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erebrovascular accidents (CVAs) on the right side ot the brain don't usually produce speech deficits, since the left cerebral hemisphere houses the speech center in nearly all right-handed and most left-handed people. For that reason, patients with right CVAs may seem to have escaped serious impairment. But, in fact, they're often left with perceptual difficulties that severely compromise their daily living skills. They may also be at greater risk for falls and subsequent injuries than patients with left-hemisphere strokes. Decreased or absent awareness of the affected side of the body after a stroke-a syndrome referred to as hemineglectis much more prevalent among patients with right than left CVAs. This deficit, which usually accompanies left-sided weakness, can also include loss of vision in the left visual field of both eyes (homonymous hemianopia). Hemineglect puts patients at great risk for tripping over, knocking over, or bumping into objects in their vicinity. Sometimes they simply don't see them and move on as if they weren't there; other times, they aren't aware of their deficits and move as though they aren't handicapped (a condition called anosognosia). In many cases, the risk of falling is enhanced by age-related decline in balance control. Impaired judgment and impulsive behavior, both common effects of right CVA, may complicate matters further. Developing a plan of care When Sally Hanover, age 68, was admitted to a neurology ulIit after a right CVA, her primary nurse, Alice White, explained all safety precautions to her-keeping the side rails of her bed up while she was in it, locking her bed in the low position, and placing her call bell within reach. And Alice reminded her to call for assistance whenever she needed it. Because Ms. Hanover exhibited hemineglect, her plan of .are included turning her bed so that her unaffected side faced the door to her room. The funi,ture was also moved around :o her unaffected side. Since she couldn't see the left side of her food tray, all her food was placed on the right half. And she iJas taught to scan the environment by turning her head in order to see areas not within her field of vision. One day, during afternoon rounds, Alice helped Ms. Hanover out of bed to a nearby chair. She positioned everyTh ing she thought Ms. Hanover might want within her r:each-call bell, telephone, TV remote control, and water glass-and reminded her not to get up without calling for assistance. Ms. Hanover smiled and nodded, and Alice left to continue her rounds. Half an hour later, Alice found her patient lying on the tloor, with an upper arm laceration that required sutures. Ms. 1-anover was shocked that she'd fallen. Alice was dismayed, lout she knew Ms. Hanover's attempt to get up unassisted ~o:lod be the result of cognitive and personality changes associated with right CVA that aren't always immediately appar:nt. In this instance, Alice had assessed her patient to be reliable. But the accident demonstrated that she wasn't. Alice obtained an order for a vest restraint to be worn coninuously to discourage Ms. Hanover from mobilizing herself unassisted. She also reminded her once again not to get up without calling for assistance. But in spite of these interventions, Ms. Hanover eventually untied her vest restraint, tried tO get out of her chair, lost her balance, and fell to the floor. X-rays confirmed a hip fracture.