intake using bedside water swallow test; watch for wet voice after swallowing, incomplete oral-labial closure, or high NIHSS score as predictors of aspiration risk 1
• Insert nasogastric tube if swallowing is impaired to maintain nutrition and medication administration; consider percutaneous endoscopic gastric tube if prolonged need is anticipated 1
• Monitor for urinary retention with post-void residual measurements; if PVR >100 mL, initiate scheduled intermittent catheterization every 4-6 hours rather than indwelling catheter to reduce infection risk 1
• Administer prophylactic stool softener to prevent constipation, which occurs in 45% of patients during acute hospitalization 1
• Implement fall prevention program as most falls occur during transfers and toileting; use bed/chair alarms and ensure supervision 1

Begin Functional Recovery

Rehabilitation assessment should be performed within 48 hours of admission, with therapy beginning as soon as the patient is medically stable. 3

• Transfer to dedicated stroke unit within 24 hours of hospital arrival, as stroke unit care reduces death and dependency compared to non-specialized units 3
• Follow the "out of bed within 24-hour principle" when feasible to prevent deconditioning 3
• Initiate daily stretching of hemiplegic limbs to avoid contracture development 1
• Position hemiplegic shoulder in maximum external rotation for 30 minutes daily (in bed or chair) to prevent shoulder contracture 1
• Use resting ankle splints at night and during assisted standing to prevent ankle contracture in the hemiplegic limb 1

Long-Term Goals (2 Weeks to 6 Months and Beyond)

Maximize Functional Independence

Comprehensive specialized stroke rehabilitation incorporating aerobic exercise training improves not only motor function but also cardiorespiratory fitness and reduces recurrent stroke risk. 1

• Implement short, frequent exercise sessions with progressive intensity; early mobilization improves outcomes 1
• Incorporate treadmill exercise training (with or without body weight support) to increase aerobic capacity, sensorimotor function, and gait velocity 1
• Provide cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning 1
• Train family members to assist with transfers and positioning to facilitate home discharge 1

Prevent Recurrent Stroke and Cardiovascular Events

Aerobic conditioning programs reduce multiple cardiovascular risk factors and decrease recurrent stroke incidence. 1

• Achieve moderate-to-high cardiorespiratory fitness levels, which confer 63-68% lower risk of stroke death compared to low fitness 1
• Target blood pressure reduction through exercise, as aerobic conditioning decreases blood pressure particularly in hypertensive patients 1
• Promote weight loss and improved glucose regulation through regular physical activity 1
• Improve lipid profiles as exercise increases HDL cholesterol and decreases total cholesterol, triglycerides, and LDL cholesterol 1

Restore Aerobic Capacity

Aggressive rehabilitation beyond the traditional several-month window continues to improve motor function and aerobic capacity. 1

• Continue supervised or home-based walking/treadmill training programs after hospital discharge 1
• Progress from remedial gait retraining to independent ambulation as tolerated 1
• Implement specialized training to improve skill and efficiency in self-care, occupational, and leisure-time activities 1

Address Neuropsychological Complications

Depression occurs in up to one-third of ischemic stroke patients and requires early screening and intervention. 1

• Screen for depression early using validated tools, as depression impairs rehabilitation and recovery 1
• Assess for pseudobulbar affect (occurs in 10-48% of patients) using the Pathological Laughing and Crying Scale; educate patients and families about this condition 1
• Monitor for delirium (affects 1 in 4 patients during acute period) using the 4 Assessment Test for Delirium or Confusion Assessment Method ICU 1
• Provide cognitive stimulation and regulate sleep/wake cycles to prevent delirium; consider having family members stay with patient for orientation 1

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation in patients with moderate-to-large hemispheric infarcts, as early involvement is critical particularly in the first 2-5 days 2
• Do not start antiplatelet or anticoagulant therapy before the 24-hour post-thrombolysis CT scan has excluded intracranial hemorrhage 3
• Do not use indwelling bladder catheters routinely due to infection risk; use intermittent catheterization instead 1
• Do not limit rehabilitation to the first several months, as aggressive rehabilitation beyond this period continues to improve motor function and aerobic capacity 1
• Do not allow patients to remain bedbound beyond 24 hours unless medically contraindicated, as early mobilization prevents complications 1, 3