Post-CVA — Home Health Training

Two jobs run in parallel after a stroke: recovering function, and preventing the next one. The second is the one that gets less attention in the home and carries the higher stakes.

Every visit

Blood pressure — the single most important modifiable risk factor for a second stroke
Neurological status against their baseline, not a textbook's
Swallowing — coughing, wet voice, pocketing food, avoiding fluids, weight loss
Skin, particularly on the affected side, where sensation may be reduced
Mobility, transfers, and fall risk
Medication adherence, especially antihypertensives and antithrombotics
Mood — post-stroke depression is common, under-recognised, and treatable
Caregiver strain

Preventing the second stroke

Say it plainly to the patient: the work now is to stop this happening again.

Blood pressure control — the biggest single lever. Know their target and their parameters.
Antithrombotic adherence — antiplatelet or anticoagulant, taken every day. See Anticoagulation and INR Management.
Atrial fibrillation, if present — is it rate-controlled, and are they anticoagulated?
Diabetes control — see Diabetes
Lipids, smoking, alcohol, activity
Teach FAST to the patient and the family, and what to do — see Emergencies in the Home

Swallowing

Any patient coughing at meals needs an SLP referral, and it is urgent. Aspiration pneumonia is a leading cause of readmission after stroke, and the signs are quiet.

Watch for: coughing or throat-clearing during or after eating, a wet or gurgly voice after swallowing, food pocketed in the cheek, prolonged mealtimes, avoiding particular textures or fluids, unexplained weight loss, recurrent chest infections, or a low-grade temperature nobody can explain.

Until they are assessed, follow any existing diet and fluid orders exactly, and use aspiration precautions: upright at 90 degrees to eat, upright for 30 minutes afterwards, small bites, no straws unless specified, no talking while eating, and full oral care — oral bacteria are what make aspiration dangerous.

The deficits that get missed

Hemiparesis is obvious. These are not, and they change what is safe at home.

Neglect — the patient does not attend to one side. They eat half the plate, shave half the face, and collide with door frames. This is not a vision problem and it is a major safety risk.
Hemianopia — loss of half the visual field in both eyes. Teach scanning.
Apraxia — they know what a toothbrush is for and cannot sequence the movement. Easily mistaken for non-compliance.
Impulsivity and poor safety awareness — often after a right-hemisphere stroke. The patient who insists they can walk unaided, and cannot.
Emotional lability — sudden crying or laughing out of proportion. Explain it to the family; they usually find it frightening.
Aphasia — expressive, receptive, or both. Intact intelligence. Speak to the adult, not to the caregiver about them.
Sensory loss — burns and pressure injuries on the affected side, unnoticed.

Positioning and the affected limb

Never pull on the affected arm during transfers — shoulder subluxation is common and painful
Support the arm when sitting; pillow or lap tray
Teach the family to support, not drag
Inspect the affected side for skin damage every visit
Watch for developing contracture and get the therapist to review

This patient needs the whole team

Post-CVA is the clearest case in home health for interdisciplinary care:

PT — mobility, transfers, balance, gait
OT — ADLs, the affected upper limb, adaptive equipment, perception, functional cognition in daily tasks, home modification
SLP — communication, cognition, and swallowing
MSW — caregiver strain, benefits, long-term planning
Nursing — secondary prevention, medications, skin, mood

If a discipline is missing, raise it at case conference — see Changing the Plan Mid-Episode.

The caregiver

Stroke caregiving is abrupt and total. A spouse who was not a carer last month now is, often overnight, with no training.

Ask directly how they are managing. Teach transfers properly rather than letting them improvise. Talk about respite before they are desperate. Make the MSW referral early rather than after they break.

When to call

Any new neurological change — FAST, and call 911
Blood pressure outside parameters
New coughing or choking with food or fluid
Signs of aspiration pneumonia — fever, new cough, breathlessness
Signs of DVT in the affected limb
New or worsening depression, and any expression of hopelessness
A caregiver at breaking point