RUHS Stroke Education for Patients and Families

Stroke Education for Patients and Families

Welcome to Riverside University Health System – Medical Center (RUHS-Medical Center). Your healthcare team looks forward to making your stay here as pleasant as possible.

The mission of RUHS-Medical Center is to provide superior quality health care to Riverside County residents with a special focus on individuals and populations in need.

Our vision is that RUHS Medical Center will benefit all residents of Riverside County by serving as an academically affiliated primary, secondary, and tertiary level health care center, with a tradition of superior quality and service.

RUHS Medical Center is a designated Primary Stroke Center certified by the Joint Commission. RUHS Medical Center Stroke Program’s mission is to provide excellent stroke care through early recognition and evidence-based practice interventions while maintaining a safe, patient centered environment.

The packet you are receiving has general information you may find helpful in dealing with your condition or your loved one’s condition. Additional handouts will be given to you for any other risk factors that may be present. Handouts are available for medications you may be taking or will take at home. These handouts will be given to you when you are admitted and others may be added before you are discharged.

Your nurse or your primary healthcare provider can answer any questions you may have. We encourage you to write down your questions or comments on the “Notes” pages provided at the back of this booklet. Please use these pages to speak to your nurse or primary healthcare provider about anything regarding your hospital stay with RUHS Medical Center.

What is a Stroke?

A stroke is a disease that affects the arteries of the brain. A stroke occurs when a blood vessel bringing blood to the brain gets blocked or ruptures so brain cells don’t get the flow of blood that they need.

Deprived of oxygen, nerve cells cannot function and die within minutes. When these nerve cells die, the parts of the body they control cannot function either. These devastating effects are often permanent because brain cells cannot be replaced.

Other names for a stroke include:

Cerebral Vascular Accident (CVA)

Ischemic Stroke

Transient Ischemic Attack (TIA)

Intracranial Hemorrhage (ICH)

Cerebral Thrombosis

Types of Stroke

There are three types of strokes:

An Ischemic Stroke is a stroke caused by a blocked artery. This is the most common type of stroke and can sometimes be treated with clot busting drugs.

A Hemorrhagic Stroke is a stroke caused by bleeding into the brain tissue. This stroke is caused by a ruptured blood vessel.

A Transient Ischemic Attack (TIA) is also called a "mini stroke" and occurs when a blood clot blocks and artery for a short time. The symptoms of a TIA are like the warning signs of a stroke, but they usually last only a few minutes. About 10% of strokes are preceded by TIAs and are a very strong predictor of stroke risk. TIAs are a medical emergency and should be treated immediately.

The type of stroke I have had is:

Warning Signs of a Stroke

Warning signs of a stroke can include:

Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes.

Sudden trouble walking, dizziness, loss of balance or coordination.

Sudden, severe headache with no known cause.

If you recognize any of these signs, BE FAST:

"B" stands for Balance - Sudden loss of balance, trouble walking. "E" stands for Eyes - Sudden visual changes in one or both eyes. "F" stands for Face - Ask the person to smile. If the face droops to one side, that is a sign of stroke.

"A" stands for Arm - Ask the person to raise both arms. If an arm falls down or has no resistance, that is a sign of stroke. "S" stands for Speech. Slurred speech is a sign of stroke. "T" stands for Time. Diagnosis and treatment must be within 3 hours of the onset of symptoms.

If you recognize any of these symptoms in yourself, or someone around you, a stroke could be happening. CALL 911 IMMEDIATELY.

Stroke Diagnosis

It is critical to diagnose a stroke in progress because the treatment of stroke depends on the type, source, and even the location of the injury in the brain.

The type of stroke also must be determined because treatment is different for an ischemic versus a hemorrhagic stroke.

Timing is extremely important when it comes to diagnosing a stroke.

Different types of diagnostic tests that your physician may order to diagnose a stroke can include:

CT Scan (Computerized Tomography)

•An imaging test that uses radiation to create a picture of the brain. It is usually the first test ordered for a patient with stroke symptoms. This test will give the stroke team valuable information about the cause and location of the stroke and the extent of the injury to the brain.

MRI scan (Magnetic Resonance Imaging)

•MRI scans use a large magnetic field to produce an image of the brain that also show the location and extent of the stroke. The image that is created is sharper and more detailed than a CT scan so it is often used to diagnose small, deep injuries of the brain.

Treatment of Acute Stroke

Once the diagnosis of stroke is suspected or confirmed, treatments to try to restore blood flow to the brain are started. Timing is everything and will affect what treatments are used. Treatment options can include medications and medical procedures.

Thrombolytic

Medications

These medicines (also called clot busters) are used to dissolve blood clots that are blocking the arteries in the brain. To be most effective, these medicines must be given within 3 hours after the start of stroke symptoms. For some patients, it can be given up to 4.5 hours after the onset of symptoms. Many new procedures are being developed for treating acute stroke but all these therapies are time dependent. Therefore, the need for determining the exact onset of the stroke symptoms is extremely important.

Since timing is everything, it is important to call 911 if you or someone around you is experiencing the signs of a stroke. Do not drive yourself or let someone else drive him/herself to the hospital. Emergency Medical Services (EMS) will notify the Emergency Department of your symptoms and the stroke team will be activated before you arrive.

Who is at Risk?

Certain risk factors make it more likely that you will develop artery disease and have a stroke. Some risk factors for stroke can be controlled, while others can't.

Major risk factors for a stroke that you can control include:

• Smoking

• High blood pressure

• High blood cholesterol

• Overweight and obesity

• Physical inactivity

• Diabetes (high blood sugar)

• Atrial Fibrillation

• Illicit drug use

• Excessive alcohol consumption

• Diets high in salt, fried or greasy foods

Risk factors that you cannot change include:

• Age: Stroke affects all ages but the older you are, the greater your risk of stroke

• Heredity: The risk of a stroke is greater in people whose close blood relatives have had a stroke.

• Race: African Americans have a higher risk of death and disability from a stroke because they have a greater incidence of high blood pressure. Hispanic Americans are also at an increased risk for stroke due to complications of diabetes.

• Prior Stroke: Someone who has had a stroke is at higher risk of having another one.

• Gender: While more men have strokes each year, over half of the stroke deaths occur in women.

My Personal Risk Factors

Risk Factors are different for each person.

Check the risk factors below that apply to you.

– Remember that some of your risk factors cannot be changed but others can be managed successfully by working with your health care team.

High blood pressure

Obesity High Cholesterol

Atrial fibrillation

Diabetes Smoking

Sedentary lifestyle

Previous heart attack or stroke

Smoking

Tobacco use is the number one preventable cause of serious illnesses such as heart disease, stroke, lung cancer, and emphysema.

An estimated 25.1 million men and 20.9 million women smoke cigarettes.

The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. Some helpful tips to quit smoking include:

• Making an agreement with yourself to quit.

• Asking your nurse or physician about quit smoking aids (Chantix, Zyban, Nicoderm).

• Attending a smoking cessation class.

• Avoiding people who smoke.

Stop Smoking Now

Smoking can make cardiovascular disease worse, so if you smoke, you should stop immediately.

Quitting takes hard work and a lot of effort, but you CAN quit smoking.

For help refer to information provided by your nurse or contact the California Smoker’s Helpline: English 1-800-NO-BUTTS Spanish 1-800-45-NO-FUME

High Blood Pressure

High blood pressure (BP), or hypertension (HTN) is the single most important risk factor for stroke. Many people believe control of high blood pressure is a key reason for the decrease in death rates for stroke.

It is estimated that the prevalence of high blood pressure in adults over the age of 20 is approximately 72 million in the United States alone.

Up to 95 % of high blood pressure are from unknown causes,but the condition is easily detectable and treatable. In addition to medications, diet, exercise, and weight loss can assist in controlling your blood pressure.

Please ask to see a dietitian to assist you with healthy meal planning to lower both your blood pressure and your cholesterol.

•Normal blood pressure is 120/80.

•High blood pressure is 130/80 or higher.

•If you are diabetic, you are considered to have high blood pressure if your blood pressure is 130/85.

Mybloodpressureis:

High Cholesterol

About 36 million American adults have total cholesterol levels above 240 mg/dL. –Your total cholesterol should be below 200 mg/dL. Your triglyceride level should be below 150mg/dL. –Your HDL, or good cholesterol, should be 40 mg/dL or higher. –Your LDL, or bad cholesterol, should be less than 70mg/dL. In addition to medications, diet, exercise, and weight loss can help control you cholesterol levels. –Please ask to see a dietitian for healthy meal planning to

Atrial Fibrillation

Atrial fibrillation is a condition that causes the upper chambers of the heart, the atria, to quiver instead of beating effectively to move blood into the ventricle. This causes blood flow to slow and pool and can increase the risk of clotting.

If a clot breaks loose from the atria and enters the bloodstream, it can lodge in an artery leading to the brain and can cause a stroke.

About 15 to 20 percent of people who have a stroke have this heart arrhythmia. People with atrial fibrillation have an increased stroke risk of about 5% per year.

Treatment for atrial fibrillation includes medications such as Coumedin or warfarin, Asprin and Plavix. My heart rhythm is:

Diabetes

Diabetes is an independent risk factor for stroke.

Many people with diabetes also have high blood pressure, high cholesterol, and are overweight.

Diabetes is manageable with medications such as insulin, glipizide, and/or metformin. Diet and exercise can also help manage diabetes.

Your physician may perform a lab test called a hemoglobin A1c which will let them know how well your diabetes has been controlled in the last 90 days. The goal is to have a number less than 7.0%.

My hemoglobin A1c (HgbA1c) is:

If you have questions regarding diabetes, please ask to speak to any one of RUHS MC’s Diabetes Nurses

DASH Diet

(Dietary Approaches to Stop Hypertension)

The DASH diet is simply what the name implies, a diet to stop hypertension or high blood pressure. It is based on research that has shown that eating a low fat, low sodium diet rich in whole grains, low fat dairy foods, fruits and vegetables lowers blood pressure significantly. While it may seem difficult or overwhelming to change a lifetime of eating habits, making a few changes over a couple of days or weeks is often easier than changing your entire diet overnight.

Add a serving of vegetables at lunch one day and dinner the next, and add a fruit at one meal or snack. Increase your use of fat free and low fat milk products to three servings a day

Limit lean meats to 6 ounces a day three ounces a meal which is about the size of a deck of cards. Include two or more vegetarian style, or meatless meals each week.

Following the DASH Eating Plan

US Department of Health and Human Services, National Institute of Health. ww.nhlbi.nih.gov/health/public/heart/hbp/dash/new dash.pdf

DASH Eating Plan:

Dietary Tips to Reduce Cholesterol

Eat less saturated fat and cholesterol

Eat less total fat, even “good” fats such as olive oil. Avoid fried foods, fatty meats and whole milk products, including cheese and ice cream.

Select foods low in cholesterol. Cholesterol is found only in foods from animals. Foods from plants contain no cholesterol.

Choose foods low in saturated fat. Saturated fats are usually found in animal fats. But you should not eat the three plant oils (coconut, palm and palm kernel) that are high in saturated fat. These oils are often added to packaged foods.

Use as little hydrogenated and partially hydrogenated fats as possible.

Select tub or liquid margarine rather than stick margarine.

Medications

Anticoagulants and Antiplatelet Medications

Medicines such as aspirin and clopidogrel, and Aggrenox stop platelets (a blood cell related to clotting) from clumping together and forming unwanted clots.

Aspirin is recommended for preventing a first stroke in some patients. Along with other antiplatelet agents it also has an important role in preventing recurrent strokes.

These medications should not be stopped without first talking to your physicians. It is also important to tell all physicians treating you that you take these medicines.

Medications such as Coumadin (or warfarin) thin the blood and prevent clots from forming in your arteries. They are different from antiplatelet agents and are recommended primarily for patients with a high risk of stroke and people with atrial fibrillation. While these drugs are more effective preventing clots in people with atrial fibrillation, they may have side effects including bruising and bleeding. Careful follow up with one’s primary care physician, including blood tests to measure warfarin effect, is essential for people taking these drugs. Again, please be sure to tell any physician treating you that you take these drugs.

Beta Blockers

These medicines decrease the workload on your heart. Beta blockers also are used to relieve chest pain or discomfort and to help prevent additional heart attacks. Beta blockers also are used to correct arrhythmias (irregular heartbeats).

Medications

Angiotensin-Converting Enzyme Inhibitors (ACE-I)

These medicines (such as captopril, benazapril, and lisinopril) lower blood pressure and reduce the strain on your heart. They also help slow down further weakening of the heart muscle. Studies have also shown that in certain patients, use of ACE-I’s may reduce subsequent stroke incidence even if blood pressure is normal. In diabetics, these drugs may preserve renal function. In patients with kidney disease, these drugs slow decline in renal function and prolong time till dialysis is required.

Angiotensin Receptor Blockers (ARB)

These drugs are very similar to the ACE-I’s in terms of function, but instead of blocking formation of angiotensin as ACE-I’s do, they block the effect of angiotensin on the arteries themselves. Most of the positive effects of ACE-I’s as listed above are also noted with ARB’s.

Statins

These medicines, (such as atorvastatin or simvastatin and others) help lower cholesterol in the body. Statins also need to be monitored by your primary care physician and the dose adjusted to provide maximum benefit. Side effects can include muscle soreness and weakness which should be brought to the attention of your physician immediately.

Other Medicines

Medicines may also be given to relieve pain, anxiety, and depression which often occur during and after a stroke

If you need help paying for any of your medications, please talk to your nurse, case manager, or pharmacist for assistance.

Taking Medications

Here are a few tips for taking your medications. Most medicines need to be taken every day even if you feel fine. Ask your doctor or nurse about any special issues you should be aware of concerning your medications.

Have a routine: Take your medications at the same time each day and use reminders to help you stay on track.

Take all your medicines: Some work better when used together with others. Don't take one and skip another. Plan ahead: Refill your prescriptions before you run out.

Be sure to bring your medications when you travel. Never change your dosage or stop taking a medicine without talking to your primary care physician, and if you miss a pill, don't take two when it is time for the next dose.

Tell your primary care physician if you think you are having a side effect to a medication. Your physician may change the dose or give you a new prescription.

Carry an up-to-date list of your medicines and bring the list with you each time you visit your primary care provider. The pharmacy where you fill your prescriptions should also know about all the medications you take even if you do not have the prescriptions filled at the same pharmacy. This will help to prevent any potential medication reactions. Use a pill box to be sure you take all your medications properly every day. If you have difficulty filling the box correctly, ask a friend or relative to help.

Consult your physician if you are having difficulty swallowing pills, for example, coughing, or "getting stuck."

Life After a Stroke

When brain cells injured by a stroke cannot work, the part of the brain they control cannot work either. This is why a stroke can be so devastating. Brain injury from a stroke can affect the senses, motor activity, speech and the ability to understand speech. Brain injury can also affect a person’s behavior and thought patterns, memory and emotions.

Paralysis or weakness on one side of the body is common. These effects may be temporary or lasting depending on the area of the brain affected and the extent of the brain injury.

Injured and dead brain cells cannot heal or replace themselves.

Recovery from a severe stroke usually takes months or years of medical treatment, rehabilitation therapy and determined effort by the stroke survivor.

Many survivors never regain all their lost functions but despite these losses, many go on to lead full, productive lives.

Almost everyone feels tired after a stroke and while feeling fatigued is normal at first, you will probably start to feel less tired in a few months.

It is important to plan your activities to conserve your energy.

Aphasia

Aphasia is a language disorder that affects the ability to communicate. Aphasia is most often caused by a stroke that affects the left side of the brain which controls language.

Aphasia does not affect intelligence. Many stroke survivors remain mentally intact even though their speech may be jumbled, fragmented or impossible to understand.

Aphasia may manifest itself as trouble speaking, trouble finding words, understanding what others say, difficulty with reading, writing, or math, and/or the inability to process long words and infrequently used words.

People with aphasia are often frustrated and confused because they cannot speak or understand things the way they did before the stroke. They may act differently because of these changes in their brain. They report feeling isolated and alone. While these feelings are normal, they should be reported to your physician so they can determine if short term medications will help the situation.

Types of Aphasia

Receptive Aphasia: A patient with receptive aphasia is not able to follow directions or has difficulty understanding questions.

Some tips to make communicating with your loved one easier include:

Using visual cues

Using simple gestures

Simplifying instructions even to one word

Speaking slowly

Asking to perform tasks one step at a time Checking for comprehension frequently (don't assume they understand)

Expressive Aphasia: Patients with expressive aphasia have limited ability to use words. The patient may say words that they do not mean, for example, "no" for "yes."

Some tips to make communicating with your loved one easier include:

Using a communication board

Giving extra time for the patient to answer

Giving auditory/visual/written choices

Using yes/no questions

Asking the patient to point or gesture

Using writing if appropriate

My communications strategies include:

Dysarthria

Dysarthria is another communication and speech problem that can occur with stroke. Dysarthria is characterized by slow, “slurred,” or unintelligible speech.

In other words dysarthria affects how words are spoken. While this often occurs with aphasia, a language problem, it is not the same and can occur alone. Patients may experience weakness of the lips and tongue.

Some tips for improving communication with the patient with dysarthria include:

Sitting the patient up, if possible, for better breath support

Asking the patient to slow down and speak up Asking the patient to over-articulate or pretend they are speaking for a lip-reader

My Speech strategies are:__________________________________

If you have any questions regarding communication between you and your loved ones, please talk to your speech therapist or nurse for more helpful tips.

Swallowing Difficulties

Immediately following a stroke, patients sometimes have difficulty swallowing or may not be able to swallow at all. This disorder is called dysphagia. People with this problem often cough or choke when or immediately after they eat or drink. Food particles or liquid can then go into the lungs and cause aspiration pneumonia. Safe eating or drinking guidelines may be recommended by a speech therapist. Please follow the provided directions when feeding yourself or your loved one. While in the hospital, do not feed your loved one unless the staff has given you permission to.

The speech therapist working with your physician will develop a treatment program to help you with any swallowing difficulties. The therapist may recommend special consistencies for food and liquids to decrease the risks of aspiration and pneumonia. Please ask your speech therapist, nurse or a dietitian for specific details on the special food consistency that you may need.

Life After a Stroke

Treatment After You Leave the Hospital

Most people spend several days in the hospital after a stroke. When you leave the hospital, treatment does not stop. At home, your treatment may include daily medicines and rehabilitation (rehab).

Your doctor may recommend lifestyle changes including quitting smoking, losing weight, changing your diet, and increasing your physical activity, to lower your chances of having another stroke. Your care team may feel you are not strong enough to go directly home after your hospital stay and may suggest that you go to a skilled nursing facility or acute rehabilitation hospital for more rehab and strengthening. Your case manager will assist you and your family with these arrangements.

Rehabilitation After a Stroke

Rehabilitation is a critical part of the recovery of a stroke survivor. The effects of stroke may mean that you must relearn, change, or redefine how you live. While rehab does not reverse the effects of the stroke, it can help you return to your optimum level of function.

Rehabilitation begins when your physicians determine you are medically stable, you have the stamina to tolerate the therapy, and that you will benefit from it. Rehabilitation services are started in the hospital as early as medically possible but can be continued in various settings such as an acute rehab unit, skilled nursing facility, at home with home health, or in outpatient facilities. What you will do in rehab depends on what you need to become independent. The rehab team will assess your needs and determine a plan which may include:

Self-care skills such as feeding, grooming, bathing and dressing

Mobility skills such as transferring, walking or use of a wheelchair

Speech and language skills to improve communication

Rehabilitation After a Stroke

The Rehabilitation Team consists of several specialists.

They include:

Physical Therapists

Occupational Therapist

Speech Therapist

The services you may require from each will be determined by your physician and the team members working together with you to develop an individual rehab plan.

Patient & Family Services

During this time, you will interact with a Medical Social Worker. These Social Workers will help you and your families deal with social, emotional and financial concerns. They assist by helping in crisis intervention, counseling and/or helping cope with grief or loss. They may assist with finding resources, such as insurance programs, nursing homes, rehabilitation, home health care or other services that are needed for a safe and secure discharge from RUHS-MC care.

Case Management is responsible for multiple functions that allow patients within the system to receive needed services in the most cost-effective and efficient manner possible. They well provide reviews for insurance companies and will assist with provisions for home health care needs.

Being a Caregiver

When a loved one is disabled, it changes the family system by changing how each of the members relate to each other. Being a caregiver can be a satisfying experience, but can also be stressful. Family roles become confused. Some members may not feel comfortable in their new roles or the caregiver’s new role. Some may not want to “interfere” with what has already been planned or decided.

Family meetings can be uncomfortable and awkward, especially for people who have not talked openly about family matters before. Talking about feelings or asking for help is difficult for many people.

Case managers, social workers, physicians, and nursing staff at Riverside University Health Systems – Medical Center are available to assist you, your family and caregivers through this difficult time. Please notify your nurse or physician if you would like to speak to anyone about this new role in your life.

Anxiety & Depression After Stroke

Immediately after a stroke, a survivor may respond one way and weeks later respond entirely different. These emotional reactions may occur due to biological causes resulting from the stroke or psychological causes. Emotional changes such as rapid mood changes, crying or laughing that does not match a person’s mood or that lasts longer than seems appropriate, and depression are common. Psychological changes including frustration, anxiety, anger or apathy are common and often helped by talking to someone and acknowledging these feelings.

Depression is common after a stroke and can be treated with a variety of medicines. Depression often occurs within two weeks of the event and may seriously affect your rehabilitation and recovery. Depression also affects people who care for you during your recovery.

If you think you or your loved one is suffering from depression, please talk to your physician or nurse about possible treatments available to you.

Prevention

Modifying your personal risk factors is a very important step in preventing another stroke. It is also important for your friends and loved ones to know their risk factors to prevent their first stroke.

Healthy Lifestyle Choices

Healthy lifestyle choices to help prevent a stroke include:

Following a low-fat diet, rich in fruits and vegetables. Pay careful attention to the amounts and types of fat in your diet. Lowering your salt intake. These changes can help lower high blood pressure and high blood cholesterol.

Losing weight if you are overweight or obese. Quitting smoking. Doing physical activity to improve heart fitness. Ask your doctor how much and what kinds of physical activity are safe for you.

Prevention

Treat Related Conditions

In addition to making lifestyle changes, you can help prevent a first or recurrent stroke by treating your modifiable risk factors such as:

High blood cholesterol:

You may need medicine to lower your cholesterol if diet and exercise aren't enough.

High blood pressure: You may need medicine to keep your blood pressure under control. Diabetes:

If you have diabetes, control your blood sugar levels through diet and physical activity (as your physician recommends). Quit smoking now!

We Are Here for You

Living with the effects of a stroke is a chronic condition and requires continuous follow-up with a primary care physician. If you do not have a physician you see on an ongoing basis, please ask the physician treating you here to assist you in finding a solution. The case manager and social worker can also assist you with this process.

If you are having trouble sticking to your treatment plan, please do not change anything. Talk with your nurse or primary healthcare provider for help!

The Hurdles People Often Experience Are:

Cost of medicines

Communication issues Depression Caregiver issues

We can help and we want to help. Talk with your nurse or primary healthcare provider about these barriers and we can work out solutions together! We are here for you!