136
158
HTHS

THE DEVELOPMENT OF A RISK ASSESSMENT TOOL FOR _ -
SECONDARY STROKE PREVENTION: ‘ ._

IMPLICATIONS FOR THE AOVANCEO PRACTICE NURSE
IN PRIMARY CARE ‘ '

Scholarly Project for theDegree of MS. N. -
MICHIGAN STATE UNIVERISITY
DEBRA A. HANSEN ,
1999 '

 

 

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University

 

 

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THE DEVELOPMENT OF A RISK ASSESSMENT TOOL FOR
SECONDARY STROKE PREVENTION:
IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE IN PRIMARY CARE
By

Debra A. Hansen

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing

1 999

ABSTRACT
THE DEVELOPMENT OF A RISK ASSESSMENT TOOL FOR
SECONDARY STROKE PREVENTION:
IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE IN PRIMARY CARE
By

Debra A. Hansen

Stroke continues to be the third leading cause of death in the United States and it
has a major negative impact on the survivor, the family, and society as a whole.
Disabilities from a stroke force physical limitations to be a part of daily life which in turn
increases the person’s family’s economic burden. The major concern of this project is
with stroke survivors’ recurrent stroke prevention. There is a significant amount of
research regarding primary prevention of stroke, but there is a paucity of information
concerning secondary prevention. Yet, secondary prevention is essential in decreasing
the incidence, morbidity and mortality of stroke.

The focus of this scholarly project was to develop a tool for advanced practice
nurses (APN) to assess for the risk factors of a client who has had a stroke. The tool
includes collecting assessment data which would place the stroke client at risk for a
recurrent stroke and includes secondary prevention measures and strategies for
intervention. With the initial assessment by the APN, risks would be identified for the
stroke survivor. Mutual goals will then be developed. The stroke intervention strategies
will help increase adherence to preventive health behavior to reduce the risk of future
strokes.

The Health Belief Model provided the theoretical basis for this scholarly project.

The model identified the perceived susceptibility, perceived severity, perceived benefits,
perceived barriers, and cues to action for taking preventive health action. The focus of
this project will be the use of the risk assessment tool as a cue to action. The tool will
identify secondary risk prevention measures that should be a part of the routine care of a
stroke survivor in primary care. The roles of the APN as well as implications for further

research will be discussed.

ACKNOWLEDGMENTS

I would like to thank God for giving me the faith, will, and determination to pursue my
desire in obtaining an Advanced Practice Nursing Degree.

I want to express my sincere gratitude to the members of my committee who helped
guide me through this process. Thanks to Laura Struble PhD, RN, CS who was an exemplary
chairperson. She is truly a visionary scholar and always available to offer encouragement.
Thanks to Brigid Warren MSN, RN who provided insight and a critical eye from family practice.
I appreciate the neuroscience and medical expertise as well as the patience of Daniel Murrnan
MD. My committee’s interest and commitment to stroke survivors was greatly appreciated.

My sincere appreciation goes to Sharon King PhD, RN, CS, my Program Adviser, who
has been a mentor throughout my graduate education. Her positive and caring attitude, together
with her patience, cheerleading and humor has helped to make graduate school an enjoyable
learning experience.

I would like to acknowledge my friends, family, and the people who have been apart of
my life throughout this very long worthwhile process. I also wish to thank two close friends,
Diane Rabe and Janette Buhl, for their masterfully skilled proofreading and suggestions. I can
not thank you enough for your countless hours of devotion. I especially want to thank my
mother, Ila Hansen, for her unwavering support and encouragement. Thank you to my

grandmother, Anna Hansen, who made this experience possible.

iv

TABLE OF CONTENTS

LIST OF FIGURES ........................................................................................................... vi

INTRODUCTION ............................................................................................................. 1
Purpose of the Project ........................................................................................... 4
Conceptual Framework: Health Belief Model ...................................................... 6
Health Belief Model and Secondary Stroke Prevention ...................................... 12
Review of Literature ............................................................................................ 20
Project Plan .......................................................................................................... 58
Procedure for Use of the Risk Assessment Tool in Primary Care Practice ......... 60
Evaluation of Tool ................................................................................................ 67
Implications for Advanced Practice Nurses ......................................................... 69
Conclusion ............................................................................................................ 75

REFERENCES ................................................................................................................. 78
Appendix A: Geriatric Depression Scale ........................................................... 89
Appendix B: Mini-Mental State Exam .............................................................. 91
Appendix C: Food Guide Pyramid .................................................................... 92
Appendix D: Risk Assessment Tool for Secondary Stroke Prevention ............ 94
Appendix E: Issues for Patient and Family/Caregiver Education ................... 103

LIST OF FIGURES

Figure 1: Health Belief Model ........................................................................................ 9

Figure 2: Modification of the Health Belief Model for application of a secondary
stroke prevention risk assessment ................................................................. 13

vi

INTRODUCTION

Stroke, also known as apoplexy, cerebral vascular accident, and brain attack, is
on the increase for the first time in 35 years. Since 1993, age-adjusted stroke rates have
risen (Joint National Committee VI [JNC VI], 1997). Stroke is the number one cause of
adult disability and the third leading cause of death after heart disease and cancer
(American Heart Association [AHA], 1997; Stroke Prevention Council, 1998).
Approximately 160 thousand people in the United States (US) die of a stroke each year.
The American Heart Association (AHA) (1997) estimates every 53 seconds someone in
the US. suffers a stroke and every 3.3 minutes someone dies of a stroke. Stroke costs the
US. 30 billion dollars annually due to health care expenses and lost productivity. The
average cost per patient for the first 90 days is 15 thousand dollars (National Stroke
Association [N SA], l998b). In addition, patients with recurrent strokes have documented
higher costs 4 to 24 months afier their stroke. On the average, recurrent stroke totals
approximately 375 dollars per month more than first stroke (Samsa, Bian, Lipscomb, &
Matchar, 1999). The above statistics are unfortunate when considering that 80 percent of
all strokes are preventable (Stroke Prevention Council, 1998).

Costs include not only financial expenditures, but also personal losses of the
person surviving a stroke and the care-giver burden. Physical and mental disabilities are a
major problem after surviving a stroke. Approximately 4 million stroke survivors are
alive today in the US. (AHA, 1997). Three million of these stroke survivors are

permanently disabled because of stroke. In terms of disabilities, approximately one-third

of stroke survivors have mild impairments, one-third have moderate impairments, and
one-third have severe impairments (N SA, l998b). The impact of premature morbidity
from stroke on the ability of stroke survivors to function independently or to participate
fully in activities of daily living is devastating in terms of personal loss, pain and
suffering, the effects on families and loved ones, and economic burden.

The likelihood of a stroke recurrence is a significant problem. Each year more
than 700 thousand Americans experience a new or recurrent stroke (Stroke Prevention
Council, 1998). Patients with recurrent strokes ofien have a greater degree of impairment
and they have poorer survival rates compared to first stroke survivors. At 24 months, 57
percent of first stroke survivors were alive as compared to 48 percent of recurrent stroke
survivors (Samsa et al., 1999). When no prevention efforts have been attempted, stroke
recurrence is calculated to be 8 to 13 percent annually. When attention to secondary
prevention efforts is made by health care providers, stroke recurrence is estimated to be
14 percent the first year of stroke, and 5 to 8 percent thereafter annually (Viitanen,
Eriksson, & Asplund, 1988). Secondary prevention efforts documented in the literature
includes anticoagulation in patients with a presumed embolic brain infarction,
antiplatelet therapy in patients with small nonembolic brain infarctions and careful.
control of hypertension, cardiac failure, and diabetes mellitus. The high frequency of a
recurrent stroke and the poor outcomes related to that recurrence underscores the
importance of secondary prevention.

As the elderly population living in the US. increases, the importance of stroke

prevention will increase. The incidence of stroke is ten times greater in the 75 to 84 age

group than in the 55 to 64-age group (Kane, Ouslander, & Abass, 1994). Americans 65
years old and above are projected to make up 20 percent of the population by the year
2030 as compared with 12 percent in 1997 (US. Department of Commerce, 1997). Most
of the growth projected will occur between 2010 and 2030 at a rate of 2.8 percent
annually, when the baby boom generation enters their older adult years (US. Census
Bureau, 1995). Since stroke incidence increases with age, the prevalence of stroke is
expected to increase as the baby boom generation ages (Goldberg, 1991 ). The need for
health providers to assess and develop strategies to prevent stroke and its recurrence is
imperative because of the aging population, the high incidence of stroke and the
damaging neurological consequences of a stroke.

Management of stroke survivors is impacted by the changes in health care,
primarily in managed care. Managed care is a system that attempts to achieve the best
product at the lowest price. With managed care, a Shift occurs from costly specialists to
primary care providers. Often a stroke survivor is referred from the neurologist and
physiatrist to a primary care provider, once the survivor has been stabilized and initial
rehabilitation completed (Ozer, Materson, & Caplan, 1994). The primary care provider
facilitates access to health care and rehabilitation, develops holistic management plans,
and provides ongoing follow-up utilizing specialists for consultation.

Stroke is a problem with potentially grave consequences. Many assumptions have
been made regarding stroke due to lack of knowledge, such as “a stroke is a stroke,” yet
location and type of stroke are important data to know for proper management. Because

of the increasing number of people affected by stroke and changes in the health care

system, it is becoming increasing important for primary care providers to play a role in
stroke management. Ofien, after initial contact with specialists and rehabilitation, stroke
survivors return to their primary care provider. Therefore, primary care providers need a
strong knowledge base in stroke management and coordination of care. Not enough
thought is given to stroke recurrence prevention in primary care journals. No articles
were found in primary care journals within the last five years that discuss post stroke
care. With the potential increase in number of stroke survivors and high stroke morbidity
and mortality statistics, the primary care advanced practice nurse (APN) needs to be able

to assess secondary stroke risk factors and develop a prevention management plan.

Purpose of the Project

The purpose of this project was to develop a risk assessment tool to assess and
identify secondary prevention interventions for patients that have experienced stroke.
This tool will be utilized by the APN in the primary care setting. Although primary
prevention of stroke is clearly a preferred goal for care of at risk populations, secondary
prevention of stroke is equally important in the care of stroke survivors (Golberg, 1991).
Secondary prevention consists of screening for risk factors, patient education, and
appropriate interventions to halt the disease process (Fender, 1996). Most strokes can
now be prevented using research based interventions, but the challenge remains to apply
the treatments effectively in a clinical practice. The pr0posed tool will determine those
interventions that will decrease the likelihood of stroke recurrence for a particular

individual. The purpose of this tool is to assist the APN in assessment and management

of stroke survivors in primary care enhancing the overall care of the stroke survivor and
is not intended to be a comprehensive management instrument. The premise will be
stroke recurrence prevention through risk factor reduction (Wolf, D’Agostino, Belanger,
& Kannel, 1991).

The goal of this risk assessment tool is to obtain optimal patient health by
reduction of stroke risk factors which are based on current research and standardized
practice interventions. The APN’s role in managing stroke in primary care is invaluable
toward achieving positive outcomes. Positive outcomes would include decreased
morbidity, mortality, and decreased number of stroke recurrences. Discussion of an
individual’s risk for stroke recurrence with an APN and implementation of strategies to
diminish the risk are key elements of secondary stroke prevention. In a survey of
Americans, more than one half of people at risk for stroke were unaware of their risk.
People who were aware of their increased risk were more apt to participate in stroke
prevention practices (Samsa et al., 1997).

This research-based tool provides decision points for the APN to effectively
screen and manage the stroke survivor in the primary care setting, after the individual has
received acute care and rehabilitation. The targeted population for this tool is stroke
survivors with no dysfunction or mild dysfunction, which combined make up
approximately 50 percent of stroke survivors (Robbins, 1978). The targeted population
could most likely be followed in a primary care office situation. To facilitate the
development of this tool, the Health Belief Model (HBM) will be used as a conceptual

framework (Becker, 1974; Janz & Becker, 1984; Pender, 1996).

Conceptual Framework: Health Belief Model

The HBM is used as a framework for developing a tool aimed at assessment of
stroke survivors and stroke recurrence prevention in a primary care environment. The
HBM was formulated by Hochbaum and associates during the 1950's (Champion, 1984).
The HBM provides a method for understanding and predicting health behavior
(Davidhizar, 1983). An understanding of health behavior is necessary to develop methods
to influence and facilitate behavior change. Control of risk factors for recurrent strokes
such as obesity, hypertension, and diabetes will need to take place by motivating the
stroke client to behaviorally change their health habits.

It is possible that the health promotion model (Pender, 1996) could be used as a
framework for developing a tool used in stroke recurrence prevention, rather than the
HBM. The health promotion model does not rely on personal threat as a primary source
of health motivation. Immediate threats to health have been shown to motivate action for
positive health behaviors. Threats in the distant future, however, may lack the same
motivational strength. The health promotion model, then is more applicable to the young
and people who perceive themselves invulnerable to illness. In this project, the illness or
stroke is present. Because the HBM utilizes threat, the threat is present, and the threat has
been shown to motivate behavior, the HBM will be utilized.

The HBM originated from social-psychologic theory as a framework of exploring
why some people took preventive health action through screening tests to avoid illness
while others did not. The theory underlying the HBM has been attributed to the Lewinian

theory of goal setting. Lewin, Dembo, Festinger, and Sears (1944) hypothesized behavior

depends mainly upon two variables. One variable was the value placed by an individual
on an outcome and the second was the individual’s estimate of the likelihood that a given
action will result in the desired outcome. The HBM makes the assumption that health is
highly valued (Janz & Becker, 1984).

The HBM has been derived from theories of decision making. In making the
decision whether or not to take on a preventive health action, an individual goes through
a progression of steps. Rosenstock (1966) stated studies performed by Koos (1954),
Stoekle (1963), Zola (1964), Friedson (1961), and Suctrnan (1965) explained
relationships between demographic factors and utilization of services. They individually
proposed that an individual, when confronted with symptoms, goes through a decision
making process in which the individual moves through stages. The individual interacts
with persons and events at each of the stages which influences the individual’s decisions
and subsequent behavior.

The definitions of health behavior, illness behavior and sick role behavior are
important within the HBM. Kasl and Cobb (1966) defined health behavior as any activity
done by a healthy person for the purpose of preventing or detecting disease. Illness
behavior was defined as an activity done by a person who believes himself to be ill. The
purpose of illness behavior was to seek to define the disease state and find appropriate
treatment. Sick role behavior was the activity taken on by an individual that considers
himself ill, for the purpose of getting well. Sick role behavior included the activities of
receiving treatment, dependent behaviors and omission of one’s usual activities. The

three behaviors are on a continuum on which the borders are blurred.

The HBM is organized into three vertical columns. Those column headings are
Individual Perceptions (the individual’s perceptions of susceptibility to a disease the
perceived seriousness of the disease), Modifying Factors (demographics,
sociopsychologic and structural variables, perceived threat, and cues to action), and
Likelihood of Action (the benefits and barriers associated with the choice of action that
may prevent the disease process). The constructs of the model will be discussed in the
order in which they appear within the HBM (see Figure 1).

The two constructs within the individual perceptions column are perceived
susceptibility and perceived seriousness. W refers to the risks the
individual believes he has of contracting a condition. People are believed to vary in their
perceived susceptibility of disease whether or not there is a statistical chance that they
could contract a disease. W is created by the degree of emotion
related to the thought of a certain disease as well as the number of problems that the
individual believes that the illness could create for him and his family. Perceived
susceptibility and perceived seriousness influence perceived threat and are influenced by
demographic, sociopsychologic, and structural variables as depicted by the arrows. The
acceptance of an individual’s susceptibility to a serious disease was thought to lead an
individual to action, but does not define the course of action (Rosenstock, 1966).

l I if . E
Modifying factors include demographic, sociopsychologic, and structural

variables, perceived threat, and cues to action. W are personal

Individual Percepflons

Modflying Factors

 

 

Demographic variables
(age, sex, race,
ethnicity, etc.)

Sociopsychologic
variables

(personality, social class,

peerand
reference-group pressurel
etc.)

Structural variables
(knowledge about the
disease, prior contact
with the disease, etc.)

Ukellhood of Action

 

 

Perceived benefits of
preventative action

minus

Perceived barriers to
preventative action

 

 

 

  

‘ Perceived

  

I

Perceived threat of

 

l—+

 

 

Likelihood of taking

recommended
preventative hea

action

 

 

 

 

 

 

magazine article

susceptibility to disease X
disease X T
Perceived seriousness
(severity) of disease Cues to action
X Mass media
campaigns
Advice from others
Reminder postcard

from physician or
dentist
Illness of family
member or friend
Newspaper or

 

HERE—L. The Health Belief Model. (From Pender, NJ. (1996). Health Promotion in
Nursing Practice (3rd ed.) Stamford, Connecticut: Appleton & Lange, pg. 36).

 

characteristics such as age, sex, race, and ethnicity. Kasl and Cobb (1966) understand
health and illness behaviors as a function of personal characteristics which are variables
in the perception of symptoms. MW include personality and social
class and are influenced by the norms and peer pressure. MW, such as the
individual’s knowledge of health and disease, impact both perceived susceptibility and
perceived seriousness (Rosenstock, 1966). The demographic, sociopsychologic, and
structural variables influence perceived susceptibility and seriousness, perceived threat,
and perceived benefits and barriers.

Perceived susceptibility and seriousness, demographic, sociopsychologic, and
structural variables, and cues to action all influence mm as depicted by the
arrows on the model. The perceived threat is an important construct of the HBM because
the individual must perceive his or her health as threatened in order to consider
preventive action. Perceived threat influences the likelihood of taking action.

The HBM contends that Winn or internal and/or external stimuli must
occur to trigger the health behavior. Cues to action make the individual aware of the
health threat and thereby increase the likelihood of taking action (Davidhizar, 1983;
Pender, 1996). Cues to action can be strategies to activate an individual’s readiness to
follow a prescribed regimen (Davidhizar, 1983). Cues to action can be in the form of
warning labels, comments, internal feelings, symptom recognition, pamphlets, health
care education or recommendations encountered by the person in his or her environment.
Rosenstock (1966) identified clear symptoms of disease as a frequent source of health

behavior initiation or cue to action.

10

I '1 1'] l E 9 .
“W5 are beliefs about the effectiveness of recommended actions in

preventing the health threat” (Pender, 1996, p.35). The action or inaction on a health
behavior will depend on the individual’s beliefs regarding the efficacy of the advised
health action. “W are perceptions concerning the potential negative
aspects of taking action such as expense, danger, unpleasantness, inconvenience, and
time required” (Pender, 1996, p.35). A barrier is an obstacle preventing the individual
from following the suggested health behavior. Perceived benefits and barriers influence
the likelihood of taking action. Perceived baniers are believed to be the most powerful of
the HBM constructs in predicting various health behaviors (J anz & Becker, 1984;

Pender, 1996).

If the level of readiness to act, which is a high perceived susceptibility and
severity level, and the barriers are low, the health action is more likely to take place. The
amount of one necessary for the action to occur is directly related to the level of
readiness (Davidhizar, 1983). Thus the lower the level of readiness, the greater the cues
needed.

The definitions of health, illness and sick role behaviors and the definitions of the
major constructs of the HBM support the use of the model in secondary stroke
prevention. A substantial amount of research has been based on the HBM constructs.
Janz and Becker (1984) critically reviewed 29 HBM related investigations from 1974-
1984, tabulated the findings from 17 studies prior to 1974, and provided a summary of

the 46 HBM studies. They found perceived barriers to be the most powerful of the HBM

11

concepts across the various study designs and diversity of populations. Perceived
susceptibility was identified as a stronger contributor to understanding preventive health
behaviors than sick role behaviors. Perceived benefits were stronger contributors to
understanding sick role behaviors than preventive health behaviors. Perceived severity
was strongly related to sick role behaviors. Overall the research provides substantial
evidence supporting the HBM as an important contribution to the explanation and

prediction of individuals’ health-related behaviors.

Health Belief Model and Secondary Stroke Prevention

The HBM constructs are used to define the components required in a tool for
secondary stroke prevention in order to facilitate preventive health action. The following
section will explain the various facets of the HBM as it relates to secondary stroke
prevention risk assessment (see Figure 2). The constructs will be discussed as they appear
within the model. Although the entire model is required in behavior change for stroke
prevention, the cues to action construct will be the focus of this project.

I l' . l l E .

Under individual perceptions, Becker (1974) identified three dimensions of
pergg'yed susceptibility in the case of diagnosed disease. The three dimensions are the
individual’s belief in the accuracy of the diagnosis, the individual’s estimate of
resusceptibility or recurrence of illness, and the individual’s perception of vulnerability
to disease and illness in general. The dimensions add more specific information about

susceptibility in patients that have experienced stroke. An individual who has

12

individual Perceptions

Modifying Factors

 

Demographic variables
(increasing age. sex.
African American. etc.)

Sociopsychologic variables

Health motivation

Self efficacy

Locus of control

Structural variables
(knowledge about stroke.
prior contact with stroke
survivors. etc.)

 

Likelihood of Action

 

Perceived benefits of
preventive action

minus

Perceived barriers to
preventive action:
'Depression
'Lack of social support
'Lack of knowledge and /or
understanding

'Functional impairments
'Cognitive impairments

 

 

 

 

 

Perceived susceptibility to
stroke recurrence
'accuracy of diagnosis
'statistics and risk factors
related to stroke recurrence
'vulnerability to illness

Perceived seriousness
(severity) of stroke
recurrence
'worsening disability
'death

 

 

 

 

ercerve rea 0
stroke recurrence

V

 

Outcome

 

 

 

 

CUES i0 3C|i0 T

APN Risk Assessment

Hawaiian
‘Survivor Completion of Tool
‘APN Chart Revrew/History
'APN Physical Assessment

[Complete Neuro Exam]
‘Determination of Rial-((3):
II lschemlc Risk
CardiO/Atheroembolic (20%)
Atherothrombotic (20%)
Lacunar Disease (25%)
Cryptogenic (Unknown) (30%)
Other (5%)
II. Hemorrhagic

 

Ill. Lifestyle Factors

 

HTN

Diabetes
Hyperlipidemia
Smoking
Weight

Physical Activity

 

 

Likelihood of taking
recommended

preventative health
action

‘Goal Setting 8- Education
'Ongoing Evaluation

 

 

 

 

Outcome
Decreased incidence of
recurrent stroke

Decreased cardiovascular
events at cornorbidities

Increased adherence to
preventive behavior

 

EMILE; Modification of the Health Belief Model for application of a secondary stroke
prevention risk assessment.

13

 

experienced poor health, such as a previous stroke, is more likely to perceive himself
vulnerable to health threats from an illness and comply with health promotion behaviors
than someone who has experienced good health (Becker, 1974).

MW relates to the perceived impact of a second stroke on the
individual and family. An individual’s estimates of the seriousness of stroke and stroke
recurrence are predictive of compliance with the prescribed medical regimen. The
presence of physical symptoms probably increases perceived severity which in turn
motivates the individual to follow medical recommendations as long as the symptoms
persist (Becker, 1974). Data regarding recurrences and potential consequences
(worsening disability or likelihood of death) can impact an individual’s perception of
seriousness. Both the perceived susceptibility and seriousness related to stroke will
impact the perceived threat of stroke recurrence as shown by the arrow in the model.

I i if . E

Many of the modifying factors discussed in the original HBM also apply to the
modified HBM. Only those factors peculiar to stroke will be discussed at this time. There
are specific demographics that impact or are modifying factors for stroke survivors.
African Americans, older adults, and stroke survivors are at higher risk for stroke and
should be targeted for stroke prevention. Structural variables, such as personal
experiences of individuals and significant others, may affect an individual’s health
beliefs toward stroke.

In addition to the original constructs, health motivation, self efficacy and locus of

control have also been used as a part of the HBM in predicting health related behavior

14

and have been added to the modified HBM. Healmmgtiyatjgg refers to a general state of
concern about health that results in behaviors to maintain or improve health and diminish
disease (Becker, 1974). Selfefilgag was added later into the interventions based on the
model by Rosenstock, Strecher, and Becker (1988). Perceived self-efficacy is a judgment
of one’s ability to perform a behavior to the level needed to influence the outcome.
WM relates to outcome expectations or an individual’s belief that a given
behavior will lead to certain outcomes (Rosenstock et al., 1988; Pender, 1996). Locus of
control is either internal, such as personally controlled outcomes, or external, referring to
outcomes determined outside of the person’s control. The author believes these concepts
are very important to consider in developing a plan for secondary stroke prevention.

The modifying factors mentioned above and the cues to action impact the
perceived threat of the chronic disease process. W that may accompany
stroke include: increased mortality and morbidity, increased costs, decreased functional
status, and decreased quality of life. An assessment of perceived threat and additional
cues to action is critical to determine the triggers necessary to stimulate the appropriate
healthy behavior.

The W in the modified HBM is the implementation of the risk
assessment tool by the APN in primary care, which is the focus of this paper. The
original HBM indicates that external information received is one of the primary items
that affect the perceived threat of a disease. Rather than relying on information from one
of several sources such as mass media or advice from friends, the assessment tool can

serve as an effective cue to action for the stroke survivor. In the case of recurring stroke,

15

it is important that information conveyed to the stroke survivor be tailored to that
individual. The likelihood of action will increase if the stroke survivor perceives the
information being received is relevant to their situation. The assessment tool can serve as
a systematic method to gather information regarding stroke risks, evaluate the risks, and
create the plan utilizing the appropriate suggested strategies within the tool.

With the modified HBM as a guide and prior to the use of the tool, the APN
would identify the survivor’s perceptions of susceptibility/severity of the disease and
acceptance of the diagnosis along with the survivor’s understanding of recurrence. The
influence of factors such as demographics, sociopsychologic and structural variables,
locus of control, self efficacy, knowledge, perceived threat, and benefits and barriers
would be addressed on an individual basis. Through the use of the risk assessment tool,
chart review, and physical assessment, the APN would go through a process of risk
appraisal and determination of risk(s).The risks are divided into ischemic risk,
hemorrhagic risk, and lifestyle factors. Each of these three areas will be discussed later in
the project.

I 'l H l E 5 .

Benefits are perceived advantages of health or illness prevention behaviors. To
increase perceived benefits, health actions must demonstrate effectiveness in preventing
stroke recurrence. Listing benefits of the new preventive health behaviors may be
helpful. Encouraging behavior changes in a step by step fashion, allowing time to
integrate the new behavior before suggesting the next step may be beneficial. Current

prevention strategies will be integrated into the plan.

16

Barriers, the perceived negatives relating to a desired outcome, must be addressed
in the assessment tool as barriers are the strongest predictors of whether or not an
individual will take on the health behavior (J anz & Becker, 1984). Identifying barriers
reflects individual acknowledgment of potential obstacles to change, appraises readiness
to initiate and sustain lifestyle change, and provides an important way of choosing
between alternative means of goal achievement. The stronger the perceived barrier, the
less likely the individual will make the behavior change. Therefore, stroke prevention
behaviors need to be as simple, convenient, and as tailored to the individual as possible.
Examples of barriers that affect stroke survivors are depression, lack of social support,
lack of knowledge and/or understanding, functional impairments, and cognitive
impairments. Each of these barriers will be discussed further in the review of literature
section.

Once the benefits and barriers have been assessed, it is time for action. Goal
setting and education of the stroke client and family increases the hkehhmdgflakmg
WW. Goal setting with the survivor is important to
increase knowledge related to the disease process, increase awareness of potential
barriers, and address ways to overcome barriers, increase awareness of benefits to
adherence, and to assist him or her in identifying and using social support (Given &
Given, 1983). Maintenance of realistic goal setting allows for a sense of enhanced
efficacy and control over potentially uncontrollable outcomes. In accepting ownership of
change, survivors accept responsibility or accountability for their behaviors and for

desired changes.

17

Self regulation is “the process through which individuals transform goal
intentions into personalized action” (Fleury, Thomas, & Ratledge, 1997, p. 31). The
concept of self regulation offers health care providers a basis for facilitating risk
reduction and individualized participation, thereby enhancing self management in
behavior change. Self-monitoring reflects the individual assessment of adherence to self-
deterrnined performance criteria and progress toward desired goals. An example of self-
monitoring could include a checklist that provides information about the frequency and
timing of behavior as well as feelings associated with the behavior. Self-monitoring
serves an important role in the maintenance of internal standards for behavior. Through
monitoring efforts, survivors are aware of the positive physical and mental changes that
came with risk factor modification efforts and perceived the ability to continue with life
changes and achieve valued goals (Fleury et al., 1997).

Because stroke is complex, survivors and support people need to be educated
about the disease process and prescribed therapeutic regimen. Survivors should be
educated about the symptoms of stroke and importance of seeking treatment emergently
should symptoms of stroke occur. Patient education should be an ongoing process and
patient’s understanding should be evaluated. Education at the time of discharge from the
acute care setting may not always be the best time for education. Education should be
reviewed during rehabilitation and in office settings. It is important to be sensitive to the
survivor’s educational and cognitive level, language, culture. All of these impact
understanding and adherence.

Once information (individual perceptions, modifying factors, and likelihood of

18

action) regarding the stroke survivor has been gathered and assessed, a plan of action can
be formulated with the use of the tool. This plan will encompass recommended
preventive health action, goal setting, education, and ongoing evaluation. As part of the
recommended preventive health action, stroke survivors need to acquire certain beliefs,
knowledge, and behaviors in order to manage their chronic disease, according to the
HBM. Therefore, the survivor must be aware of his or her beliefs, recognize barriers to
and benefits of following the recommended regimen, know how to obtain support for the
adopted behaviors, and how to self-monitor the new behaviors (Given & Given, 1983).

Following rehabilitation or acute care (if no rehabilitation required), the APN
would see the survivor in an outpatient office visit, within one month of discharge, and
initiate the tool. The survivor should also be evaluated at regular intervals during at least
the first year post discharge, consistent with the survivor’s condition and goals set. The
overall goals of monitoring regularly are to support and document the maintenance of
functional gains achieved during rehabilitation, making further progress toward
functional independence, and reintegrating successfully with the family and community
(Gresham et al., 1995).
Queenie

The last segment of the modified HBM addresses outcome. Successful
application of the risk assessment tool with the modified HBM will result in reduced
recurrent stroke, reduced cerebrovascular risk, and reduced comorbidities. Adherence to
preventive behavior plays a key role in each of these improvements. For the best chance

of behavior change to occur, the individual will need an internal locus of control and

19

positive self efficacy expectations regarding the proposed health behavior (Given &
Given, 1983).

Stroke survivors can be a major challenge to the health care provider due to their
complex health problems, the recovery and rehabilitation process, and the psychological
adjustment to the chronic disease. Successful management of a stroke survivor requires
major lifestyle changes within the individual, which may affect the support network as
well. The modified HBM can provide a solid framework for determining the predictive
variables that influence health choices of stroke survivors. The application of the
modified HBM for secondary stroke prevention risk assessment when used by the APN

can help motivate and sustain behavior change.

Review of Literature

The concepts of the HBM are used to define the components that need to be
addressed in a risk assessment tool designed to aide in secondary stroke prevention. The
literature review delineates these components. The definition and types of stroke,
pathophysiology, signs and symptoms of stroke, consequences, and stroke recurrence will
be briefly reviewed. Risk appraisal and risk reduction will be highlighted. Risk factors
will be discussed at length. Treatments, baniers to adherence to secondary prevention,
and secondary stroke prevention will also be discussed. Furthermore, the review of the
literature addresses the multiple variables and prevention issues of the condition and
limitations of the review. The literature review supports the need for primary care

provider and consumer education if prevention and behavior change are to occur.

20

5 I . I; [i . . l I

“Stroke is a heterogeneous, neurological event characterized by the gradual or
rapid nonconvulsive onset of neurological deficits that fit a known vascular territory and
that lasts for 24 hours or more” (Hickey, 1997, p. 543). Over the years, the stroke disease
process has been identified in different ways. Stroke was originally designated as
apoplexy. The meaning of apoplexy can be traced from the Greek words “apo” which
means from and “plesso” which means to strike (Camarata, Heros, & Latchaw, 1994).
Apoplexy was meant to convey the belief that the potentially devastating disease was
caused by a stroke of God’s hand in response to unsuitable living. The term cerebral
vascular accident (CVA) evolved in the 1900's. Currently, CVA has not been used as
often as stroke because of the true nonaccidental nature of the disease process
(Bronstein, Popovich, & Stewart-Amedei, 1991). The term “brain attack” is currently
. used to denote the emergent nature of the disease similar to heart attack or myocardial
infarction (Camarata et al., 1994). It is important to convey the need to seek emergent
medical attention with the advent of therapeutic interventions that are beneficial only
within the first few hours after the onset of stroke symptoms. Cardiac resuscitation
training programs in basic cardiac life support (BCLS) and advanced cardiac life support
(ACLS) have been redesigned to include material on stroke with a focus on saving brain
tissue. The previous dismal views of stroke outcomes are being replaced with optimism
for better outcomes for stroke survivors.

Two major types of stroke are ischemic stroke (or cerebral infarction) and

hemorrhagic stroke (or intercerebral or subdural hemorrhage). Ischemic stroke is caused

21

by the interruption of the blood supply to an area of the brain supplied by an arteriole.
Ischemic stroke is further divided into W or of unknown origin (30%),
small penetrating artery thrombosis or W (25%), large artery thrombosis or
Wheat»: (20%), W (20%), and mhetnrie (5%).
Hemorrhagic stroke is a rupture of one of the arterioles that feed an area of the brain.
Atherosclerosis of small and large cerebral arteries which result in blockage or
thrombosis makes up 45 percent of the strokes in the US. (Hickey, 1997; Albers,
Easton, Sacco, & Teal, 1998).

Ischemic vascular disease is divided into two broad categories of thrombotic and
embolic. Between 10 and 20 percent of people with thrombotic strokes have had at least
one prior transient ischemic attack. Thrombotic strokes often present with changing or
fluctuating symptoms that worsen over minutes to hours. In comparison, embolic strokes
usually present with a neurologic deficit that is maximum at the onset of symptoms
(Easton, Hauser, & Martin, 1998).

Stroke is differentiated from Transient Ischemic Attack (TIA) and Reversible
Ischemic Neurologic Deficits (RINDS) by the length of time of neurologic deficit. The
majority of TIAS are short, between two to fifteen minutes, with complete clearing of
neurologic deficits within one hour. Neurologic symptoms of TIA usually fit a known
vascular territory may last up to twenty-four hours (Uphold & Graham, 1998). TIAS are
thrombotic ischemic events (Schretzman, 1999). RINDs are defined as a focal cerebral
ischemia that lasts greater than twenty-four hours and resolves completely within three

weeks (Uphold & Graham, 1998).

22

WW

Atherosclerosis is the gradual underlying process resulting in ischemic
cerebrovascular disease. There are two theories of atherogenesis, which is the process of
developing atherosclerosis. One is the vessel reaction to injury and the other is the lipid
hypothesis. No matter which theory, the artery undergoes a series of changes that result
in structural alteration of the vessel. Atherosclerotic plaque slowly accumulates in the
cerebral arteries and facilitates the formation of thrombi (Hickey, 1997). Thrombus
formation, which is secondary to atherosclerosis, begins with plaque formation which
intrudes into the lumen of the artery. The plaque formation may enlarge to cause stenosis
of the artery. The surface of the plaque is rough and irregular creating a site for platelet
aggregation. Fibrin networks develop when platelets clump together. Blood cells stick to
the platelet and fibrin network forming blood clots, further narrowing the artery (Bratina
et al., 1997). The narrowed artery may eventually occlude, usually during hypotension,
and typically in early morning. The lack of blood flow to the area fed by the artery leads
to the signs and symptoms of ischemia.

Embolic ischemic strokes are caused by occlusive material, such as blood clots or
atheromatous debris from outside the brain. Emboli commonly originate from the left
chambers of the heart, the internal carotid arteries, or the vertebral arteries. This material
detaches from the vessel wall and eventually occludes a cerebral vessel (Bratina etal.,
1997). Individuals with atrial fibrillation, valvular heart disease, coronary heart disease
are at significant risk for embolus formation.

Brain cells do not tolerate the absence of blood flow regardless of mechanism. In

23

acute ischemic stroke, the area in the brain lacking the blood flow is considered the core
of the ischemic area. The area between the ischemic core and the surrounding perfused
brain tissue is known as penumbra (Bratina et al., 1997). Within the penumbra, the blood
flow is reduced, but for a limited period of time, the neurons are able to survive.
Emergency treatment is directed at the penumbra] region to prevent it from being added
at the infarcted zone. Decreased blood flow to an area in the brain initiates an ischemic
cascade resulting in eventual death of the under perfused cells if the ischemic condition
is not reversed.

W

A 1996 National Stroke Association/Gallup survey on stroke awareness in the
US. revealed among adults over the age 50, 38 percent did not know where in the body
a stroke occurs. Only 40 percent of the respondents would call 911 immediately if they
were having a stroke. Two-thirds of the respondents were unaware of the short time
frame in which an individual must seek treatment (N SA, 1998a). These statistics are
staggering in light of the National Stroke Association (N SA) and American Heart
Association (AHA) attempts to educate the public.

Common stroke symptoms include weakness, numbness, or paralysis of one side
of face, arm and/or leg. Sudden blurred or decreased vision in one or both eyes and
difficulty speaking or understanding words may occur. Dizziness, loss of balance, or loss
of coordination can indicate stroke especially if combined with one of the other
symptoms. Sudden severe headache may occur with stroke. A headache described as “the

worst headache of your life” is an indication of a hemorrhagic event (N SA, l998a).

24

Specific signs or manifestations of stroke can be divided into anterior circulation
and posterior circulation strokes. The anterior circulation can further be divided into
anterior cerebral artery and middle cerebral artery. Signs of anterior cerebral artery
disruption include any or all of the following: abulia (lack of initiative) flat affect and
apathy, aphasia (dominant hemisphere), gaze deviation toward the affected side,
contralateral (opposite side of the body) hemiparesis or hemiplegia (leg involvement
greater than arm), apraxia (inability to perform purposeful movements) on the affected
side. Signs of middle cerebral artery disruption include any or all of the following:
aphasia (dominant hemisphere), dysarthria (difficulty or inability to speak due to
impairment of muscles essential to speech), gaze deviation toward the affected side,
homonymous hemianopia (blindness of nasal half of the visual field of one eye and
temporal half of the other), contralateral hemiparesis or hemiplegia, contralateral sensory
deficits, and visual and sensory neglect (nondominant hemisphere) (Bratina et al., 1997).

The posterior circulation can be divided into the posterior cereme artery and
vertebrobasilar arteries. Manifestations of posterior cerebral artery disruption include any
or all of the following: memory deficits, Wemicke’s aphasia, and contralateral
homonymous hemianopia. Manifestations of vertebrobasilar arteries include any or all of
the following: impaired level of consciousness, cranial nerve palsies, nystagmus,
dysarthria, dysphagia, ipsilateral Homer’s syndrome, vertigo, nausea and vomiting,
contralateral hemiparesis or hemiplegia (arm and leg), ataxia (impaired muscular
coordination), ipsilateral (same side of body) face with contralateral body sensory

deficits, and locked-in syndrome (Bratina et al., 1997).

25

W

Complications of stroke or consequences can impact an individual’s perception
of severity and susceptibility to a recurrent stroke. Each year, 160 thousand Americans
die after stroke (AHA, 1997). Mortality from stroke ranges from 17 percent to 34 percent
during the first 30 days and from 25 percent to 40 percent during the first year (Gresham
et al., 1995). More women die each year from a stroke than from breast cancer (Stroke
Prevention Council, 1998). Stroke is the leading cause of serious, long-term disability in
the US. (AHA, 1997). Approximately 10 and 40 percent of stroke survivors have no to
mild dysfunction, respectively. Forty percent have significant dysfunction and 10 percent
require institutional care (Robbins, 1978). Stroke survivors can be left with significant
neurological deficits based on stroke location. Cognitive impairment, functional
disability, and risk of falling may affect an individual’s ability to live independently.
SW

Stroke recurrence is a major threat and potential consequence facing the stroke
client. Stroke recurrence was docrunented as more frequently associated with a history of
TIA, atrial fibrillation, male gender, and hypertension, and not associated with age, daily
alcohol consumption, smoking, diabetes, ischemic heart disease, serum cholesterol, or
hematocrit (J orgensen, Nakayama, Reith, Raaschou, & Olsen, 1997). However,
previously the top two prognostic variables associated with stroke recurrence in survivors
of cerebral infarction had previously been documented as smoking and diabetes (Bum et
al., 1994). Jorgensen (1997) and co-researchers found a history of TIA, atrial fibrillation,

male gender, and hypertension significantly increased the risk of stroke recurrence. They

26

also found clients with recurrent strokes have larger lesions, more severe strokes, and a
higher mortality (almost doubled) than patients with a first ever stroke. However, those
clients with a recurrent stroke recover as well and as fast as clients with a first stroke
(Jorgensen et al., 1997).

Nine studies have addressed predictors of stroke recurrence, but the results have
been contradictory. Differing methods of analysis and relatively few patients with
recurrent strokes included in the research may account for varying results. Within the
nine research studies, recurrent stroke was associated with hypertension in five studies,
with male gender, diabetes, and heart disease in three studies, with a previous TIA and
atrial fibrillation in two studies, and smoking and age in one study (Sacco, Wolf, Kannel,
& McNamara, 1982', Hart, Coull, & Hart, 1983; Alter et al., 1987; Meissner, Whisnant,
& Garraway, 1988; Viitanen et al., 1988; Sacco etal., 1989; Heir et al., 1991', Burn et al.,
1994; Jorgensen et al., 1997).

E . l . 1

Risk appraisal or risk assessment is the process of obtaining specific health
information to estimate the risk of developing the disease (Kelly-Hayes, 1991). To obtain
modifiable risk factors, a risk assessment or appraisal needs to be completed.
Concentration on risk factors that can be modified leads to the best preventive approach.
Secondary stroke prevention involves the identification of stroke type, risk factors for
stroke, and the development of strategies directed toward reducing risk as well as

determining need for further treatment and rehabilitation.

27

E . l l .

Risk reduction is the process of reducing one’s risk of disease by modifying or
treating the risk factor(s). Mosby (1996) defines risk factor as an element that causes a
person or group of people to be vulnerable to an unwanted, unpleasant, or unhealthful
event. Some risk factors are modifiable, such as smoking, and some are not, such as age.
Nursing is concerned with the reduction or elimination of the modifiable factors that
place a person at risk for a specific disease process. APN’s are able to assist individuals
understand and adopt lifestyle changes to reduce risk and disability (F leury, 1992).
Cerebrovascular risk reduction includes management of hypertension, diabetes, and
hyperlipidemia, regular exercise, dietary modification, smoking cessation, and
compliance with medication regimen.
Writs

Risk factors for stroke as identified in the literature can impact an individual’s
perception of susceptibility. Modifiable or potentially modifiable risk factors for stroke
include hypertension, diabetes mellitus, hyperlipidemia, cigarette smoking, obesity,
excessive alcohol consumption, atrial fibrillation, left ventricular hypertrophy, transient
ischemic attacks, coronary artery disease, congestive heart failure, stress, sedentary
lifestyle, and cocaine use. Nonmodifiable risk factors for stroke are age, race, gender,
prior stroke, mitral valve disease, and family history (Wolf, D’Agostino et al., 1991;
Gresham et al., 1995; Hickey, 1997).

11mm. Hypertension is the major risk factor for stroke (Powers, 1993;

Bronner, Kanter, & Manson, 1995). It is the single most controllable risk factor.

28

Approximately 50 million Americans age six and older have high blood pressure (AHA,
1997). However, 29 percent of those being treated have blood pressure lower than 140/90
mm Hg (JNC VI, 1997). These statistics support the need to translate the results of
research into improved health. Hypertension accelerates the formation of atheromatous
plaques which damage the integrity of the vessel walls. Vessel wall damage predisposes
the vessel to thrombotic occlusion or cerebral infarction. Hypertension also promotes the
grth of aneurysms in parts of the small intracranial arteries. Aneurysm can be the site
of intracranial bleeds and lacunar infarctions (Kane et al., 1994).

History of hypertension (>150/90) after initial stroke has been documented as
being associated with an increased risk of second stroke. Alter and co-researchers found
that controlling diastolic pressure substantially reduced this risk. The authors point out
that in previous studies, the association between hypertension and stroke risk is unclear
(Alter, Friday, Lai, O’Connell, & Sobel, 1994).

It has been documented that hypertension prior to the stroke has an adverse effect
on survival. Hypertension with the comorbidity of heart failure or coronary artery disease
worsens the survival rate (Sacco et al., 1982). Early diagnosis and treatment of
hypertension, coronary artery disease, and heart failure may offer an opportunity to
prevent recurrence and improve longevity among stroke survivors.

Both diastolic hypertension and isolated systolic hypertension are
pathogenetically related to the occurrence of stroke (Doyle, 1993). Systolic hypertension
occurs in approximately 15 percent of people 60 years or older. The Systolic

Hypertension in the Elderly (SHEP) trial documented treatment of systolic hypertension

29

in which diuretics prevented stroke, myocardial infarction, and congestive heart failure.
Specifically, stroke risk was reduced by 36 percent (SHEP Cooperative Research Group,
1991). The Systolic Hypertension in Europe (Syst—Eur) Trial confirmed the findings of
the SHEP study. Treatment of one thousand patients for five years with a long-acting
calcium channel blocker reduced stroke risk by 42 percent (Staessen et al., 1997).
Another more recent study documented antihypertensive therapy with nitrendipine as
being beneficial in older patients with systolic hypertension and diabetes. Tight control
of blood pressure (<1 50/ 85) was found to reduce fatal and nonfatal strokes by 73 percent
(Tuomilehto et al., 1999).

W. Individuals with diabetes may have a higher stroke risk
primarily due to the circulation problems diabetes can cause. Diabetes is the most
prevalent endocrinologic problem in primary care and a prominent risk factor for stroke
(Wolf, D’Agostino et al., 1991; Gorelick et al., 1999). The probability of stroke in
diabetic males is 2.5 times greater than the rate in nondiabetic males of the same age
(Goldberg, 1991). The stroke risk due to diabetes is between two and 5 percent for stroke
of all types (Bronner et al., 1995).

Diabetes mellitus may increase the risk of thromboembolic stroke through
differing and possibly synergistic mechanisms. The mechanisms include advancement of
large artery atherosclerosis via glycosylation-induced injury, negative effects on both
low-density lipoprotein and high—density lipoprotein cholesterol levels, and promotion of
plaque formation through hyperinsulinemia (Gorelick etal., 1999).

Stroke recurrence in diabetics was examined by Alter et a1. (1997). Alter and co-

3O

researchers found no association between HbAlc level over time and risk of stroke in
diabetic patients with an initial stroke. However, the authors determined that the majority
of diabetics in this study were well controlled and the adverse effects of poor control
could not be adequately tested. The data did support the conclusion that when blood
glucose is well controlled, the risk of recurrent stroke up to four years after an initial
stroke is no greater than in clients without diabetes.

Another factor for individuals at risk for diabetes is syndrome X. Syndrome X
comprises obesity, glucose intolerance, dyslipidemia, and hypertension, though not all
individuals with the syndrome are hypertensive. Other conditions that may be found
within individuals with syndrome X include coagulation abnormalities, elevated serum
uric acid concentrations, and atherosclerosis. The underlying abnormality in syndrome X
is insulin resistance. In individuals with insulin resistance, glucose utilization by the
tissues is impaired and excess glucose accumulates in the bloodstream. To compensate,
the beta cells of the pancreas produce more and more insulin, leading to secondary
hyperinsulinemia. If a patient has both hyperinsulinemia and hyperglycemia, then the
patient may also have diabetes. Individuals with syndrome X have a tendency to form
blood clots. Thus, thrombus formation explains the increased prevalence of stroke in
individuals with syndrome X (Gavin, Peters, & Lewis, 1999).

W. Lipid abnormalities are associated with an increased risk of
stroke (Kane et al., 1994). An increase in serum cholesterol can lead to atherosclerosis of
the internal carotid artery and larger cerebral arteries, which could lead to ischemic

stroke. Another more speculative mechanism pertains to the weakening of the

31

endothelium of smaller intracerebral arteries due to low serum cholesterol levels
(Bronner et al., 1995).

Cumming. Cigarette smoking contributes significantly to coronary artery
disease and stroke risk. Smokers have an increased risk for atherosclerosis which can
lead to stroke. People who smoke cigarettes are two to three times more likely to have a
stroke than people who have never smoked (Wolf, D’Agostino et al., 1991; Terry,
Berkowitz, & Kerstein, 1998). The risk of stroke in smokers who smoke more than 40
cigarettes per day was found to be nearly two times the risk for persons smoking fewer
than ten cigarettes per day (Wolf, D’Agostino, Kannel, Bonita, & Belanger, 1988). Wolf
(1988) and co-researchers found smoking to be a risk factor for stroke for persons with
and without hypertension. In fact, cigarette smoking continued to exert a significant
independent impact on stroke incidence even after cardiovascular disease risk factors
were taken into account. Smoking affects steps in the clotting cascade that promote the
progression of atherosclerosis and thrombus formation (McBride, 1992). Smoking two
cigarettes has been found to increase platelet activation more than 100 fold. The overall
effect of smoking on the blood is the creation of a thrombogenic environment that can
lead to the progression of atherosclerosis and acute thrombosis (Wolf et al., 1988; Terry
et al., 1998).

The total years of cigarette smoking is the most significant independent predictor
of the presence of severe carotid atherosclerosis (Whisnant et al., 1990). In their study,
Whisnant and co—researchers (1990) obtained cigarette smoking histories and

information on other potential risk factors from consecutive patients undergoing carotid

32

arteriography. The extent of carotid atherosclerosis was assessed in 752 patients in whom
at least one extra cranial carotid artery was visualized. Other independent predictors, in
order of significance, were found to be age, hypertension, diabetes mellitus, sex (male),
and current systolic blood pressure.

Qhesjty. Obesity increases the risk of stroke indirectly by increasing the risk of
hypertension, hyperinsulinemia, glucose tolerance, and hyperlipidemia (Schretzman,
1999). A sedentary lifestyle contributes to obesity and hyperlipidemia, both of which
contribute to coronary artery disease. Excess weight may put a strain on the circulatory
system as well as the entire body.

WW. Excessive alcohol consumption has been

associated with stroke in a mechanism not yet fully determined. Excessive drinking can
weaken the cerebral blood vessels which can contribute to stroke (Schretzrrran, 1999).
Excessive or higher levels of alcohol intake can cause cardiac arrhythmias, increase in
blood pressure and decrease in cerebral blood flow, and affeCt blood coagulation
(Gorelick et al., 1999). The relative risk of ischemic stroke associated with moderate
alcohol consumption, which was defined as one to two drinks a day, as compared with
nondrinking, is between 0.3 and 0.5 in some populations. The relative risk increased to
two for people consuming three or more drinks per day. The relative risk for hemorrhagic
stroke varies from two to four (Bronner et al., 1995).

MW Atrial fibrillation is the most important and treatable cardiac
precursor of stroke (Sacco et al., 1997). Atrial fibrillation is a heart rhythm caused when

the atria of the heart beat rapidly and irregularly. Blood pools in the heart, then tends to

33

form clots which can be carried to the brain. Prospective research has established
nonrheumatic (nonvalvular) atrial fibrillation as a common cause of stroke. Nonvalvular
atrial fibrillation increases the risk of stroke by about six times (Wolf, Abbott, & Kannel,
1991). The prevalence of atrial fibrillation increases with age (Barnett, Eliasziw, &
Meldrum, 1995). More than 2 million adults in the US. have nonvalvular atrial
fibrillation and about 36 percent of strokes in peeple between the ages of 80 and 89 years
are attributed to this risk factor (Wolf, Abbott et al., 1991).

Age. The chance of having a stroke increases with age. Seventy-two percent of
people who suffer a stroke in a given year are over the age of 65 (AHA, 1997). Older
adults are more likely than adults less than 65 to experience serious injury both during
and after stroke (Schretzman, 1999). Common age-associated physiologic changes can
contribute to stroke severity in elders. Baroreceptor response and subsequent impaired
response to stress may lead to decreases in cerebral perfusion and then to ischemia. Many
older adults have comorbid medical conditions, such as hypertension, coronary artery
disease, hyperlipidemia or diabetes, which are risk factors for stroke. Older adults
commonly use multiple medications which can contribute to the incidence of stroke
(Schretzman, 1999).

W. Afiican Americans are more at risk for stroke than individuals from
another race (N SA, 1998). African Americans have a 60 percent greater incidence of
death and disability from stroke than Caucasians (Mohr, Albers, & Amarenco, 1997).
Compared with Caucasians, young African Americans have a two to threefold greater

risk of ischemic stroke, and African American men and women are 2.5 times more likely

34

to die of stroke. The 1995 death rates for stroke were 97 percent higher for black males
and 71.4 percent higher for black females as compared to white males and white females
respectively (AHA, 1997). Another study documented that African Americans, even afier
accounting for established baseline risk factors, had a 38 percent greater risk of ischemic
stroke as compared with Caucasian individuals (Rosamond et al., 1999). Because women
in the US. live longer than men, more stroke survivors over age 65 are women (N SA,
1998).

W. Stroke risk is higher for people with a family history of stroke
or TIA (N SA, l998b). People with coronary artery disease are more likely to have
cerebrovascular disease, specifically carotid artery disease. Individuals with mitral valve
disease are at risk for embolus formation and, therefore, at risk for stroke. Though there
is research on stroke risk factors and stroke management, patients who haVe recemly had
a TIA or stroke have a substantially increased annual risk for a subsequent stroke, from
4.5 percent to 6.6 percent (Matchar, McCrory, Barnett, & Feussner, 1994). In patients
who do not have a second stroke in the next five to ten years, the risk of stroke
approximates that of the general population. Previous TIA is reported to have occurred in
50 to 75 percent of patients with stroke (Kane et al., 1994).

Imminent

The most important issues for people diagnosed with stroke are prevention of
recurrent stroke, prompt diagnosis, proper treatment including rehabilitation, and
reintegration into the community. Advances in research have indicated that proper

treatment, rehabilitation, and risk reduction are key elements in the decline of morbidity

35

and mortality. “The benefit of reduction in stroke mortality is particularly striking in
women 50 years and older: one half of the benefit among white women and nearly two
thirds of the benefit among African American women can be attributed to the fall in
blood pressure” (JNC VI, 1997, p. 2413). Because of advances in medical science, stroke
prevention requires increased community awareness and changes in health seeking and
disease prevention behaviors. In addition to the importance of proper medical
management, active participation of the patient and family are vital.
WW

Adherence, Mosby (1996) defined adherence as “the quality of clinging or being
closely attached; the process in which a person follows rules, guidelines, standards,
especially as a patient follows a prescription and recommendations for a regimen of
care.” Adherence and compliance have been used interchangeably. Buchmann (1997)
defined compliance as a willingness to concur with the objectives of another person. He
goes on to define adherence as the action of sticking to or following a person or an idea.
Compliance and adherence, then, can be used synonymously based on the assumption
that human behavior and adherence are connected to human thought and compliance
(Buchmann, 1997). The term ‘compliance’ can have an underlying authoritarian tone on
the part of health care providers. Thus, other terms such as ‘adherence’ or ‘therapeutic
alliance’ have been used instead (Cameron, 1996). Nonadherence leads to poor clinical
outcomes which in turn adds to health care costs. When people do not adhere to a
prescribed regimen or recommendations from health care professionals, deleterious

effects may happen to their health.

36

A literature search did produce articles that examined the issue of compliance
with therapeutic regimens including hypertension (Given & Given, 1983; Jones, Jones, &
Katz, 1987; Plawecki & Mallory, 1988). Nothing was found regarding secondary stroke
prevention behaviors, let alone compliance or adherence to the same.

Cameron (1996) concluded the main social and psychological factors involved in
patient adherence were knowledge and understanding including communication, quality
of interaction including the patient-provider relationship, and patient satisfaction. In
addition, social isolation, social support including the family, health belief model
variables, and duration and complexity of the regimen are main factors involved in
patient adherence. All of these factors can exert positive or negative influences on
compliance. Understanding health related behavior and the many interrelated factors
involved is essential to promoting adherence, according to the author.

Barrie; A barrier can be any factor or perception that the survivor and/or health
care provider identifies as hindering the implementation of a prescribed therapy. A few
of the barriers can be expense, danger, unpleasantness, inconvenience, and time required
(Pender, 1996). When a barrier is identified, it must be removed in order for adherence to
begin or resume. Some barriers identified within this project that will be discussed
include depression, lack of social support, lack of knowledge and/or understanding,
functional impairments, and cognitive impairments. This is not an all inclusive list. Each
individual with stroke is unique and has their own surrounding set of circumstances and
barriers. An analysis of barriers may clarify difficult points for the survivor leading to the

selection of successful strategies for more effective interventions.

37

No literature was found on barriers to treatment and secondary prevention in
stroke patients with the exception of depression. There are, however, many barriers
documented to the implementation of preventive health services. The barriers have been
broken down into the following four categories: patient, physician, health care setting,
and community. The patient related barriers include lack of knowledge and motivation,
lack of access to care, cultural and social factors. Some of the physician related barriers
include time constraints, lack of specialist-generalist communication, and problem-based
focus. Two of the health care setting barriers include lack of resources and systems for
preventive services. The community barriers identified are a lack of policies and
standards and a lack of reimbursement (Castelli, Ockene, & Roberts, 1997). Barriers in
addition to depression that could relate to the stroke population include but are not
limited to lack of social support, lack of knowledge and/or understanding, functional
impairments, and cognitive impairments.

W- A barrier specific to stroke survivors and a preventive health plan is
depression. Often chronic disease, such as stroke, can lead to depression. Also, the
elderly often take numerous medications, some of which have depression as a side effect.
Loss of motivation, fatigue and failure to achieve goals that seem to be within the
survivor’s capacity can be observed. Change in body image and loss of function may
cause grief for the stroke survivor, leading to depression (Hafsteinsdottir & Grypdonck,
1997)

Psychological adjustments of the survivor may include the burden of living with

new limitations and the acknowledgment of a shortened life expectancy. The survivor

38

may experience the grieving process as a result of losses brought on by the stroke. Three
categories of loss have been documented in the literature: activities, abilities, and
independence. Depression can occur as a result of the stroke, the survivor’s struggle to
adjust his or her losses, and the whole experience of stroke. The most important
predictors of major depression were left anterior brain lesions, dysphasia, and living
alone. Dysphasia is a frustrating condition with psychological and social consequences
which may contribute to depression. Thus, it is of importance for health care providers to
use and teach helpful communication methods to the stroke survivor. The stroke survivor
needs to be able to communicate his own thoughts and to be able to communicate his
goals (Hafsteinsdottir & Grypdonck, 1997).

Treatment of depression in people with stroke has been found to improve
outcome. Depression may affect a stroke survivor’s perception of susceptibility and
seriousness as well as their motivation to participate in lifestyle changes. Gonzalez-
Torrecillas, Mendlewicz, and Lobo (1995) claim to have been the first to document the
beneficial effects of early antidepressant treatment on the cognitive function of post
stroke depressed patients. The authors compared patients treated for post stroke
depression with patients not treated for post stroke depression and with post stroke
nondepressed patients who received no depression treatment. They found the prevalence
of post stroke depression to be 37 percent. Post stroke depression was found more
frequently in those patients with an anterior lesion (statistically significant). Findings
demonstrated in fourth week post stroke treatment with fluoxitine or nortriptyline

significantly improved the depressed patients’ mood, functional and cognitive ability.

39

Effective treatment of depression was found to enhance stroke rehabilitation in a
study by Morris, Raphael, and Robinson (1992). They examined 49 patients at two
months and 14 months post stroke. Clinical depression occurring soon after stroke was
found to be associated with impaired recovery when patients were assessed 14 months
later. Depression had a negative effect on recovery in functional status, as measured by
the Kamofsky score, and cognitive performance. Health care providers need to be alert
for depression in stroke patients and treat it appropriately.

Cornerstone of assessment remains with the collection of subjective and objective
data regarding depression. Tools for assessing depression can assist in collecting
objective data. A tool specific to the older population is the Geriatric Depression Scale
(GDS) (Appendix A). It is meant for not only the physically healthy elderly, but also for
those that are physically and/or cognitively impaired to some extent. The authors suggest
that the GDS represents reliable and valid self-rating depression screening scale for
elderly populations (Yesavage etal., 1983).

MW Another barrier to nonadherence found in the literature is
lack of social support. Support from family, friends, and/or a support group has been
described as important to the issue of adherence. The literature documented the
importance of family involvement to the success of rehabilitation (Hafsteinsdottir &
Grypdonck, 1997). Fleury et al. (1996) found that support from family and friends is one
of the few variables consistently associated with success in compliance to cardiovascular
health behaviors. Family members, fiiends, coworkers, and church members are part of

the social context that can affect both the individual’s health and sense of well being.

40

Social relationships may include role models, friends, or family members whose
behavior either inhibits or supports effective goal setting or the development of strategies
for behavioral change (Fleury et al., 1997). Increased involvement of family and friends
may provide encouragement to increase lifestyle modifications among post-stroke
patients.

W Poor patient-provider relationships
may foster lack of understanding leading to nonadherence. If patients do not trust or have
a good relationship with their health care provider, they may not disclose important
information, or be willing to follow recommendations. Cognitive impairments may also
affect understanding. If patients do not understand the rationale for prescribed treatment,
they may not be as likely to adhere to the treatment.

Wiles, Pain, Buckland, and McLellan (1998) documented the information needs
of stroke patients post-discharge as information on recovery, treatment, prognosis,
practical caring tasks, social activities, and resources available in the community. In
some cases lack of information in their study resulted in the care givers limiting the
activities of the stroke patient out of fear that too much activity might bring on another
stroke. This research identified that without adequate information, care givers may be
unsure of the level of care that is appropriate, patients may not access the services that
are available, and both patients and care givers may have unrealistic expectations about
the extent of recovery. Unrealistic expectations regarding recovery may cause distress
due to residual disability. To help improve knowledge in relation to stroke topics, the

authors recommend general information about causes and prevention of stroke be

41

provided in written format. Specific written information could be provided on the
physical effects an individual’s stroke has had, how the physical and psychological
symptoms can be managed, the individualized treatment plan, and the period of time for
which treatment is likely to continue.

Johnson, Pearson, and McDivitt (1997) documented long-term learning needs
(greater than six months post stroke) identified by stroke survivors. Stroke survivors
strongly indicated they wanted to learn about all of the topics suggested by the authors.
These topics included causes of stroke, why does stroke affect people differently, the role
of foods and vitamins in stroke recovery, and how can stroke pain be treated. Other
topics included coping with loss, and do treatments like massage and acupuncture help
survivors improve. The authors concluded that providing stroke survivors with the
information they seek empowers them to find ways to adapt to their disabilities.

MW Functional impairments are common with stroke and
vary in degree of severity. Weakness and paralysis are the most common form of motor
deficit, a type of functional impairment. Incoordination, clumsiness, involuntary
movements, or abnormal postures may also occur (Gresham et al., 1995). Alterations in
functioning may decrease independence related to activities of daily living, thus affecting
an individual’s capability to follow the therapeutic regimen. Patients have described how
immobility has facilitated dependency and powerlessness (Hafsteinsdottir & Grypdonck,
1997)

W Cognitive impairments can be a barrier to the stroke

patient’s adherence to the therapeutic regimen. Cognitive changes of aging as well as

42

changes related to stroke can be present. Cognitive deficits may involve problems with
attention, orientation, concentration, learning (short-term memory), or problem solving.
Effects of cognitive deficits on task performance depend on the pattern of deficit.
Common stroke specific patterns are unilateral neglect (hemi-inattention) and apraxia.
Unilateral neglect is a disttubance of a patient’s awareness of space on the opposite side
of the body from the location of stroke. Apraxia is a disorder of learned movement that
cannot be explained by the survivor’s deficits in strength, coordination, sensation, or
comprehension. Dementia is rare after a first stroke, but can occur as a result of multiple
strokes (Gresham et al., 1995).

The presence of cognitive or perceptual deficits often increases the severity of
functional disabilities, causes emotional distress, and interferes with the survivor’s
ability to participate in rehabilitation. Learning is affected and the survivor’s risk of
injury is increased. Treatments for cognitive deficits emphasize retraining, substitution of
intact abilities, and compensatory approaches (Gresham et al., 1995).

Assessment of cognitive function can be accomplished by clinical exam and the
use of tools such as the “Mini-Mental State” Exam (MMSE) (Appendix B). A general
impression of memory and the ability to retain new information can be obtained from
observation of the patient’s interaction. Another method is through questions on
orientation, current events, recent personal history, or arithmetic. It is important to
distinguish cognitive deficits from difficulties in communication. A neuropsychological
examination may be needed to define cognitive or behavioral deficits more fully

(Gresham et al., 1995).

43

The MMSE is a valid test of cognitive functioning. The hallmark of the MMSE is
that it makes objective what is commonly vague and subjective impression of cognitive
disability during an assessment of a patient. The exam concentrates only on the cognitive
aspects of mental function. It excludes questions concerning mood, abnormal mental
experiences and thinking. It includes eleven questions and requires only five to ten

minutes to administer making it practical to use serially and routinely (F olstein, Folstein,

& McHugh, r975).

 

Pender (1996) defined prevention as those activities directed toward decreasing
the probability of disease by active intervention. Primary, secondary, and tertiary
prevention activities overlap. Primary prevention focuses on addressing modifiable risk
factors before the disease process begins. Primary prevention is considered promoting the
general health of the population. Secondary prevention focuses on modifiable risk factors
to halt the disease process and prevent recurrence because the pathology is already
present. Tertiary prevention is focused on minimizing disability from disease and
assisting the patient to live productively within society (Kelly-Hayes, I991; Pender,
1996). Reduction in the incidence of stroke requires all three levels of prevention. This
assessment tool utilizes secondary prevention. The tool assists in the determination of
risk factors for stroke and prevention intervention strategies, with consideration for
factors affecting behavior change.

Therapeutic interventions directed at modifiable risk factors for stroke, including

hypertension, diabetes mellitus, hyperlipidemia, cigarette smoking, and heavy alcohol

44

use should be a part of any stroke prevention plan (Matchar, et al., 1994; Reddy &
Reddy, 1997). Primary prevention and prevention of stroke recurrence are very similar in
content. Prevention of stroke recurrence is tailored to the individual and education is
provided based an assessment of the individual’s knowledge. The complexity of health
behaviors to treat stroke positively correlates with an individual’s perception of barriers.
As perceived barriers increase, an individual is less likely to follow through with a health
behavior. The literature indicates that stroke can be prevented through management of
risk factors.

Medical and surgical interventions should be employed as applicable. Coumadin,
aspirin therapy in persons with atrial fibrillation, reversal of left ventricular hypertrophy
confirmed by electrocardiogram, and treatment of heart failure and coronary artery
disease may decrease stroke incidence (Wolf, Abbott et al., 1991).

Wm Controlled trials have not conclusively established
the effect of long-term antihypertensive therapy on stroke recurrence (Meissner et al.,
1988). However, it is generally accepted that antihypertensive treatment is of benefit to ’
reduce cerebrovascular disease. Treatment of isolated systolic hypertension in the elderly
with dihydropyridine calcium channel blockers and angiotensin-converting enzyme
inhibitors has been documented to reduce the risk of stroke (Staessen et al., 1997). Most
of the information on cerebrovascular effects of antihypertensive medications comes
from studies on animals that have not been subjected to cerebral ischemia or
hemorrhage. Thus, the designation of a level of blood pressure as too high or level of

desirable blood pressure reduction cannot be made due to lack of data (Powers, 1993).

45

The Sixth Report of the Joint National Committee (JNC VI) on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (1997) has provided
guidance for primary care providers in hypertension management, yet does not replace
provider clinical judgment. Lifestyle changes for all individuals with hypertension are
strongly encouraged. Pharmacologic therapy with a diuretic or betablocker for an
individual with a systolic blood pressure of 140-159 or a diastolic pressure of 90-99 is
recommended. Other classes of antihypertensive agents are recommended for certain
clinical situations and other comorbid conditions.

Hansson (1998) and co-authors describe the importance of the Hypertension
Optimal Treatment (HOT) randomized trial. The trial shows benefits of lowering the
systolic blood pressure to 140 mm hg and the diastolic blood pressure to 85 mm hg
resulting in a low rate of cardiovascular events. Acetylsalicylic acid also reduced major
cardiovascular events with the most benefit seen in myocardial infarction. There was no
increase in the incidence of stroke or fatal cerebral bleeds. The addition of acetylsalicylic
acid to antihypertensive therapy is recommended as long as the blood pressure is well
controlled and the risk of gastrointestinal and nasal bleeding is monitored. Lowering of
blood pressure was particularly beneficial for individuals with diabetes mellitus.

Management, American Diabetes Association (ADA) (1999)
recommends tight glycemic control balanced with the risk of developing hypoglycemia.
The influence of tight glycemic control on stroke risk is uncertain (Bronner et al., 1995).
Standards outlined by ADA (1999) of medical care for patients with diabetes mellitus are

presented. The standards do not include specific management for stroke survivors, but do

46

discuss patients with hypertension and hyperlipidemia, two risk factors for stroke.
Maintaining blood pressure below 150/85 mm Hg in people with type 2 diabetes mellitus
and hypertension has been documented as reducing the risk of fatal and nonfatal strokes
by 44 percent (UK Prospective Diabetes Study Group, 1998). By controlling blood
pressure and decreasing cholesterol, the person with diabetes mellitus benefits by
decreasing risk for further development of atherosclerosis.

WW1]; Ahmed, Clasen, and Donnelly (1998) reviewed the
target low-density lipoprotein (LDL) cholesterol value (100 mg per dl or lower) in
patients with coronary heart disease or other atherosclerotic disease. Recommendations
do not specifically identify stroke other than “other atherosclerotic disease.” The
National Cholesterol Education Program guidelines and a patient educational sheet were
reviewed as well as diet information. It is interesting to note that the American Heart
Association diet may lower total cholesterol by 5 to 7 percent, whereas similar diets that
emphasize dietary fiber may reduce total cholesterol by 11 to 32 percent and may exert
beneficial effects on LDL as well as high-density lipoprotein (HDL) cholesterol levels
(Anderson & Gustafson, 1987).

The National Institutes of Health (1997) published a document that reviews
clinical trials, provides a meta-analysis, and contains management strategies for differing
cholesterol levels. Included are the roles of health care providers in attaining adherence
to treatment regimens. The National Institutes of Health document provides patient
educational materials and specific strategies to enhance adherence.

Two cholesterol-reducing agents have been approved by the US. Food and Drug

47

Administration for the prevention of first stroke or TIA in post heart attack coronary
heart disease patients. Pravastatin (brand name Pravachol) is indicated to reduce the risk
of stroke or TIA and recurrent heart attacks in patients with heart disease and an average
cholesterol of less than 240. Simvastatin (brand name Zocor) is indicated to prevent heart
attacks and reduce the risk for first stroke or TIA in patients with high cholesterol and
coronary artery disease (N SA, l998a). In addition to these drugs, a recent meta-analysis
of clinical trials using statin drugs in patients with coronary artery disease showed a risk
reduction of 25 percent in fatal and nonfatal stroke (Bucher, Griffith, & Guyatt, 1998).

Sntoktnggcssntjon, Smoking cessation demonstrates many health benefits.
Elevated blood viscosity, hematocrit, plasma fibrinogen, and white blood cell counts
have been shown to normalize after eight weeks of smoking cessation (Ernst & Matrai,
1987). Stroke risk decreased significantly within two years of smoking cessation and was
documented at the level of nonsmokers within five years after smoking cessation (Wolf
et al., 1988). In 1996, the Agency for Health Care Policy and Research published
smoking cessation guidelines. These guidelines provide detailed strategies for clinicians
to promote smoking cessation (Fiore et al., 1996).

Medication In addition to antihypertensive medication and lipid lowering agents
both tailored to the patient, clot prevention medication is indicated for ischemic stroke
prevention. Neuroprotective medications are in various stages of clinical development
(Schretzman, 1999). Anticoagulants and antiplatelet drugs are two primary classes of clot
prevention medications. Anticoagulants inhibit further clot formation or enlargement in

the cerebral arteries. Clinicians weigh an individual’s need for anticoagulation against

48

the risk of hemorrhage. The goal of anticoagulant therapy is to administer the lowest
possible dose of an anticoagulant to prevent clot formation or expansion, in an easy to
follow regimen (Horton & Bushwick, 1999). Effective anticoagulation was documented
by Horton and Bushwick (1999). They recommend utilizing a single Warfarin tablet
strength and alternating fractions and multiples of that tablet within a weekly plan.

Warfarin is indicated for individuals who are candidates for anticoagulation and
have nonvalvular atrial fibrillation or who have had a previous myocardial infarction
(MI) (Matchar, et al., 1994; Reddy & Reddy, 1997). Intensity of anticoagulation needs to
be carefully monitored by use of the International Normalized Ratio (INR). The optimum
range of prothrombin time (PTT) is 1.5 time baseline normal value and an INR of 2.5
(Reddy & Reddy, 1997) or an INR of 2 to 3 (Horton & Bushwick, 1999). INR levels
below 2 raises the risk of ischemic stroke and INR levels above four to five unnecessarily
raises the risk of major hemorrhage (Wolf & Singer, 1997).

Warfarin is more likely to be used safely by a stroke survivor if the stroke
survivor and/or caregiver are aware of the potential for drug interactions, rationale for lab
test monitoring, and can easily identify the symptoms of warfarin toxicity early (Horton
& Bushwick, 1999). Patient instructional books are available to individuals on warfarin
therapy from the company at no cost (1-800-COUMADIN). Patient instructional books
reinforce teaching by the health care provider.

Antiplatelet drugs or antithrombotics work at the beginning of the clot formation
process by inhibiting an enzyme necessary for platelet adhesion and activation.

Thrombotic strokes are the result of a thrombus or clot forming on top of the

49

atherosclerotic deposit. Because platelet activity can initialize the formation of these
clots, the antiplatelet agents are the drugs of choice to prevent a thrombotic stroke. Four
antiplatelet drugs are aspirin, ticlopidine (brand name Ticlid), clopidogrel (brand name
Plavix), and dipyridamole (Schretzman, 1999). Aspirin is the drug of choice for people
with cerebral ischemia either transient or persistent and of a noncardiac origin (Barnett et
al., 1995). Recommendations for aspirin dosage have not been standardized and range
from 81 mg once a day to 325 mg four times per day.

Ticlopidine, 250 mg twice a day, is an alternative to aspirin in patients who
cannot tolerate it, or for whom aspirin therapy has failed. Ticlopidine can cause
neutropenia, which can occur in I to 2 percent of recipients between three weeks and
three months after therapy is started. Therefore, careful monitoring is required.

Clopidogrel was compared to aspirin in an international trial involving more than
19 thousand participants with variations of vascular disease. Of 6,431 patients with
recent ischemic stroke, the small reduction in subsequent stroke attained by the use of 75
mg. of clopidogrel compared to 325 mg. of aspirin was not statistically significant.
However, clopidogrel was shown to be more effective in reducing the combined risk of
ischemic strokes, myocardial infarction, or vascular death (CAPRIE Steering Committee,
1996). An advantage to clopidogrel over ticlopidine is that clopidogrel does not cause
leukopenia. Clopidogrel produces irreversible platelet inhibition. In contrast to aspirin,
there is no inhibition of platelet aggregation.

A large European randomized trial documented 200 mg. dipyridamole twice daily

in a sustained release preparation, plus 25 mg. aspirin twice daily, to be superior to

50

aspirin alone. A 21 percent risk reduction occurred with this combination therapy. Other
combinations of antiplatelet therapy have not been researched (Diener et al., 1996).

Sumo-Ly, Carotid endarterectomy decreases the risk of stroke and death in patients
with recent TIAS or nondisabling strokes and ipsilateral high-grade (70-99 percent)
carotid stenosis. Benefit has not yet been documented for patients with either moderate
symptomatic stenosis or asymptomatic stenosis of any degree (Golstein et al., 1996a).
Carotid artery stenting has been used experimentally in high risk patients without repeat
stenting at two years (Al-Mubarak et al., 1999).

Catheter ablation techniques are being researched for long-term management of
atrial fibrillation (Gallagher & Camm, 1997). Balloon angioplasty of intracranial vessels
has provided a therapeutic option for secondary stroke prevention in selected patients
(Callahan & Berger, 1997). More research is needed before these treatments are
available to the general population.

W Exercise has many benefits such as decreased platelet aggregation,
increased sensitivity to insulin, decreased weight, increased I-IDL levels, and decreased
blood pressure (Schretzman, 1999). All of these benefits help to decrease stroke risk.
Kiely, Wolf, Cupples, Beiser, and Kannel (1994) prospectively examined the influence of
increased levels of physical activity on stroke risk in members of the Framingham study
cohort for a period of 32 years. The results indicated medium and high levels of physical
activity among men are protective against stroke. High levels of physical activity did not
provide additional benefit over medium levels of activity. Analyses showed no

significant protective effect for women. The researchers acknowledged the majority of

51

women in the cohort were classified as housewives and the level of physical activity
associated with housework could be underestimated. Moderate levels of physical activity
as part of a primary prevention strategy for reducing stroke risk was advised.

In more recent research, exercise vigorous enough to work up a sweat is
associated with decreased stroke risk in men. As with the previous study, participants
entering the study had not had a stroke. As physical activity increased, an inverse
relationship was found with body weight, blood pressure, serum cholesterol, and glucose
tolerance. The researchers concluded that further data are needed to clarify the relation
of physical activity to stroke subtypes and the optimum amount of exercise in frequency,
duration, and intensity (Lee, Hennekens, Berger, Buring, & Manson, 1999).

Burns (1996) reviewed the Centers for Disease Control and Prevention and the
American College of Sports Medicine combined recommendation for physical activity.
The goal behind this recommendation is to achieve health promotion and disease
prevention. They defined exercise as “a subset of physical activity that is planned,
structured, and involves bodily movement to improve or maintain some component of
physical fitness. Physical activity is any bodily movement of the skeletal muscles that
results in energy expenditure. Fitness refers to a set of attributes that relate to the ability
to perform physical activity” (Burns, 1996, p. 21). The recommendation emphasizes the
relationship of physical activity to health as opposed to exercise and fitness. The
recommendation is that “every US. adult should accumulate 30 minutes or more of
moderate-intensity physical activity on most, preferably all days of the week” (Burns,

1996, p. 21). Moderate physical activity is equated to a brisk walk of three to four miles

52

per hour. Strategies to help individuals achieve moderate levels of activity and examples
of moderate occupational activities are provided.

Notation, Dietary recommendations for stroke survivors were not found in the
literature. There are dietary recommendations specific to hyperlipidemia, diabetes, and
other comorbidities. Dietary recommendations for individuals with diabetes closely
match those for the general population, and can be used for stroke patients. The best
approach to nutrition for the general population and the one most easily understood by
patients is the Food Guide Pyramid, which was developed by the US. Department of
Agriculture (1992) (Appendix C). The Food Guide Pyramid describes the number of
servings and serving size recommended per day. Daily diet should include 20-35 grams
of dietary fiber. Sodium should be restricted to 2,000 mg or less per day for individuals
with hypertension or nephropathy. Assuming an adequate dietary intake, individuals
generally do not need supplementation. The exception to this is vitamin E for its
antioxidant properties. Serum magnesium should be evaluated at intervals as deficiency
of this mineral can lead to insulin resistance, carbohydrate intolerance, and hypertension.
In individuals taking diuretics, potassium levels should also be monitored.
Approximately 10-20 percent of daily caloric intake should be from protein, 30 percent
from fat, and 55-60 percent of calories from carbohydrates, both simple and complex
(Fishman, 1996; Cefalu, 1998).

There have been few studies concerning the possible dietary determinants of
stroke. One such study was a 20-year follow-up study of middle-aged men from the

Framingham study, an inverse association was found between a fruit and vegetable intake

53

and the development of stroke. For each increment of three servings per day, there was a
22 percent decrease in the risk of all strokes. The findings were not substantially altered
by adjustment for other cardiovascular risk factors (Gillman et al., 1995).

Another such study analyzed data in regards to fruit and vegetable intake from the
Nurses’ Health Study and the Professionals’ Follow—up study. The data was found to
support a protective effect of higher consumption of fruits and vegetables against
ischemic stroke. In particular leafy green vegetables, citrus fruits, and citrus juice seemed
to have a greater effect. The results support the recommendation to consume at least five
servings of fruits and vegetables a day (Joshipura et al., 1999).

SttokostkflotLle, Wolf, D’Agostino et al. (1991) developed a stroke risk
profile based on the Framingham Study. The profile can be used to evaluate an
individual’s risk for stroke and suggest risk factor modification to reduce risk.
D’Agostino, Wolf, Belanger, and Kannel (1994) modified the risk profile to better assess
the effects of the use of antihypertensive medication. The authors recommend further
investigation of treatments for blood pressure and also for other risk factors such as
management of increased cholesterol and glucose.

W. Health care providers must frequently
make prevention and health promotion recommendations for patients without the benefit
of unambiguous data from well designed clinical trials. Keeping up with the latest trial
data can be a challenge. In a national survey, Goldstein (1996 a & b) and co-researchers
found discrepancies between trial data and clinical practice. They found frequent

reported use of anticoagulants instead of carotid endarterectomy by primary care

54

physicians and internists for patients without surgical contraindications who had a recent
TIA and had more than 70 percent stenosis of the extra cranial carotid artery. In addition,
39 percent of primary care physicians and 22 percent of internists who responded that
they would seldom or never use carotid endarterectomy in this situation also reported that
they always or often use anticoagulants for these patients. Aspirin and antiplatelet agents
were used by most physicians regardless of degree of carotid artery stenosis, symptoms,
or presence of surgical contraindicatiOns. However, carotid endarterectomy reduces the
risk of stroke in symptomatic patients with at least 70 percent stenosis (Barnett et al.,
1995; Goldstein et al., 1996b). Three randomized clinical trials established the efficacy
of carotid endarterectomy and were published in 1991 (Golstein et al., 1996a). The
results imply that therapy of unproven value are possibly being used instead of therapy of
proven value. In another national survey by Goldstein (1996a) and co-researchers,
physician specialty was found to significantly influence the reported frequency of use of
carotid endarterectomy. In patients with newly symptomatic hi gh-grade stenosis, carotid
endarterectomy was reported as always or often used by more than 80 percent of
neurologists and surgeons but only by about half of internists and primary care
physicians.

O’Connell and Gray (1996) also found discrepancies between recommendations
from current research and actual practice. Out of 91 patients registered with a general
practice in England, the majority of patients were not receiving aspirin or warfarin as
primary or secondary stroke prevention. O’Connell and Gray (1996) recognized that one

of the determinants of more widespread use of anticoagulants in the community is the

55

practicality of regular International Normalized Ratio (INR) monitoring in an older
population. Although comparison studies were not available for APNs, it is possible that
a primary care APN would manage a stroke survivor differently than an APN that
specializes in neuroscience. For example, one of the practice guidelines for primary care
nurse practitioners (NPs) by Uphold and Graham (1998) does not delineate strokes by
type and location and therefore does not differentiate management issues.

WW Discharge instructions from the hospital
or rehabilitation facility may set the pace for follow-up of stroke patients in the
community. Gariballa, Robinson, Parker, and Castleden (1995) examined and followed
468 stroke patients for a period of one year that were admitted to one hospital. All of the
patients were followed in the hospital and upon discharge or death. All medical records
were reviewed. They found many risk factors were not corrected and preventive
measures could be improved within both the hospital and community. Even though
hypertension, the major risk factor for stroke, was the best treated risk factor in the
community, 43 of the stroke patients with a past history of hypertension had not been on
antihypertensive medication. Secondary and tertiary prevention needs to continue after
discharge from the hospital or rehabilitation facility.
I . . .

There is a large amount of research on cardiovascular risk factors and primary
prevention of stroke. Unfortunately there is a paucity of information on secondary
prevention of stroke. Limited research is available on the effects of prevention behaviors

on recurrent strokes. The majority of literature reflects studies on acute care and

56

immediate rehabilitation of stroke patients and prevention of initial stroke through stroke
screening. Assessment tools to evaluate a stroke survivor were aléo limited. To date, no
studies were identified that examine health seeking behaviors of persons experiencing
signs of stroke, except in relation to timing of presentation with an acute stroke. Studies
have been done to examine health beliefs of hypertensive patients.

Primary care management of stroke survivors has been limited in the literature
perhaps due to specialist (neurology and rehabilitation) literature. However, research that
is available reveals that primary care and internal medicine physicians may not be
following recommendations (Golstein et al., 1996 a & b). No literature is available
regarding APN care of stroke survivors.

Summary

The literature review reveals stroke to be a serious medical problem with
financial, social, spiritual, and health consequences. The risk of stroke for elderly
individuals is significant due to the predisposition to chronic diseases. The consequences
of stroke can range from mild disability, to cognitive and functional impairment, to
death. The signs and symptoms of stroke can be over looked, especially in those living
independently. Early detection, proper treatment and rehabilitation, and prevention are
essential if morbidity and mortality are to be reduced. Little information on secondary
prevention was found as efforts have concentrated on primary prevention as evidenced by
numerous articles on primary prevention. Primary care providers need to become aware
of issues relative to adherence to secondary prevention and the consequences of not

following preventive behaviors. Action must be taken on the part of the primary care

57

provider in order to improve the quality of health care information provided to stroke
survivors, reduce the incidence of stroke recurrence which would decrease costs incurred
by the survivor, families and society as a whole, and improve the quality of life for the
individuals diagnosed with stroke. Information gained in this literature review and
discussion of the HBM can be used for future evaluation of the health seeking behaviors
and health promotion behaviors in the stroke population. Application of the information
can be used to influence the development of educational programs, support groups, case
management of stroke survivors, and stroke recurrence prevention in order to improve

patient outcomes.

Project Plan

The focus of this project is the development of a risk assessment tool for APNs in
primary care to improve knowledge and assessment skills, promote proper care and assist
in the secondary prevention of stroke recurrence. Because little literature was found on
secondary prevention and few specifics found in the family practice nurse practitioners’
guidelines (Uphold & Graham, 1998), a resource tool is needed. The tool will be used to
identify secondary prevention interventions for stroke survivors. This tool will be based
on the HBM and a review of the literature. The assessment tool will be used in an
ambulatory care setting by an APN. The initial assessment and information gathering
appointment will take the greatest amount of time, unless this patient is an established
patient. Updating the information at subsequent visits in the event that a change occurred

in the data, may only take five to ten minutes.

58

The first part of the tool will address data that the patient would be able to answer
ahead of the scheduled appointment time. Data the patient can complete includes patient
demographics, medical diagnoses/problems, names of physicians seen by the patient, and
information regarding dates of preventive care exams, such as last physical exam and last
vision exam. The tool will elicit complete information relative to blood pressure,
exercise, weight, dietary habits, and medications.

The second part of the tool will contain a chart review and the various risk factors
divided into three sections: ischemic risk, hemorrhagic risk, and lifestyle factors. Each of
the three sections will be further broken down into more specific areas with
accompanying strategies for intervention in each area. The strategies for intervention will
give broad-based ideas for the APN to individualize specific goals and interventions for
the patient. To assess for barriers relative to adherence, the APN will have to ask non-
tlrreatening, open-ended questions that could elicit the information. The percentage risk
for a recurrent stroke has not been researched as risks have been studied for first stroke.
Thus, a risk score or percentage risk for a recurrent stroke cannot be determined at this
time. Having had a stroke places the survivor at greater risk than the general population
for further strokes.

Increasing awareness of stroke as a medical emergency and education about this
condition is essential if the associated morbidity and morality are to be reduced. Stroke
survivors need to recognize and respond to stroke signs and symptoms quickly, as they
would for chest pain. Stroke survivors also need to have a management plan tailored to

the type of stroke they have had with individualized treatment goals. This tool can assist

59

the APN in the development of the stroke survivor management plan. Given that stroke is
a complex problem with many areas requiring assessment and follow through, the tool
will give some structure to the assessment process. Primary care providers such as APNS
can play a significant part in coordinating stroke recurrence prevention efforts.

The format of the tool is open ended so that the maximum amount of information
can be gathered, yet the information is easily followed and can be quickly utilized when
in the office environment. Although this tool will not be a substitute for clinical
judgement, formal education, or individual research on the topic of stroke, it will provide
cues for the APN to consider various assessment items. There are other aspects of living
with the disease that are assumed as this tool is not comprehensive. The physical needs,
functional support, and impact of stroke on the family and patient are very important
areas as well. They impact the survivor’s ability to adhere to the management plan.

In summary, the risk assessment tool will be designed to be used by APNS in
primary care. The tool will allow for organization of data from chart review and patient
interviews and for stroke survivor care management post rehabilitation. In addition, the
tool will assist with planning individualized interventions, setting goals, promoting

continuity of care, and addressing secondary prevention with sound research and theory.

Procedure for the use of the Risk Assessment Tool in Primary Care Practice
The risk assessment tool (Appendix D) is intended for use in a primary care
ambulatory center, for stroke survivors with minimal to mild disability. Because of the

comprehensive nature of the tool and time constraints within each practice, the APN may

60

find it appropriate to complete the assessment tool over a series of office visits. The time
required to complete the tool will decrease as the APN becomes more familiar with the
tool. A well educated and experienced APN will quickly be able to identify neurologic
deficits, barriers to adherence, and utilize the tool within a short period of time.

Instructions are available with the tool for both the stroke survivor and the APN.
As previously described, the first part of the tool can be completed by the stroke survivor
prior to the office visit. The first part of the tool should be self explanatory with the
examples and directions provided. However, office staff should have an understanding of
the tool to be a resource for possible questions. The instructions for patients encourage
the patient to select and bring a support person with them to office visits, since support
people are necessary for behavior change to occur. This part of the tool will alert the
APN to the number of chronic illnesses, number of other health care providers, number
of medicines, health habits, and perceived health problems. The APN may gain
information from the first part of the tool to enable partial completion of the second part
of the tool. It should be noted that it may not be possible to complete the entire tool in a
single office visit.

The first step in part II of the risk assessment tool for the APN is a medical record
review or patient history. An in depth review of the medical record is ideally completed
prior to an initial interview with the stroke survivor and significant other(s) to expedite
the interview. Referral letters from rehabilitation therapists, discharge summaries from
acute care and rehabilitation, medical record from hospitalization, or conversation with

other health care providers are options in which the APN can gather information prior to

61

the initial office visit. The medical record review should include stroke type, pattern of
neurologic deficit, diagnostic tests and results, treatment including rehabilitation, and
discharge plan. There are spaces to the left of the radiology and laboratory sections on
the tool to indicate tests completed. The APN can document abnorrnals immediately to
the right (or left) of each item for reference. At the end of the first page of part II is a
comment section for the APN to use at his or her discretion for additional notes specific
to the stroke survivor. The tool can assist in organizing the data collection process to
avoid omissions.

The initial interview or office visit post stroke allows for the collection and
validation of a comprehensive history, which is a vital component for the continuing care
of a stroke survivor. A comprehensive history should include but not be limited to past
and present adult illnesses, present health status, functional health patterns, self care and
preventive health habits, and social history. Present health status includes a clear
description on the initial onset of symptoms of stroke, duration if TIA or RIND,
diagnostics and rehabilitation. Though functional health patterns, self care, and social
history are not on the tool, they are a part of the comprehensive care of a stroke patient
and should be addressed to increase adherence. Discussion regarding self care is
important for determining motivation to utilize abilities to the maximum level.
Functional limitations affect the survivor’s ability to complete self care.

Social history consists of the stroke survivor’s lifestyle, interests, meaningful
activities and roles. Obtaining educational background, cultural influences, patterns of

socializing, patterns of stress and coping strategies will assist in designing the

62

intervention according to the HBM. Cultural beliefs, health motivation, self efficacy, and
locus of control may affect adherence to the management plan. The impact of stroke on
the survivor’s life can have an effect on willingness to take on preventive health action.
Other components include social support, economic and home environment assessment.
Understanding these factors and identifying the social context provides the APN with
clues for strategy utilization.

In addition to the risk assessment tool, a physical assessment with neurologic
exam needs to be completed at the first visit post discharge. The physical exam
incorporates appropriate follow-up diagnostics from the tool, if not already completed.
Special attention should be paid to current functional and neurologic status as compared
to status from the hospital or rehab facility. Confirming that status has not changed is
important because many stroke recurrences happen within the first year of stroke (Samsa
et al., 1999). Functional status consists of an assessment of impairment in
communication, mobility, cognitive status, and psychosocial adjustment to stroke.
Neurologic status is determined through a complete neurological exam to determine
baseline ability and to determine need of further rehab and/or possible stroke extension.
Neurologic symptoms may be grouped for ease into domains of neurologic impairment.
The domains can also be documented in number and severity of deficits creating an
outcome score (AHA, 1998). These domains are, motor, sensory, vision, language,
cognition, and affect. Additional assessment within the physical exam should include a
focus on the cardiovascular system, such as listening for carotid bruits.

After completion of data collection and assessment, a management plan is

63

developed utilizing the intervention strategies. Risk interventions for different stroke
types are listed in part II of the tool. These risk interventions and goals need to evolve as
new information and procedures become available. It is recommended that the tool be
reviewed at least annually and be updated as appropriate. Interventions from the tool
should be used to formulate individualized goals specific to the survivor’s needs and
comorbidities. The stroke survivor must be involved in goal setting for preventive
behaviors to occur. Mutually set goals are then initiated

These goals should be updated on subsequent visits to provide for close follow-up
and monitoring of progress. Upon each follow-up visit, an assessment should be
performed to monitor adaptation to the community and maintenance of gains made
during recovery. Part I and the first page of part II of the tool should be placed in a
prominent place in the patient’s chart for easy access and remains a part of the
permanent medical record. A separate sheet listing the mutually agreed upon goals
provides for tracking and monitoring of outcomes with the stroke survivor once
interventions have begun. Both the patient and the APN should sign the sheet to signify
mutual agreement for goal setting. Prior to the patient leaving each office visit, he or she
should receive a copy of the goals and an appointment date set for follow-up.

The APN would address the survivor’s perception of barriers and benefits relative
to treatment and goals as related to adherence. Strategies to intervene and decrease
barriers would be a mutual process between the stroke survivor and the APN through

goal setting. Risk assessment and goal setting toward risk reduction would be a priority.

Gardening

Goal setting has been regarded as extremely important in effective behavior
change. Goal setting can direct attention away from a disease driven approach to a more
problem based, holistic perspective. Goal setting is a strategy for clarification of
expectations and responsibilities. It provides for client participation, open
communication, motivation through feedback, and evaluation of outcomes. Goals must
be specific, measurable, realistic, and contain a time frame (Brykczynski, 1982).

In the management of the person with stroke, the goals are to enable the survivor
to function free of illness, to prevent recurrent stroke, to minimize impairments arising
from stroke, and to maximize functional abilities. To attain these goals when utilizing
strategies for intervention, it is imperative to go through the process of goal setting.
Particularly important is the contribution by the primary participants, the stroke survivor
and family. Therefore, it is necessary that the stroke survivor and support person
participate in the planning process. Subjectively, recovery is distinguished by what
matters most to the stroke survivor. The importance of respecting the survivor’s personal
goals should not be underestimated. Often the survivor has clear goals for himself,
against which he measures success and progress. The role of the APN in lifestyle change
is to make clear recommendations, offer support and encouragement, and respect the
individual’s personal goals in the goal setting process (Ozer et al., 1994; Lawler,
Dowswell, Heam, Forster, & Young, 1995; Hafsteinsdottir & Grypdonck, 1997).

Once the goals are agreed upon, the survivor can take on a greater role in

monitoring the outcome. Survivors independently can self monitor blood glucose, blood

65

pressure, and weight. Monitoring of lipids and INR requires a laboratory, but the survivor
can be educated about the results. The monitoring component of the management plan
contributes to the over all effectiveness of the interventions. The survivor still requires
prOper supervision, especially in achieving and maintaining a therapeutic level of
anticoagulation (Ozer et al., 1994).

At each follow-up visit, the goals need to be evaluated. The degree to which an
individual goal or several goals have been achieved can spur the setting of new goals.
The methods that helped with goal achievement must be reviewed and revised as needed.
Barriers to reaching goals should be discussed with options for overcoming barriers
given. After evaluation, new goals can be set as well as making appropriate means to
reach them. The time for next evaluation or office visit can be revised based on the rate
at which results are anticipated (Ozer et al., 1994).

Another important step in the planning process for stroke survivors is to assist the
survivor examining the effects of the impairments on his life. This discussion helps to
identify what is most important for that particular person. If not addressed, this focus
could become a barrier for the individual in succeeding with the management plan.
Defining the impairment, problem, or obstacle in functional terms can lead to ways of
alleviating the problem even if the disability remains (Ozer et al., 1994).

The use of the tool along with goal setting should assist in identifying stroke
survivors not receiving or adhering to proper medical treatment or recommended lifestyle
changes. If secondary prevention is optimized with the support of the APN, stroke

recurrence statistics will be reduced. Secondary prevention adherence through successful

66

goal setting should result in the stroke survivor’s perception of control over health,
maintenance and/or improvement in quality of life, and decreased costs to patient family
and society. Positive outcomes would be identified by the decrease in the number of
recurrences, decreased number of cardiovascular events, and improved risk factor

management.

Evaluation of Tool

In order to evaluate the risk assessment tool, one needs to determine if the goals
for the tool are met. The goals for the tool are to increase APN awareness of the different
types of stroke and their management, review with the survivors and significant others
their risk factors, consequences, signs and symptoms, and prevention of stroke
recurrence. The outcome is to decrease the incidence of recurrence, morbidity, and
mortality associated with stroke through prevention, early detection, and intervention.
The evaluation of the tool can be based on process/implementation analysis or outcome
analysis. Process/implementation analysis is a descriptive evaluation about the process of
procedure implementation and how it functions during actual use. Outcome analysis is a
descriptive evaluation of whether a procedure is effective in meeting its objectives.
Neither analysis uses rigorous design. The purpose of these types of evaluation is to
decide whether the tool should be discarded, revised, replaced or continued (Polit &
Hungler, 1995).

Process/implementation analysis typically involves an in-depth evaluation of the

performance of a procedure, often involving the collection of both qualitative and

67

quantitative data. This type of analysis may be used with the goal of improving a new or
ongoing program (Polit & Hungler, 1995). For example, data could be compiled for
completeness or case of use of the tool by primary care APNS. An anonymous survey
could be given to primary care APNS to obtain accurate assessment of the provider’s
thoughts and criticism related to the tool.

An outcome analysis typically documents the extent to which the goals of a
program are attained, or the extent to which positive outcomes occur (Polit & Hungler,
1995). Examples of outcome analysis for the tool are a pre and post test of stroke
survivors for knowledge and/or satisfaction survey, and a chart review for lifestyle
changes, morbidity, mortality, and/or recurrence statistics. Increased awareness of the
different types of stroke and their management, knowledge of the risk factors,
consequences, signs and symptoms, and recurrence prevention can be obtained by verbal
interview, survey (written or telephone), or pre and post test.

To evaluate the impact on health outcomes, a chart review at primary care
practice could be done before and after the APN intervention. Outcomes could be
measured by recording results from the individually set goals at each follow-up visit. It
would be important to note changes in behavior, goal accomplishment, and setting of
new goals each visit, frequency of office visit, recurrence, and hospitalization. An area of
interest would be to determine if the health care provider was providing closer
monitoring and follow up of the stroke survivor which may positively impact preventive

behavior adherence.

68

Implications for Advanced Practice Nurses
Practice

It is critical that APNS have a clear sense of the uniqueness they bring to health
care. Advanced practice nurses deliver holistic care which includes the physical,
psychosocial, mental, and spiritual aspects of patient care. APNS are educationally
prepared to provide and coordinate care for a stroke survivor. APNS in primary care are
in an optimal position to identify those at high risk for stroke as well as care for the
stroke survivor. The management of the stroke survivor can be a challenge for any health
care provider, but someone must coordinate care by playing a key role in assisting the
stroke survivor adult adapt to stroke and the required lifestyle changes. The APN’S
role(s) in the care of the stroke survivor is not documented in the literature. However, the
APN can play multiple roles in the care of the stroke survivor including advocate,
assessor, clinician, educator, consultant, counselor, change agent, collaborator, case
manager, evaluator, and researcher. Although, all of the roles are important, a selection
of these roles will be discussed briefly within the scope of this project.

As assessor and clinician, the APN is capable of obtaining subjective and
objective data on an ongoing basis. Completion of serial neurological exams is important
to detect the extension of stroke and can be mastered by the APN. The APN formulates
diagnoses and provides direct primary care based on sound theory. Advanced clinical
judgement is used to promote self-care abilities, maintain health, prevent complications,
and manage disabilities. Utilization of a quick reference tool by the APN can aide in

assessment and increase quality and efficiency of the APN’s practice.

69

As educator, APNS are able to teach potential stroke survivors methods to reduce
risk factors, and how to recognize stroke recurrence because of their focus on health
promotion, illness prevention, and support of the human response. Education is an
important part of a plan of care followed by an assessment of the patient’s, caregiver’s,
and family’s level of understanding. Patients and families should receive written
instructions regarding stroke pathophysiology and etiology, medications, and prescribed
regimen. The NSA has many well-written brochures directed toward stroke survivors and
care givers. Without the understanding of the disease process, purpose of medications,
and the important supportive strategies, patient adherence is at risk. Knowledge deficit is
a major barrier and one that can be reduced by the APN. A list of suggested topics for
patient, family, and caregiver(s) is included in Appendix E (Gresham et al., 1995). In
addition, informed stroke survivors and care givers are more likely to become effective
partners in their care.

The APN with neuroscience expertise can function as consultant to other health
care providers in the care of stroke patients. Consultants facilitate communication,
deveIOp knowledge of leadership structure, negotiate issues of role conflict of care
givers, and provide expert clinical knowledge (Kearney & Yurick, 1996). Consultants
utilize problem solving process and provide information to broaden the scope of health
care planning for other health care professionals. Consultants can also provide
educational sessions to lay groups.

As counselor, the APN assesses the human response to stroke. The APN provides

support to the stroke survivor and family and allows for expression of feelings and

70

concerns. Assessment of coping behaviors in adjusting to the lifestyle modifications and
providing alternative coping behaviors are also areas within the counseling role.

APNS can be change agents in the lives of a stroke survivor. Change agents utilize
a deliberate approach to coordinate activities to bring about positive alterations in an
individual’s health behaviors. APNS in primary care can be the initial or follow up
contacts related to health care for the consumer, thus putting them in an ideal position to
provide the needed assessment, screening and education for stroke survivors.

Collaboration and utilizing the APN to the full extent of their training allows
outreach opportunities and increased access to health care. Incorporation of the patient
into the collaborative patient/health care provider relationship can increase patient
satisfaction and adherence. Historically the nurse has had significant interaction with the
patient, therefore, it would be a natural transition to have the APNS be the liaison or
advocate for the patient. Part of getting the patient involved requires educating the
patient on the collaborative process. Collaboration with the patient refers to provision of
information by the APN to the patient to achieve joint responsibility in planning
decisions. An example of collaboration in stroke care is the mutual goal setting and
ongoing follow-up. Once the patient understands the methods of involvement, he will be
able to make informed decisions, become an active participant, and more likely adhere to
the treatment plan.

Collaboration between members of the health care team is also extremely
important in stroke care. Interdisciplinary collaboration is the best means of ensuring that

stroke survivors receive consistent information while receiving integrated care.

71

Interdisciplinary collaboration refers to a team approach to health care delivery.
Members of each discipline, appropriate to the survivor’s care, meet to discuss their
individual assessments in order to reach agreement on their recommendations. In
contrast, multidisciplinary collaboration refers to the process where each discipline is
consulted separately, completes an individual assessment, and presents the findings and
recommendations to the stroke client and/or to the provider who takes the responsibility
to make an independent decision. Little or no communication occurs between the
disciplines. The multidisciplinary process can lead to the client and provider receiving
conflicting messages from the different disciplines which can confuse the client and
make the decision making process difficult (Gage, 1994). In primary care, the APN
would receive information from the disciplines previously involved in the care of the
stroke survivor and would continue a collaborative relationship through exchange of
information with the disciplines that are continuing to work with the survivor.
Interdisciplinary collaboration is preferred, however, not always logistically feasible if
not all of the providers are working within the same health center.

In summary, the APN has the capability of effectively providing high quality,
cost-effective care to the stroke survivor. With tracking and monitoring of outcomes,
APNS can validate their worth to the patient, family, society, peers, and the health care
industry. The APN who has the knowledge and skills to care for the stroke survivor can
educate, provide support, assess, and intervene to help the stroke client adhere to

preventive health behaviors to maintain or improve quality of life.

72

Education

Since the prevalence of stroke is projected to continue, the challenge of stroke recurrence
prevention is likely to continue. It is, therefore, essential to educate the public about
stroke and stroke recurrence. Education programs for the community could be developed
by the APN. Using the HBM, a program could be created to help identify those at risk for
stroke, to teach high risk patients how to recognize stroke, and how to implement
lifestyle changes to prevent stroke and stroke recurrence. Including significant others in
education programs lends support to survivors. Providing stroke signs and symptoms to
the patient and significant other will help them in identifying stroke symptoms so that
they will emergently seek medical attention.

Education, of course, occurs one on one with the stroke survivor. APNS can
utilize the HBM and the risk assessment tool to help effect behavior change in the stroke
survivor, through education, for example. Increasing the stroke survivor’s knowledge
base about stroke recurrence prevention and taking appropriate action could help to
prevent recurrent stroke. Increased knowledge will enable and empower care givers and
stroke survivors to make informed choices regarding appropriate and effective
interventions.

Education of the interdisciplinary team which cares for the stroke survivor is
important. The APN educator/consultant is capable of providing education to other
health care personnel. Health care providers need to understand the effect of stroke on
the patient and family. It is essential that the health care team support each others efforts

and is working toward the same goal in stroke care provision.

73

Research

Recurrent stroke has been identified as a perplexing problem facing the
increasingly older population. Current research indicates that the prevalence of stroke
will increase as the baby boomers reach their elder years. Current research abounds with
information relative to primary prevention of heart disease and stroke. No research was
found as to which lifestyle change strategies can alter stroke recurrence. In order to
determine the appropriate interventions for stroke survivors to decrease recurrent stroke,
it is necessary to conduct further research into stroke recurrence prevention and
management of stroke survivors. Replication studies related to specific interventions and
evaluation of intervention effectiveness could clarify the existing ambiguities regarding
the management of stroke survivors. More research could mean an eventual decrease in
number of recurrent strokes or a longer length of time before stroke recurrence.
Undoubtedly, more research on stroke recurrence prevention will increase understanding
of the disease process.

More research is needed to understand the barriers to adherence to preventive
health behaviors for stroke survivors. Further research is needed in the area of age
specific assessments as they impact diagnosis and treatment. Incorrect or delayed
treatment greatly impacts outcomes both in terms of cost and quality of life. It would be
relevant to research what type of follow-up enhances adherence.

Research is also warranted to validate the risk assessment tool as well as identify
factors that may be involved in the health seeking behaviors of stroke survivors.

Research regarding behavior change and successful adaptation of preventive behaviors is

74

needed. A study could be developed to include a teaching plan related to stroke
recurrence and methods to alter lifestyle related risk factors. Then, a follow-up study in
six months to determine changes and degree of risk after intervention. In summary, more
research is needed to guide the care of the stroke survivor and increase adherence with
prescribed regimens. The goal of further research is to produce positive patient
outcomes, decrease morbidity, mortality, and frequency of recurrence.

APNs within the researcher role can pursue the systematic and scientific
investigation of the aforementioned topics for research. APNs can test nursing as well as
other theories in the care of stroke patients. APNS can foster the spirit of inquiry within
the nursing profession through participation in research with the goal of advancing
nursing knowledge. APNs can also utilize research within clinical practice to improve the

care of stroke survivors.

Conclusion

Stroke is the third leading cause of death in US. The risk of stroke increases as
people age. Stroke and recurrent stroke is a common and serious medical problem for the
elderly. As the baby boomers enter their elderly years, it is likely the number of
individuals at risk for stroke will increase. Changes in the health care system have
resulted in more stroke survivors being treated by primary care providers. The
combination of increased stroke patients and advances in managed care could lead to
APNs caring for an increasing number of stroke patients.

Even though pervasive, stroke is largely preventable. Prevention and early

75

intervention which maximize functional status and quality of life are desired. Education
and prevention strategies tailored to the patient are important keys to recurrence
prevention. No single strategy is effective for all patients as noted by the HBM. However,
an APN intervention with the risk assessment tool can be beneficial to the management
of stroke survivors. It is through education of the stroke survivor about the risk factors
they face, what they can do about them, and mutual goal setting for implementation of
risk intervention that they can become true partners in their health care. There is a
demonstrated need for increased public and provider understanding of stroke recurrence
and the need for implementing preventive health behaviors. The use of this tool offers a
brief, easy-to-use checklist for the APN to increase awareness of stroke and preventive
health behaviors. Acknowledging both the primary role of the stroke client as decision
maker and the relevant social, environmental, and health beliefs involved helps to more
fully explain the adoption of preventive health behaviors. With a better understanding,
APNs will be better able to identify, implement, and test interventions that will have the
greatest possible effect on preventive health behavior. Acknowledging both the primary
role of the stroke client as decision maker and the relevant social and environmental
factors and health beliefs involved helps to more fully explain the adoption of preventive
health behaviors. With an improved understanding, APNs will be able to identify,
implement, and test interventions that will have the greatest possible effect on preventive
health. It is only by increasing awareness of stroke and preventive health behavior that

both the quantity and quality of life for so many will be enhanced.

76

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preliminary report W410) 37-49

87

 

 

APPENDICES

88

APPENDIX A

GERIATRIC DEPRESSION SCALE

Functional Assessment at the Elderly" g
Assessment ‘D
:5
e..-
“—1
Affect ED
Geriatric Depression Scale ' a
This may be administered in oral or writen lorrnat. it adninlstered orally. the examiner may have to a—Q-
repeat the question in order to get a response that is more clearly a yes or no. An lndependeri lorrn. c
'Amlude Survey“. is available to: M's use as indicated. it client is doing independomly. mm to
Vtheappropnatespaceattheriphtoleachquestion. Shadedaquarescheokedlndioueadepresstve (D
answer.
Point tor 1
Answer .

 

1.Areyou basleelysatlsfledwlhywrlle?
2. Have you dropped many at your aaivities and interests?
3.Doyouteelthat yourlitelserroty?
4. Do you otten get bored?
5. Are you hopetul about the tuture?
6. Are you bothered by tttougm that you just cannot get out or your head?
7.Areyouingoodspirlts n'lostolthetirne?
8.Areyou atrald that somethingbadlsgoingtohappentoyou?
9.00youteeihappymostotthethte?
10.00 you otten teel helpless?
11.Doyouottenpet restlessandfldoettr?
12. Do you preter to stay home at night. rather than go out and do new "tings?
13.00 you trementiy worry about the tuture?
14.00youleelthatyouhavemoreproblemswithmemorythanmost?
15.00youttinkllswondertultobeallvenow?
16. Do you otten leel downheaned and blue?
17. Do you reel pretty worthless the way you are now?
18.00youworryaiotaboutthepast?
19. Do you find lite very exciting?

DBBBDBGBBEDBUBUBBQDé
GODUEDUDDDEUQDEDDDBZ

'Spenish and French Version horn T. L. Brink available: Used wih the permission 0! author T. L. Brink PhD.
Reference: Yesavage, J.A.. Brink, T.L.. Rose. T.L.. Lum, 0.. Hang, V., May, M., and Letter, V.O.. (1983). Develop-
E . . E 1

mom a Vahdalion at a Geriatric Depression Screening Scale: A Preliminary Report.
(17), pp. 3749,

89

FuwtionaiAssessmentottheElderlr

Assessment

Affect (Cont)

FORM
Anuver

.lslherdloryoulooetstartedonnewproleds?
. Doyouteelluloieneruy?

. Doyouleelthetyoursnuetloniehopelees?

. Doyouthinkthatmostpeoplearebetlerotlthanyouare?
.Doyouirementlypetupsetoverlltlethhgs?
.Doyoulrequenuyteellltecrying?
.Doyouhavetroubleconoeuratlng?

. Doyou enjoy getting uplnthe mornings?

. Do you preter to avoidsoeialgatherings?

. lsleasytoryoutomakedeolslons?
.lsyourmindasclearasltusedtobe?

g
(D
3
e-l-
9.
(D
e..-
D)
H-
C
K tn

 

seassasaese
01311113139531.3305;
danduuoauaas

TOTAL

Sma‘nn; Counrtpoinrloreadldepressiveanswer.
0-10- normal

11 -20- milddeptession
21 -30- moderateorseveredepression

Comments:

 

 

 

 

 

 

9O

APPENDIX B

 

MINI-MENTAL STATE EXAM
g FunctiondAsseesmentotthe Elderly"
:5 Assessment
e-l-
urn—,— 2. The Folsteln Mini-Mental State Examination‘
41-.- Client Score Malt Score
n) onreunnou
Fl- 1. What is the (year) (season) (date) (day) (north)? __ s
c 2. Where are we (state) (county) (town) lttoeplal)
a) (floor)? __ 5
REGISTRATION
3. Nemethreeobpctszoneseoondtoeayeedflhen
1 ukthepetlerlalthreeelteryouheveeaidthem.
Give one pair! Ior each correct arlewer. Repeat
them until he Ieams all three. Count trials and
record number. 3
A‘ITENTION a CALCULATION
4. Beginwlh 100andcount baclrwardbyflstop
after five answers). Alematively. spell Morld‘
backward. 5
RECALL
5. Ask for the three objects repeated above. 3
LANGUAGE
6. Showapencilandawatchandaslrthepatiem
to name them 2
7. Repeattheiolowirlgz'NoiIs.andsorbuts' 1
8. A three-stage command: ' Take a paper In your
handJoIdIinhaIIandputitontheIIoor.‘ 3
9. Reed and obey the IoIIowIng: (show wrlten Item) 1
CLOSE YOUR EYES
10. Wrie a sentence 1
11. Copy a design (couple: polygon) 1
TOTAL 30

0

Normal ebony score a mean or 27.6.
Comments:

 

 

 

'Repn‘nied wih permission from the Journal of Psychiatric Research (1975. 12 : 196- I 97) Mini-Medal Slate
Exam for use in Clinical E valuan'on. Copyright 1975. Pergamon Press pk:

Rec 10.72.”

91

1

APPENDIX C

FOOD GUIDE PYRAMID

'- We - 11111111111111

9 L)

- 3 1293 01189 7624

   

1...... rtedenid

DEC 08 1992
mam mt: alum
mm

 

  
  
 
  
 
 
   
   

Fats. Oils. 8 Sweets
USE SPABIIIGLY

 

Milk. Yogurt.
8 Cheese
Group

2-3 SEBVINGS

 

Vegetable
Group
3-5 SERVINGS

. ”5”,? .1". Quinn'fiw, rt ' 3 _‘-.:"".,'.'.1'I'"‘,.,

7' ‘1?
—‘.-
:lij' .
5.; \J.‘ l
1.

a
3:3), ‘3'» (' t-‘ $3”: $8va -’_-'_""..‘.',‘. - 171“}

A Guide to Daily road Choices

 

 

Group
24 SERVIIGS

m:uswvwsmummmm

UaetheFoodGuldePyramidtohelpyoueatbetter
every day. . .the Dietary Guidelines way. Start with

plenty of Breads. Cereals. Rice, and Pasta; Vegetables;

and Fruits. Add two to three servings Inom the Milk
group and two to three servings from the Meat group.

9‘; 511.. - . .
pToordteoopyel'IheFoodGudePyr-unid'm‘lde
81Nd1eeItorrltarteyordet'nladeotrttomer
immmmm,wtse~v.
tMMOWN. ~ . . .

92

Eacholtheseioodmprovldeseomemuthotal.
olthenutrlentsyouneed.Noonetoodgroupismore
importantthmanother—Iorgoodheelmyouneed
titernaII.Goeasyoniets.olls.artdsweets.tttetoodsh

thesmailtlpoithePyramid.
31:?“ F.’ .xw‘J‘ t)- m»; r" ..~.-.I,.’ ”3‘ B.,“; l_’, '
us. mammmmm
wrulgtntmmham _‘_

'r

How 16 use meoanymd"emae '

 

What counts as one sewing? ‘

Breads,Cereals,Rlee.and Pasta
1sliceolbread
1/2cupolcookedn’oeorpasta
1/20upotoookedoereal
lanceotready-to-eatoereal

MeaLPouu'leaIuDryBeene,

Vegetables

1/2 cup of chopped raw or
cooked vegetables

1 cup of leafy raw vegetables

Fruits
1pieceoltruitorrnelonwedge
3/40upoljuioe
1/20upolcannedtrult
1/4eupoldrledfrult

Emandllluta

MflhYogmandCheeee
lcupotmilkoryogurt
1-1/2to2ounoesotcheese

2-1/2toaounoeeotoookedleen
meat.poultry.orfish
Counttf2cupoloookedbeme.
ortegg.or2tabieepooneot . . .. A , .,
peanutbutterastounoeotleen " " h '

 

 

 

 

Howmmfiésdowu .' ..

Wm " 2 .f-‘SV'j-x. _ 4.

~2-3 ~2-a. "243 I
store I,
Wot ‘
.7ounoee

2.91:" _ A
stat-Id
A 6m

2.1m
tot-Id
Samoa:

:Meatgroup

 

'Theeearetliecalorleleyelsltyoudiooeelowfatlean l
ioodstromthefimalortoodgmrpeendmeloodaimrh
mmmmmmw $33155;

”Wmnmuewegmorhreasfieemuens

' ‘

 

ACloeerLookatFateMAddedOugen
mmwdmmmmmu '

When-“Wandadm 177;; -

  

é-hoatmmanwbo
Nuthfatendaddedmmch
escheeeeorloeoreemtrornthemlrmorflemh

theelromthevegetahlem WWW
tmammmmmuummm

I'lyowd'roieestremallmetoodm. mill-“Ill.
dewmmmwmm _

 

 

 

 

agar: andyoungedutatoagefineedaeervlrm

 

93

APPENDIX D

Instructions to the APN:

RISK ASSESSMENT TOOL (Part I)

1.) Part I can be filled out by the stroke survivor prior to the office visit. The tool can be
mailed to the survivor’s home with the instructions to assist in the completion of the
forms. If unable to mail the tool, request that the survivor arrive 15 minutes prior to the
scheduled time to facilitate form completion.

2.) Make sure the office staff understands the tool so that they can be available for
questions.

3.) Review Part I with the stroke survivor during the appointment to clarify responses.
RISK ASSESSMENT TOOL (Part II)

4.) Gather medical record information, preferably prior to office visit.

5.) Comments section is provided for the APN’s discretionary use.

6.) Determine ischemic (I), hemorrhagic (II), or lifestyle factor(s) risk by reviewing pages
2-4 of Part II.

7.) Determine appropriate strategies for intervention based on H & P, risk factors, and
consultations as appropriate.

8.) Mutually set attainable goals with survivor for lifestyle change. Document those
goals on a separate sheet of paper for the chart. Encourage signatures (APN & survivor)
and obtain copy for the survivor.

9.) Review goals and progress made each office visit. Revise or create new goals and
complete the signature and copy process.

94

RISK ASSESSMENT TOOL (Part I)
INSTRUCTIONS FOR THE ATTACHED RISK ASSESSMENT TOOL:

1) PLEASE COMPLETE THE FOLLOWING FORMS BEFORE YOUR SCHEDULED
APPOINTMENT.

2) BRING COMPLETED FORMS WITH YOU TO YOUR SCHEDULED
APPOINTMENT.

3) WE RECOMMEND THAT YOU SELECT A SUPPORT PERSON TO
CONSISTENTLY COME TO OFFICE VISITS WITH YOU. PLEASE BRING THAT
PERSON WITH YOU TO EACH SCHEDULED APPOINTMENT.

4) IF YOU NEED ASSISTANCE OR HAVE QUESTIONS REGARDING THE RISK
ASSESSMENT TOOL, ASK YOUR SUPPORT PERSON OR GIVE OUR OFFICE A
CALL. (HOURS:
PHONE #: ).

 

5) WE ENCOURAGE ALL OF OUR PATIENTS TO HAVE AN UPDATED COPY OF
THEIR MEDICATIONS. WE WILL BE HAPPY TO PROVIDE YOU WITH EXTRA
FORMS AND/OR A COPY OF THIS COMPLETED FORM.

THANK YOU FOR YOUR TIME IN COMPLETING THESE FORMS.

95

RISK ASSESSMENT TOOL (Part I)

 

 

 

 

 

 

NAME: DATE OF BIRTH: SEX: __
PHONE (DAY): (EVENING): MARITAL STATUS: _
ADDRESS:

DO YOU LIVE ALONE? WITH SPOUSE? OTHER?

HIGHEST LEVEL OF EDUCATION: OCCUPATION:

 

 

PRIMARY SUPPORT PERSON (To Be Involved in Office Visits and Teaching):
SUPPORT PERSON’S NAME: RELATIONSHIP:

SUPPORT PERSON’S ADDRESS:

 

SUPPORT PERSON’S PHONE (DAY): (EVENING):

 

MEDICAL DIAGNOSES/PROBLEMS:

WW (7)
(2) (3)

 

(3) (9)
(4) (10)
(5) (1 l)
(6) (12)

HEALTH CARE PROVIDERS:

 

 

REHABILITATION (Type & Frequency):

 

 

PERSONAL RECOVERY GOALS:

 

96

 

 

 

PREVENTIVE CARE:

 

 

 

 

DATE OF LAST EYE EXAM: ‘ LAST HEARING EXAM:
LAST PHYSICAL EXAM: LAST DENTAL EXAM:
USE OF (AMOUNTS PER WEEK): TOBACCO: ELICIT DRUGS:
CAFFEINE: ALCOHOL:

 

 

EXERCISE (TYPE & FREQUENCY):

 

WHAT IS YOUR USUAL BLOOD PRESSURE?

HOW OFTEN DO YOU CHECK YOUR BLOOD PRESSURE?

 

TYPE OF DIET: DO YOU FOLLOW THAT DIET?

DIFFICULTY CHEWING OR SWALLOWING?

 

CONCERNS ABOUT WEIGHT LOSS/GAIN?

 

WHAT IS YOUR USUAL WEIGHT?

24 HOUR DIET RECALL
(LIST Emma AND W AND W FROM XESIERDAX)
BREAKFAST
LUNCH/DINNER

DINNER/SUPPER

SNACK(S)

97

ALLERGIES:

 

MEDICATIONS

(including prescribed, over-the-counter, homeopathic, vitamins,
food supplements, and herbal remedies):

WWWWW

23mph;

 

 

 

 

 

 

 

 

 

III

 

1L

 

12

 

Ii

 

14

 

1i

 

"' If self prescribed or recommended by someone else, indicate relationship.

98

RISK ASSESSMENT TOOL (Part 11)

W [Hospitali Medical Record #:___1
NAME: DATE OF BIRTH: SEX:

 

Date and time of occurrence of symptoms:

 

(Initial symptoms, progression/regression?):

 

Diagnosis and type of event:

 

Location and pattern of neurologic deficit (vascular territory involved):

 

 

083$.le
CT Scan (Initial, ? repeated after 48 hours)
MRI/MRA (Gives more detailed view of cerebellum and brainstem)
EKG
Chest Film
Holter Monitor
Transesophageal Echocardiogram (TEE) (Identify embolic source)
Carotid Duplex Ultrasonography or Carotid Doppler (Identify stenosis)
Cerebral arteriography (Identify degree of extracranial stenosis & intracranial disease)

 

 

 

0131mm]: OAdIrlullmaes.
CBC (differential & platelet count) (comorbiditim, risks &
Prothrombin Time complications mm

 

Activated Partial Thromboplastin Time

 

 

INR (International Normalized Ratio)

 

 

ESR (Erythrocyte Sedimentation Rate)
Fasting Glucose

 

 

Electrolytes

 

BUN/CR

 

Lipid Profile

 

Urinalysis

 

 

OCOMMENTS (Discharge summary, rehab goals, notes, & etc.):

 

 

 

99

RISK

W (20%)
Nonvalvular Atrial Fibrillation
Ml, Prosthetic Valves, Rheumatic
Heart Disease, Ischemic

Cardiomyopathy, Coronary
Artery Disease

lll ll'B'l

Aortic Atheromatous Disease

MW (Atherosclerotic

Cerebrovascular Disease) (20%)

Carotid Disease

Cerebral Disease

Vertebrobasilar Disease

100

W

O Coumadin (Warfarin Sodium)
-Conundiunons: patient refusal,
nonadherance, GI bleeding, Pregnancy,
alcoholism, coagulopathy, recent CNS or
eye surgery, history of significant bleeding
during anticoagulation, & others (see
prescribing information.

Mom patients mm at the
beginning oftherapy until INR stabilized at
2.0-3.0; then monitor at least m2
nondis-

-Review survivor’s medication; as many
classes of drugs (e.g. antibiotics &
anticonvulsants) can interfere with
anticoagulation.

-M9gitgr wiflrin 7 days of beginning or
ending medication known to afl‘ect
Coumadin response.

{21¢}; avoid foods containing vitamin K.

.ASA 325mgcanbeusedifCoumadin
contraindicated. (Enteric coated)
Antiplatelet therapy (325 mg ASA qd, 75
mg Plavix qd, 250 mg Ticlid bid, or
Dipyridamole & ASA) can also be used
instead of Coumadin.
O Atrial fibrillation: consider m
therapy

0 < 70% carotid stenosis: Antiplatelet
therapy

0 > 70% carotid stenosis: carotid
endarterectomy, or Antiplatelet therapy if
surgery contraindicated

0 Consider balloomilmrinnlstemins

O Coumadin or antiplatelet therapy as
above

0 Consider mm

C Coumadin or ASA therapy as above
0 Consider 93mm

RISK

Lacunar Disease (25%)
(Penetrating Artery Disease (also
lipohyalinotic risk)

MW (30%)

Cthenllnmalm (5%)
Prothrombotic states,
Dissections, Arteritis, Migraine/
Vasospasm, Elicit Drug use (list
not all inclusive)

W
H I’B‘l

MW

Management Goal:
<140/85 mm HG

or
<130/82 mm Hg in renal
insufficiency, heart failure or
diabetes (optimal <120/80)

Diahstu
Management Goal:

HbAlc <7

H l' 'l .
Management Goal:

LDL < 100 mg/dl

Secondary goals:
HDL> 35 mg/dl
TG < 200 mg/dl

101

W

O HTN management

0 Therapy based on presumed cause, though
no evidence formd. Often suggestive of
embolism despite clear source not identified.

0 Therapy based on Imderlying cause

0 HTN management

0 Eliminate excessive alcohol use

0 Eliminate use of elicit drugs (e.g. cocaine
& amphetamines

0 Weight control

0 Physical activity or exercise prescription
0 Limited sodium intake

0 Moderation of alcohol intake

0 Advise smoking cessation

0 Add blood pressure medication
individualized to patient’s needs as per JNC
VI and HOT research

0 Weight control

0 Physical Activity

0 Blood pressure control

O Hyperlipidemia management

0 Add appropriate therapy to achieve goals

0 Emphasize weight management and
physical activity.

O Advise smoking cessation

O Encomage AHA diet and high fiber

intake

0 Add appropriate therapy to achieve goals

RISK

Smoking
Goal:
Complete Cessation

Height
Goal:
BM] (Body Mass Index) of
21-25 kglm2

El . l I ll °|
Goal:
30 minutes or more of moderate-
intensity physical activity on most,
preferably all days of the week

102

W

O Strongly encourage survivor & family to
stop smoking

0 Provide counseling, nicotine replacement,
formal cessation program as appropriate per
AHCPR Guideline

0 Encourage life long eating habits

0 Measure height, weight, BM] at each visit
0 Encourage support program, office weigh
in’s, and resources such as dietician and
Weight Watchers as appropriate
0W:

~10-20% of daily caloric intake from
protein

~55-60% of calories from carbohydrates
(simple & complex)

Q0% of calories from fat

<10 % of calories from saturated fat

" 20 to 30 grams of dietary fiber from a
wide variety of foods

* Limit sodium intake

0 Encourage 30 or more minutes of
moderate-intensity activity up to 7 days a
week tailored to patient ability. Moderate-
intensity activity is equated to a brisk walk
of 3 to 4 miles per hour. Start slow.

0 Increase daily lifestyle activities such as
walking to the mailbox, gardening,
household cleaning, grocery shopping.

0 Utilize exercise prescription

0 Utilize light weights to build muscle
mass, increase calorie Man, as well as

strengthening.

APPENDD( E
W
(adapted from All CPR No. 16: Post-Stroke Rehabilitation)
What is stroke?
O Etiology/pathophysiology of stroke
O Signs & symptoms of stroke
O Effects of stroke on the survivor
O Effects of stroke on the family
O Role of family member(s) and caregiver(s) in treatment plan

Routine Physical/Medical Care

O Maintenance of nutrition and hydration

O Bowel and bladder care

O Sleep and rest

O Reliable medication taking

O Behavioral issues and how to deal with them

O Positioning and moving in bed

O Prevention of blood clots

O Prevention of skin breakdown

O Safety measures to prevent falls

O Rehabilitation

O Exercise during and alter rehabilitation

O Techniques for performing specific tasks, such as transfers, personal hygiene, etc.
O Training in specific skills for which patient needs assistance

Complications of Stroke (tailored to patient’s specific circumstances)

O Respiratory complications (care of tracheostomy/use Of respiratory equipment)
O Cognitive deficits, safety

O Speech or language deficits; facilitating cornmmrication

O Depression and other psychological disturbances

O Swallowing problems

O Care/use of indwelling bladder catheter or feeding tube

Prevention of recurrent stroke

O Monitoring blood pressure

O Medical or surgical interventions to prevent recurrent stroke
O Lifestyle modification

O Smoking cessation

O Alcohol restriction/abstinence

O Exercise (recreational, leisure, & work activity)

O Nutrition

After hospital care

O Care giver concerns

O Optimizing social fimctioning

O Optimizing family functioning

O Spiritual care

O Support groups for caregiver, family, and stroke survivor
O Respite care

O Sexual frmctioning

O Recreational and vocational pursuits (vocational cormseling)
O Automobile driving or operating machinery

O Commrmity resources

103

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31293 02369 9550 _