Post-Discharge Care of Stroke Patients

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Stroke is defined as an abrupt and dramatic development of a neurological deficit caused by an interruption of blood flow to the brain. Each year close to 800,000 strokes occur in the United States, of these 610,000 new and 185,000 recurrent.1 Advances in care have decreased mortality with stroke now the 5th leading cause of death in the U.S.2 While strides have been made in decreasing mortality the morbidity is still high with more than 7 million stroke survivors in the U.S.

The results of a stroke occur on a spectrum from mild to life changing disability. One study reported that among Medicare patients discharged from the hospital after stroke, about 45% return directly home, 24% are discharged to inpatient rehabilitation facilities, and 31% are discharged to skilled nursing facilities. Of stroke patients returning directly home, about 32% use home healthcare services.3

After discharge patients often have some degree of impaired physical mobility, impaired communication, swallowing deficits, and all have some degree of knowledge deficit. Neuroscience nurses are pivotal in assisting patients and caregivers to navigate the complexity of care whether the discharge is directly from an acute care hospital, rehabilitation facility, or following a stay in a skilled nursing facility.

Impaired Physical Mobility
Stroke remains the leading cause of disability in the US and many patients go home with new functional limitations. Of stroke survivors, 80% have some type of deficit as a result of hemiparesis (weakness of one side of the body, or part of it, due to an injury in the motor area of the brain) or hemiplegia (paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain).4

Forty percent of stroke patients are left with moderate functional limitations and up to 30% of patients have severe disability following stroke.5 Mobility should be assessed by physical therapy (PT) and a plan of care established and communicated to patient, family and caregivers. A program of PT may take place in the home or in an outpatient program and can help prevent complications such as contractures. Post-discharge the nurse needs to review the plan of care related to physical mobility, reinforce the importance of keeping PT appointments or help obtain a referral for PT if needed and one was not provided at discharge. Some insurance plans allow self referral and do not need a prescription.

Impaired physical mobility can lead to complications such as falls, deep vein thrombosis (DVT), and skin breakdown. Falls can be devastating to a stroke patient due to the risk of sustaining further injury, especially if patient is on anticoagulation to prevent additional stokes. Therefore a mobility plan should be assembled, barriers to ambulation should be eliminated and adaptive devices should be used if indicated. It is essential to identify safety measures to prevent falls in the home post discharge.

Anti-embolism stockings, sequential compression devices, or prevention medications (low-molecular-weight heparin or unfractionated heparin) may be prescribed to decrease the incidence of DVT resulting from immobility. After discharge the nurse needs to assess the legs for signs and symptoms of DVT (tenderness, redness, swelling, warmth, and edema), and abnormal findings are reported immediately to the Primary Care provider.

Pressure ulcers are a risk associated with impaired mobility and affect 9% of hospitalized stroke patients and 23% of patients in nursing home settings. A plan of care should be established for proper positioning and transferring techniques to avoid skin breakdown. Assessment of skin integrity should be completed at least daily to ensure that skin breakdown is not present, and it if is present that treatment for the area must begin quickly.5 Post discharge it is important to review the correct use of splints or orthotics, proper positioning, and frequent repositioning to prevent skin breakdown.

Impaired Communication and Swallowing
Impaired Communication also plagues many stroke patients. This can lead to patients not being able to adequately communicate their needs. This can be both dangerous and frustrating for patients. Speech therapy should help to develop a plan of care that includes the patient, family and care providers and established to provide the best possible communication between patient and those around him or her.6 Emotional problems associated with stroke are often related to speech dysfunction and the frustrations of being unable to communicate. A speech therapist allows the family to be involved and gives the family practical instructions to help the patient between therapy sessions.

SEE ALSO: Earn CE: Neurolgical Assessment

Difficulty swallowing can lead to impaired nutrition, weight loss and aspiration. Careful evaluation by a speech therapist is needed in the acute care setting as well as rehabilitation settings. A plan of care should be developed that includes weight checks and education for the patient, family and caregivers to proper feeding techniques, this may include swallowing techniques or mouth care efforts.

A plan of care regarding swallowing safety is in an effort to prevent Aspiration Pneumonia, which carries the leading cause of mortality for medical complications following stroke. 7 Oral care of the mucous membranes of the mouth and teeth decreases bacteria and thus plays a role in preventing aspiration pneumonia. Therefore a plan of care for oral health should also be established and reinforced post discharge.8

Knowledge Deficits
The discharge process, regardless of the setting, encompasses many areas of education including new medications, risk factor modification and self-management plans. The goal education is to help the patient and family understand how to prevent another stroke from happening. Recurrent is stroke is associated with many risk factors and is estimated to be between 2% and 4%.1

Modifiable Stroke Risk Factors

High Blood Pressure

Diabetes

Atrial Fibrillation

High Cholesterol

Smoking

Nursing care after discharge should include a plan to reinforce understanding of new medications, encourage risk factor modification, develop strategies for change, and provide other education as needed for the patient and family. The recovery and rehabilitation process after stroke may be prolonged and requires patience and perseverance on the part of both the patient and the family.

Community-based stroke support groups may allow the patient and family to learn from others with similar problems and to share their experiences. Support groups take the form of in-person meetings as well as Internet-based support programs. The patient is encouraged to continue hobbies and recreational and leisure interests and to maintain contact with friends to prevent social isolation. All nurses coming in contact with the patient should encourage the patient to keep active, adhere to the exercise program, and remain as self-sufficient as possible.9

References

1. Mozaffarian, D., Benjamin, E.J., Go, A.S., Arnett, D.K., Blaha, M.J., Cushman, M. et al. (2015). Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation, 131, e29-e322. DOI: 10.1161/CIR.0000000000000152

2. Kochanek, K, Murphy, S.L., Xu, J. & Arias, E. (2014). Mortality in the United States, 2013. NCHS Data Data Brief No.178. Centers for Disease Control. (Online). http://www.cdc.gov.

3. Buntin MB, Colla CH, Deb P, Sood N, & Escarce JJ. (2010). Medicare spending and outcomes after postacute care for stroke and hip fracture. Med Care.48:776-784.

4. Gresham, G. E., Duncan, P. W., Adams, H. P., Adelman, A. P., Alexander, D. N., Bishop, D. S., et al. (1995). Post-stroke rehabilitation. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services.

5. Duncan, P.W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J.J., Grahm, G.D., Katz, R.C., Lamberty, K., Reker, D. (2005). Management of Adult Stroke Rehabilitation Care: A Clinical practice Guideline. Stroke. e100-e143.

6. Hinkle, J.L. McKenna-Gaunci, M., & Stewart-Amidei, C. (2010). Cerebrovascular Events. Chapter 17 in Bader, M., & Littlejohns, L. R. (Eds). AANN Core Curriculum for Neuroscience Nursing. (pp. 531-568). Glenview Ill: American Association of Neuroscience Nurses.

7. Armstrong, J.R. & Mosher, B.D. (2011). Aspiration Pneumonia after Stroke. The Neurohospitalist. 85-93.

8. Terp-Sorensen, R., Skovaard, Rsmussen, S., Overgaard, K., Lerche. (2013). Dysphagia Screening and intensified Oral hygiene Reduce pneumonia after Stroke. Journal of Neuroscience Nursing. 139-146.

9. Shaughnessy, M., Michael, K., & Resnick, B. (2012). Impact of treadmill exercise on efficacy expectations, physical activity, and stroke recovery. Journal of Neuroscience Nursing, 44(1), 27-35.

Lindsey R. Siewert is clinical nurse specialist neuroscience, Norton Healthcare, Louisville K.Y. and a director at large for the American Association of Neuroscience Nurses (AANN). She can be reached at lindseysiewert@gmail.com
Janice L. Hinkle is self-employed and president of the AANN. She can be reached at:
janhinkle15@gmail.com

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