Cardiovascular

Postdischarge nursing care of stroke patients

Although recent improvements in emergency health care have reduced deaths from stroke, stroke remains a major cause of death and disability. The American Heart Association estimates that approximately 795,000 persons in the United States experience a stroke each year. Among those who survive, nearly one-third suffer permanent disability and many more face considerable functional impairments.

Nursing care is essential to stroke management during hospitalization and, in many cases, after discharge well. Research shows comprehensive care during the first 4 weeks after a stroke improves overall morbidity and mortality. Nurses are more likely than other healthcare professionals to stay in contact with patients after discharge. By collaborating with interdisciplinary team members, they can help ensure that the needs of stroke patients and their home caregivers are met. Other disciplines commonly involved in treating stroke patients include certified rehabilitation counselors, neuropsychologists, occupational therapists, primary care providers, neurologists, physical therapists, speech and language pathologists, and social workers.

Throughout recovery, the patient’s needs change, so the care plan and treatment plan must be modified accordingly. If you’re a home health nurse, make sure you’re familiar with the extensive process of stroke recovery.

Understanding stroke-related deficits

Stroke-related deficits tend to fluctuate, especially early in stroke recovery and with such stressors as illness and sleep deprivation. Reassure the patient and family that this is expected. Many stroke patients overexert themselves after discharge by trying to resume all their usual activities. This leads to extreme fatigue and a sense of worsened stroke deficits. Inform patients that although the brain represents just 2% of body weight, it uses about 25% of the body’s glucose. This energy demand increases when the brain is healing from stroke or other injuries.

As time passes, fluctuations and variability in stroke deficits usually decrease. If the patient shows new signs or symptoms or deficits become worse than they were at initial stroke presentation, suspect a new stroke event has occurred.

Recovery after a stroke

The time frame for recovery and the amount of functional recovery to expect are hard to predict. Tell the patient and family that maximum recovery could take weeks to years. Encourage patients to participate actively in rehabilitation to improve the odds for a better outcome. The type and amount of rehabilitation needed depend on specific stroke deficits; the patient may need speech, physical, and occupational therapies.


The World Health Organization developed a classification of functioning, disability, and health as an aid in developing a stroke rehabilitation plan. Components of this model include loss of body functions and structures, activity and participation limitations, and contextual factors. Assess each component of the model to make sure your patient’s stroke effects have been determined accurately and adequate treatment is implemented. (See the box below.)

Classifying the stroke patient’s functioning, disability, and health

Published in 2001 by the World Health Organization (WHO), the International Classification of Functioning, Disability, and Health provides a standard language and framework for describing health and health-related states. The chart below, adapted partly from the WHO classification, shows areas that clinicians should assess in stroke patients to ensure comprehensive nursing and interdisciplinary rehabilitation care.

FUNCTIONAL ASSESSMENT CATEGORY EXAMPLES OF FUNCTIONING, DISABILITY, AND HEALTH TO ASSESS
Loss of body functions and structures Primary: hemiparesis, cognitive dysfunction, visual impairment, sensory loss, incontinence• Secondary: contractures, pressure ulcers
Activity limitations • Difficulty performing activities of daily living
Participation restrictions • Problems reestablishing previous life or developing a new life and social involvement• Problems returning to work
Contextual factors Personal variables:• Gender

Education level

• Lifestyle habits

• Comorbidities

• Ethnocultural background

Environmental variables:

• Family support

• Social attitudes

• Architectural barriers

• Access to healthcare resources

Minimizing and managing complications

After an acute stroke, nearly two-thirds of patients develop at least one complication. Nursing care and medical management should be tailored to the individual patient, with a focus on preventing complications. If the patient is immobile, promote early mobilization and frequent turning. As with any medical condition requiring home care, extended immobility can contribute to pneumonia, deep vein thrombosis, pulmonary embolism, pressure sores, contractures, and pressure palsies. Implement fall prevention measures and teach family and other home caregivers about fall prevention.

Dysphagia (swallowing impairment) is a common result of stroke and puts patients at high risk for pneumonia. A formal dysphagia screening may have been done in the hospital; it should be repeated if signs or symptoms of swallowing dysfunction arise. A speech and language pathologist can perform a more extensive swallow study and may request a video fluoroscopic evaluation.

Be sure to monitor the patient’s nutritional and hydration status. Some patients require a nasogastric tube or percutaneous endoscopic gastrostomy tube for nutrition and medication administration. But know that these devices don’t eliminate the risk of aspiration pneumonia. Other important preventive measures include treating nausea and vomiting, performing proper oral hygiene, and teaching patients deep breathing exercises.

Stay alert for urinary tract infections, which can lead to sepsis, bacteremia, and dehydration. Dehydration in turn can cause hypotension and hypoperfusion, compromising brain recovery. Avoid using an indwelling catheter; instead, advocate for an alternative, such as an external catheter, intermittent catheterization, or incontinence pants. To ensure early diagnosis and treatment of infection, contact the primary care provider if the patient develops a fever, a change in the level of consciousness, or other signs and symptoms of infection. (For other potential stroke complications, see the box below.)

Other stroke complications

Some patients experience sleep-disordered breathing and depression after a stroke. A risk factor for ischemic stroke, sleep-disordered breathing is marked by episodes of breathing cessation during sleep. The patient’s spouse or caregiver may note loud snoring with temporary breathing pauses. Untreated, the condition may worsen hypertension and ischemic heart disease. If you observe possible sleep-disordered breathing or the patient or caregiver reports it, encourage the patient to discuss this with the primary care provider. Diagnosis and treatment options are established through a sleep study.

Like any life-changing event, stroke may trigger depression. Research shows one-third to one-half of stroke survivors become depressed. To detect signs and symptoms of depression, listen closely to the patient and caregivers, especially noting concerns about the patient’s mood. Assess thoroughly for depression; many people don’t know the signs and symptoms. You can use several assessment tools to help detect depression. The American Stroke Association recommends the Patient Health Questionnaire 9-item depression scale for its briefness and psychometric properties. Inform patients and their families that depression is common and rehabilitation is more successful when depression is treated. Assure them depression isn’t a character flaw or a sign that the patient has done something wrong. If the patient is taking antidepressant medication, assess for worsening depression or suicidal ideation.

Helping patients modify stroke risk factors

To help prevent stroke recurrence, help patients identify and modify stroke risk factors. A primary care provider or stroke specialist should oversee risk-factor management. As a nurse, you’re well positioned to promote compliance with medication and lifestyle recommendations, as well as to recognize risk factors that haven’t been identified. Medical conditions linked to increased stroke risk include hypertension, diabetes, dyslipidemia, sleep-disordered breathing, and atrial fibrillation. Know that certain lifestyle factors can contribute to stroke risk, including physical inactivity, poor nutrition, smoking, alcohol consumption, and use of illicit drugs.

Hypertension correlates positively with stroke risk. As blood pressure goes up, so does the stroke risk. The ideal blood pressure goal is below 140/90 mm Hg, or less than 130/80 mm Hg in patients with diabetes or kidney disease. Blood pressure should be addressed in patients with multiple risk factors and prehypertension (blood pressure above 120/80 mm Hg). Chronic hypertension leads to cardiac enlargement and cardiac disease. If the patient’s blood pressure is high, recheck it after the patient has been seated and relaxed with feet on the floor for at least 5 minutes. Statin therapy is initiated in most patients after stroke to decrease low-density lipoprotein levels and slow atherosclerosis progression.

Diabetes can lead to vascular disease and may contribute to blood pressure and cholesterol elevations. Advocate for diabetes education for patients who don’t understand lifestyle or medication recommendations, as well as for newly diagnosed diabetes patients who haven’t attended education classes. Reinforce blood glucose testing and goals.

Providing patient education

Educate patients about lifestyle modifications that may improve their blood pressure, blood glucose, and blood cholesterol. These may include weight loss, limited alcohol use, increased physical activity, reduced dietary sodium intake (below 2.34 g/day), smoking cessation, and a balanced diet high in fruits, vegetables, and low-fat dairy products and low in saturated fat.

Vascular disease caused by smoking doubles the risk of ischemic stroke and subarachnoid hemorrhage. Smoking also contributes to worsening of other risk factors, such as high systolic blood pressure. For patients taking oral contraceptives, smoking significantly increases the risk of all types of stroke. Teach patients and their families about available smoking-cessation support, such as counseling, nicotine replacement, and support groups. Urge patients to limit alcohol intake to two drinks per day for men and one for women.

Finally, stress the importance of avoiding illicit substances that may increase stroke risk, such as cocaine, methamphetamine, and heroin. To promote abstinence, the patient may need medication, counseling, or rehabilitation.

Increasing patient accountability

Research shows that establishing accountability can increase compliance. To promote accountability, encourage patients to keep a log, and review it with them regularly. Depending on the patient’s situation, the log may include activities, blood pressure readings, food intake, and blood glucose levels. Patients also can use online or electronic tools to track these goals. With noncompliant patients, establish a contract to reinforce the importance of changing undesirable lifestyle habits.

Educating the patient’s support persons

Be sure to assess and educate the patient’s spouse or partner, family members, and other home caregivers. Provide education on stroke pathology and assist them in helping the patient comply with the plan of care. Review their expectations and coping mechanisms. Encourage them to participate in rehabilitation sessions so they can learn functional assistance techniques and communication skills, which can enhance their ability to care for the patient.

Research highlights positive functional outcomes in stroke survivors receiving home health care—but negative health outcomes for caregivers. To better address caregiver needs, become familiar with community resources, support groups, free services, government agencies, and faith-based communities that can provide caregiver support.

Unique presentation, unique recovery

Every stroke has a unique presentation, and every stroke patient has a unique path to recovery. Being aware of potential complications and helping patients modify risk factors for stroke recurrence can help ensure you’re providing thorough nursing care. Patient and family education, goal reinforcement, and communication with other healthcare team members about the patient’s needs and concerns are crucial to maximizing outcomes.

Mary Armstrong is a neurology nurse practitioner at Bronson Methodist Hospital in Kalamazoo, Michigan.

Selected references

Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2014;127:e6-e245.

Goldstein LB, Bushnell CD, Adams RJ, et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, Council for High Blood Pressure Research, Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:517-84.

Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.

Miller EL, Murray L, Richards L, et al; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10):2402-48.

Summers D, Leonard A, Wentworth D, et al; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke. 2009;40(8):2911-44.

World Health Organization. How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO.

Zierath D, Hadwin J, Savos A, et al. Anamnestic recall of stroke-related deficits: an animal model. Stroke. 2010;41(11):2653-60.

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