Stroke Guide


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Stroke Guide

  1. 1. A Patient Guide Stroke
  2. 2. What is a stroke .......................................................................1 Types of stroke...............................................................................1 What is a transient ischemic attack (TIA)?.................................2 Warning Signs of Stroke or TIA...............................................2 Why is Stroke an Emergency? Call 911 ....................................3 Stroke Testing and Monitoring..................................................3 Acute Stroke Treatment ...........................................................6 Stroke Medications...................................................................6 Stroke Recovery and Rehabilitation..........................................8 Cognition (thinking) and Communication .................................9 Coping with Emotions ................................................................10 Social Support.............................................................................11 Eating and Swallowing................................................................11 Going Home................................................................................18 Going Places................................................................................19 Recurrent Stroke and Stroke Prevention.................................20 Personal Modifiable Risk Factor Reduction...............................20 Follow up after discharge ............................................................25 Resources...............................................................................22 Stroke Guidebook
  3. 3. Dear Patient: This guidebook was written to give you and your family some information about stroke and help you to prepare for recovery. Please keep in mind that each person has different causes and kinds of stroke as well as needs and pathways to recovery. The guidebook will help you learn or better understand what a stroke is, what the warning signs are, what to do when one occurs, tests and treatment options, risk factor reduction, rehabilitation and, and resources for support. Please let us know if you have any questions or concerns. Sincerely, Baptist Health What is a stroke? A stroke, or a brain attack, is a type of blood vessel disease which affects the blood vessels leading to and inside the brain. A stroke occurs when a blood vessel which carries oxygen and nutrients to the brain, is blocked or bursts. This may result in brain cell death affecting body functions and is a medical emergency. Stroke is the third leading cause of death and a leading cause of disability in the United States. Types of stroke • Ischemic strokes are caused by blockage of an artery that supplies blood to the brain. • Hemorrhagic (bleeding) strokes are caused by ruptured blood vessels. What is an ischemic stroke? Ischemic stroke accounts for about eighty-three percent of all cases. Ischemic strokes happen as a result of a blockage within a blood vessel supplying blood to the brain. The reason for this type of blockage is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis which can contribute to a heart attack or stroke. These fatty deposits can cause two types of blood flow blockages to the brain. There are generally two causes of ischemic strokes. • Cerebral thrombosis refers to a thrombus (blood clot) that develops and clogs the vessel. • Cerebral embolism is a blood clot that forms in the bloodstream usually in the heart and large arteries of the upper chest and neck. A part of the blood clot breaks loose, enters the bloodstream and travels through the brains blood vessels until it reaches vessels too small to let it pass. A second important cause of embolism is an irregular heartbeat, known as atrial fibrillation. It creates conditions where clots can form in the heart and travel to the brain. 1 Stroke Guidebook
  4. 4. Stroke Guidebook What is a hemorrhagic (bleeding) stroke? Seventeen percent of all strokes are hemorrhagic. This happens when a blood vessel bursts and stops the oxygen supply to the surrounding areas of the brain. Hemorrhagic strokes are different from ischemic strokes in several ways. • The death rate is higher and the overall prognosis is worse. • Usually affects younger people. • Symptoms often include a sudden severe headache, nausea, and vomiting. • May not see a TIA (mini-stroke) or other stroke warning sign first. There are two kinds of bleeding strokes. • Subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain bursts and bleeds into the space between the brain and the skull. The most common cause is a busted aneurysm (blood filled pouch that balloons out from an artery wall) most often caused by high blood pressure. • Intracerebral hemorrhage occurs when a blood vessel bleeds into the tissue deep within the brain and is most often caused by high blood pressure or aging, causing about 10-20 percent of all strokes. Treatment for bleeding strokes. Because hemorrhages can be life threatening, hospital care is required in an intensive care unit. Medication can control further bleeding, control high blood pressure, or decrease brain swelling. Surgery may be needed depending on the cause of the bleeding. What is a TIA? A transient ischemic attack (TIA), sometimes called a mini-stroke, is caused by blockage of blood flow in the brain that occurs briefly and goes away on its own. A TIA can happen days, weeks or months before a major stroke and can be a sign that a major stroke may occur. The symptoms of a TIA are the same as the warning signs of a stroke, but usually last less than one hour but may last up to 24 hours. Once you have had a stroke your risk of another is higher. It is very important to recognize the warning signs of stroke.The first step to treat a stroke is to recognize the symptoms as soon as they happen. Warning Signs of Stroke or TIA • Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance, or coordination • Sudden severe headache with no known cause2
  5. 5. Stroke Guidebook Why is stroke an Emergency? Call 911 Every minute counts. The longer blood flow is cut off to the brain, the greater the damage. Treatments are available to greatly reduce the damage caused by a stroke. The most common kind of stroke, ischemic stroke, can be treated with a drug that dissolves clots blocking the blood flow. What should you do? To receive the drug that dissolves clots you need to arrive at the hospital as soon as symptoms start. • Know stroke symptoms • Call 911 right away • Get to a hospital that is expert in caring for stroke patients. Do not wait for the symptoms to go away and do not ignore them. If you have any of these warning signs or symptoms call 911 and get help right away. If possible, know the time the symptoms started. Because stroke injures the brain, you may not realize that you are having a stroke. The people around you might not know it either. Your family, friends, or neighbors may think you are confused. You may not be able to call 911. That is why everyone should know the signs of stroke and know how to act fast. Stroke Testing and Monitoring Finding a stroke while it is happening is important because the treatment depends on the type, cause, and location. Your doctors and nurses will ask questions about your medical history and symptoms. Tests will be performed to correctly diagnose a stroke. If you have had a stroke or stroke warning signs, your doctor will need additional information to fully understand your specific problem and plan the best treatment. In addition to blood tests, you will need testing to examine your brain, heart and blood vessels. Here are the tests most often used in stroke diagnosis and treatment planning. Blood Tests and Procedures Used for Stroke Diagnosis Stroke cannot be determined by a blood test alone. However, these tests can provide information about stroke risk factors and other medical problems that may be important. 3
  6. 6. Stroke Guidebook Blood Tests CBC (complete blood count) This is a routine test and shows the number of red blood cells, white blood cells, and platelets in your blood. Hematocrit and hemoglobin show of the number of red blood cells. A complete blood count might be used to tell if you are anemic (too little blood) or have an infection (shown by too many white blood cells). Coagulation (clotting) tests PT (Prothrombin time) PTT (Partial thromboplastin time) INR (International normalized ratio) These tests measure how quickly your blood clots. An abnormality could result in excessive bleeding or excessive clotting. If you are taking blood-thinning medicine such as warfarin (Coumadin or similar drugs), the INR blood test is used to be sure that you receive the correct dose. It is very important that you obtain regular checks. If you are taking heparin, the PTT test is used to determine the correct dose. Blood chemistry tests These tests measure the levels of normal chemical substances in your blood. An important test in emergency stroke evaluation is to measure glucose (blood sugar) levels. Blood sugar levels which are too high or too low can cause symptoms which may be mistaken for stroke. Fasting blood glucose is used to help in the diagnosis of diabetes, which is a risk factor for stroke. Controlling blood sugar after a stroke can improve stroke recovery. Other blood chemistry tests measure serum electrolytes, the normal chemicals in your blood (sodium, potassium, calcium) or check the function of your liver or kidneys. Blood lipid (fat) tests These tests measure cholesterol, triglycerides, HDL (high density lipoprotein), and LDL (low density lipoprotein). Cholesterol is a natural substance found in all living tissue, but when too much of it builds up in the arteries, either because of heredity or dietary factors, it can be dangerous. Cholesterol is a wax-like substance that is found in the body. It is a lipid, or a type of fat. Cholesterol is made in your body by your liver. You also get cholesterol by eating foods that come from animals. Examples of foods that come from animals include meats, eggs, and whole-fat dairy (milk) products. Your health care provider may take a blood sample from you to see if you have too much cholesterol in your blood. You may need to fast for 9-12 hours before your blood is drawn. 4
  7. 7. Fasting (going without eating) helps to make sure that the test shows your actual cholesterol or blood sugar level. When fasting, you may drink water. Food and other drinks (such as coffee or tea) consumed during this time may affect your cholesterol or blood sugar reading. Acceptable blood cholesterol levels are specific to each individual and for that reason your health care provider should have those numbers and work with you on a therapeutic plan. In general, Normal Total Cholesterol is below 200. Normal LDL is below 100. Normal HDL is above 40 for men and 50 for women. What are triglycerides? Triglycerides are another class of fat found in the blood stream. Elevated triglyceride levels may be caused by medical conditions such as diabetes, hypothyroidism, kidney disease, or liver disease. Dietary causes of elevated triglyceride levels may include obesity and high intakes of fat, alcohol, and concentrated sweets. A healthy triglyceride level is generally less than 150mg/dL. Tests that check the brain, heart, and arteries CAT Scan (Computed axial tomography, CT) is an important diagnostic test of the brain. It uses x-rays to produce a 3-dimensional image of your head and is usually one of the first tests given to a patient with stroke symptoms. MRI (Magnetic resonance imaging, MR) like a CT scan, it shows the location and extent of brain injury. The image is sharper and more detailed than a CT scan. It uses magnetic fields to also produce a 3-dimensional image. Tests that view the blood vessels Carotid Doppler is a test that uses ultrasound waves and can show if the artery in your neck that supplies blood to the brain is narrowed by atherosclerosis (cholesterol deposits). MRA (Magnetic resonance angiogram/arteriogram) is a special type of MRI scans. In this test, special substances are injected into the blood vessels and an x-ray is taken to show the blood flow through the blood vessels leading to and into the brain. This allows the size and location of blockages to be evaluated. This test is especially valuable in diagnosing aneurysms and malformed blood vessels and providing information before surgery. Stroke Guidebook 5
  8. 8. Tests that check the heart Electrocardiogram (EKG) is a standard test of the electrical activity of the heart. Electrical sensors are attached to your chests, arms, and legs. Some strokes are caused by an irregular heartbeat. Echocardiogram (2-D echo, TTE, TEE) ultrasound waves are used to take a picture of your heart and the circulating blood. The ultrasound probe may be placed on your chest (trans- thoracic echocardiogram, TTE) or through a tube put down your throat (trans-esophageal echocardiogram, TEE). A TEE is more accurate and can be used when problems with the chest make TTE hard to do. Before a TEE you will be given medicine through your veins to relax and allow for the procedure. Acute Stroke Treatment Treatment depends on the type and cause of stroke. Surgery, medications, acute hospital care and rehabilitation are all accepted stroke treatments. When a neck artery is partially blocked by a fatty buildup, surgery might be used to remove the plaque. This surgery is called a carotid endarterectomy. Cerebral angioplasty is a new, experimental technique. Balloons, stents and coils are used to improve blood flow and treat some types of problems with the brain’s blood vessels. The widespread use will require more study of its safety and effectiveness. Sometimes treating a stroke means treating the heart. The reason is that various kinds of heart disease can contribute to the risk of stroke. For example, damaged heart valves may need to be treated surgically or with anti-clotting drugs to reduce the chance of clots forming around them. Blood clots also can form in the hearts of people with atrial fibrillation. Atrial fibrillation (A-fib) is a type of abnormal heart rhythm. If clots form, there is a chance they could travel to the brain and cause a stroke. Stroke Medications Strokes caused by a blood clot are often treated with medications that work to prevent the blood’s ability to clot. These include: • Blood clot-busting medications • Anticoagulants • Antiplatelet medications 6 Stroke Guidebook
  9. 9. 7 Stroke Guidebook In 1996, the Food and Drug Administration approved the clot-busting drug tissue plasminogen activator (t-PA) to treat stroke. This has had a positive impact on the treatment of ischemic strokes. Not every stroke patient should be treated with t-PA, particularly those having a bleeding stroke. Use of t-PA can cause bleeding. Tissue plasminogin activator is effective only if given very soon after a stroke begins. For maximum benefit, it must be started within three hours of the onset of stroke symptoms. That is why it is so important to see stroke as a medical emergency and respond immediately. If you do not receive t-PA, you may receive other medicines that improve blood flow. Both anticoagulants and antiplatelets are medicines that decrease blood clotting. What should I know if I am taking anticoagulants? Anticoagulants are medicines given to prevent your blood from clotting or preventing clots that already exist from getting larger. They can keep harmful clots from forming in your heart, veins or arteries. Clots can block blood flow and cause a heart attack or stroke. Common names for anticoagulants are warfarin (Coumadin) and heparin. • You must tell all of your doctors and dentists that you are taking the anticoagulant medication. • You must take the medication exactly the way your doctor tells you. • Have blood tests taken regularly so your doctor can see how the medication is working. • Know the level of your target Prothrombin time and International Normalizing Ratio or PT/INR. • Tell your family you are take anticoagulant medicine and wear emergency medical identification (i.e. bracelet). • Always check with your doctor before taking other medications or supplements such as aspirin, vitamins, cold medicine, sleeping pills or antibiotics. These can alter the effectiveness and safety of anticoagulants by strengthening or weakening them. • Avoid big changes in how much vitamin K you eat. Vitamin K can inactivate some blood thinners. Limit foods high in vitamin K content, broccoli, brussel sprouts, cabbage, kale, parsley, spinach, and turnip/collard/mustard greens, to ? cup cooked or 1 cup raw vegetables daily. Discuss your diet with your doctor, dietitian, or pharmacist. • You may bleed more easily while you are using this medication so avoid activities that can increase the chance of traumatic injury. Let your doctor know if you have had an injury. • Watch for signs of internal bleeding (i.e. excessive bruising, blood in stools).
  10. 10. Stroke Guidebook What should I know about antiplatelet medications? Antiplatelet medications keep blood clots from forming. They keep blood platelets from sticking together. They are used to treat atherosclerosis or if someone has an increased risk of blood clots. Atherosclerosis occurs when cholesterol builds up on inner walls of blood vessels and increases the chance that blood clots will form. Antiplatelet medicine helps prevent strokes. Common names for antiplatelets include aspirin, clopidogrel (Plavix), and dipyridamole (Aggrenox). • Antiplatelets should not be taken with anticoagulants unless your doctor tells you to do so. • You might receive directions not to take antiplatelets or anticoagulants when you are going to have surgery. Stroke Recovery and Rehabilitation Stroke is the leading cause of adult disability in the United States. There are more than 5 million stroke survivors in the United States. Rehabilitation is an important part of recovering from stroke. Through rehabilitation, you can relearn or regain basic skills such as speaking, eating, dressing, and walking. When the immediate crisis of a stroke has passed and you are medically stable, it is time to consider rehabilitation therapy. Therapy begins in the hospital and often continues after being discharged from the hospital. The goal of rehabilitation is to restore as much independence as possible by improving physical, mental, and cognitive (thinking) abilities. Not all of the negative effects of a stroke are permanent. Appropriate and adequate rehabilitation can help you work toward the goal of restoring your daily activities. Your rehabilitation may include Occupational, Physical and Speech-Language Therapy. Occupational Therapy focuses on helping stroke survivors rebuild skills that are needed for daily living activities such as bathing, dressing, and cooking. The Occupational Therapist also works on improving skills in memory, judgment, and problem solving, which are necessary to perform daily living activities. Physical Therapy works to improve stroke survivor’s movement, strength, and problems with sensation (feeling). The Physical Therapist focuses on restoring skills needed to get around more independently, to improve transfers, balance, coordination, and walking. Speech-Language Therapy focuses on improving the function and safety of swallowing, which is often affected by a stroke. The speech-language pathologist helps improve communication 8
  11. 11. skills, such as listening and understanding, talking, saying words clearly, reading and writing. Therapy may also work toward improving problem solving, memory, and reasoning skills. Because the effects of stroke vary, it is important to have an individualized therapy program to best meet your needs. You should consult a therapist who can help in selecting specific exercises that will benefit you and provide instruction for both you and your caregiver. As with any exercise program, consult your doctor and/or therapist first. For additional information on inpatient or outpatient Stroke Rehabilitation, please call Baptist Health Rehabilitation Services at the following locations: Baptist Medical Center Downtown: 904-202-9750 Baptist Medical Center South: 904-821-6575 Baptist Medical Center Beaches: 904-627-2980 Baptist Medical Center Nassau: 904-277-9677 Cognition (thinking) and Communication Stroke can cause physical problems. It can also affect cognition, or thinking abilities. Cognition is what helps people use their brains to talk, read, write, learn, understand, reason, and remember. Difficulty with cognition may affect how you manage your everyday tasks, your ability to participate in rehabilitation, and even to live on your own following a stroke. Memory Loss and Communicating Every stroke is unique. The effect that stroke has on your thinking abilities depends on where and how the stroke injured the brain and your overall health. 1. Memory loss After stroke memory loss is common, but not the same for everyone. For example, depending on where the stroke occurred in the brain you may have short-term memory loss. What may help? • Try to form a daily routine—doing certain tasks at regular times during the day. • Try not to tackle too many things at once. Break tasks down into small steps. • If a task needs to be done, make a note of it or do it right away. • Make a habit of always putting things away in the same place where they can easily be seen or found. Stroke Guidebook 9
  12. 12. 2. Aphasia After a stroke, one of the most common problems people experience is trouble with communication. Stroke survivors may experience a type of communication disorder called aphasia, which means “without language.” About one million people in the United States have aphasia. Most cases are due to the results of a stroke. There are several types of aphasia, depending on what part of the brain has been damaged. People with aphasia have a partial or total loss of their ability to talk, to understand what people say, and to read and write. One or a combination of these skills may be affected. For example, you may have trouble remembering the names of objects or putting words together to make sentences. You may recover from aphasia without treatment. But most people benefit from therapy by a speech- language therapist. The goal is to improve your ability to communicate. This is done by helping you get back some of your language skills and learning new ways to get your message across. Communication tips • Try using your hands to gesture, or nod your head, if you are unable to say words. • Draw or write things on paper. • Create a communication book that includes words, pictures and symbols that are meaningful to you. • Take your time. Try talking to people when you have plenty of time. • Show people what works best for you. Coping with Emotions Dealing with a flood of emotions can be hard for stroke survivors. It is common to be tired, frustrated, depressed, and unmotivated. Some emotions are normal responses to the changes in your life after a stroke. If you suffer from depression, anxiety or emotions that are not in line with the situation, seek help. You may be treated with medication, counseling, therapy, or all three. Joining a local stroke support group may also help. Dealing with Depression Grieving for what you lost is normal. If sadness becomes depression, talk to your doctor. Depression can surface right after a stroke, during rehabilitation, or after you go home. It can be, but not always, caused by brain damage from the stroke. Mild or major depression is the most common emotional problem faced by survivors. Symptoms of depression include: • Feeling sad most of the time. • Feeling worthless or helpless. • Crying all the time. Stroke Guidebook 10
  13. 13. Stroke Guidebook • Loss of interest or pleasure in ordinary activities. • A change in how easily you are annoyed. • Sudden trouble sleeping or oversleeping. • Sudden loss or increase of appetite. • Being unable to concentrate, remember or make decisions like you used to. • Ongoing thoughts of death or suicide. Social Support Socializing with family and friends is an important part of stroke recovery. As a stroke survivor, you may have trouble doing the things that allow you to connect with other people such as talking on the phone, writing letters, shopping, or eating out. This can make you feel disconnected and alone at a time when you need more social support that ever before. Getting the Support You Need Stroke survivors and stroke caregivers need support. There are many ways to get the support you need. A support group allows you to interact with other stroke survivors and caregivers who know what you are going through. People in a support group can: • Help you find ways to solve problems related to stroke. • Share information about products that may help recovery. • Encourage you to try new things. • Listen to your concerns and frustrations. • Give you a chance to get out of the house. Healthy Eating and Swallowing You should eat nutritious food to get better. Many stroke survivors are malnourished. This means they are not getting enough vitamins and minerals because they are not eating enough healthy foods. You need to eat healthy so you can have energy for exercise, therapy, and your favorite activities. Healthy eating will be easier once you learn to deal with new challenges you might have from a stroke. Choosing Healthy Foods Healthy eating is good for you. It will help you manage your weight and blood pressure as well as diabetes and high cholesterol. These things are all crucial to prevent another stroke and stay healthy. Most foods in the grocery store must now have a nutrition label and an ingredient list. If you are still unsure, ask your doctor to arrange a visit with a licensed dietitian. The dietitian will teach you how to plan meals and snacks to improve your health. 11
  14. 14. Stroke Guidebook Heart-Healthy Eating A diet high in saturated fat and cholesterol has been linked to chronic diseases such as heart disease and stroke. The goal of a heart healthy eating is to decrease your risk of heart disease and stroke. Research shows that the amount and type of fat you eat can affect your overall health. A heart healthy diet low in sodium, saturated and trans fats, and cholesterol can help reduce the risk and/or complications of heart disease and stroke. Eating fiber (ie. whole wheat bread, fresh vegetables) may help you decrease your cholesterol. Decreasing your fat intake will decrease your calorie intake. Decreasing the amount of sodium (salt) that you eat and drink may help to control your blood pressure. You may also lose weight on this diet because decreasing your fat intake will decrease your calorie intake. Decreasing calories in your diet can help you to lose weight. Nutrition Guidelines for Your Health • Plan to eat a variety of foods of a variety of colors each day. • Eat at least five servings of fruits and vegetables per day. • Reduce Sodium. Try cooking from scratch instead of using pre-prepared foods from a box or bag. Do not use salt during cooking and at the table. • Read food labels for the amount of sodium. Keep the sodium content of a complete meal to between 500-600mg. Keep single food items less than 240mg. • Limit Saturated Fat. Saturated fats can increase cholesterol levels, especially low-density lipoprotein or LDL (bad cholesterol). Saturated fats are found in meat, milk products, and in some vegetable fats such as coconut, palm, and palm kernel oils. To lower your saturated fat intake, choose low fat meats without the skin and limit your daily intake to 6 ounces (3 ounces = the size of a deck of cards); choose low-fat or fat-free milk products. • Avoid Trans Fat. Trans fat raises LDL levels (bad cholesterol) and lowers high-density lipoprotein or HDL levels (good cholesterol). Trans fat can be found in vegetable shortening, some margarine, crackers, cookies, chips, cakes, doughnuts and other foods made with or fried in partially. hydrogenated oils. A small amount of trans fat is also found naturally in milk products, some meat and other foods made with animal fats. • Reduce Cholesterol. Cholesterol can be found in animal products such as meat, egg yolks, and milk products. • Increase Fiber and Antioxidants. Try for a minimum of 25 grams of fiber each day. Eat a diet high fiber with foods such as vegetables, fruits and whole grains such as oats, whole wheat, brown rice, whole bran and barley. • Maintain a Healthy Weight. Lose weight if you are overweight or maintain a healthy weight. Talk with your doctor or registered dietician to determine a healthy weight for you. Be more physically active every day to help control weight. Pay attention to serving size and eat only enough for your height and body type. Avoid foods and beverages with added sugars, which can easily add too many calories with little nutritional benefit. 12
  15. 15. Stroke Guidebook 13 Heart-Healthy Food Choices Food Group: Lean Meat, Poultry, Seafood, Eggs & Other Protein Foods (5-6oz. per day/3oz. = deck of cards) Choose Most Often Avoid or Choose Less Often Beef: USDA Select or Choice grades of lean beef (trim visible fat) such as eye & top round, sirloin, flank, tenderloin, round tip, top loin, bottom round, rib, chuck & rump roast, T-bone, porterhouse, cube steak, ground round, lean & extra lean ground beef (>90% lean); lean veal chop, roast or leg; low-sodium roast beef deli meat Beef: Prime grades of beef, prime rib, heavily marbled & meats with lots of visible fat, regular ground beef; ground or processed veal cutlets Poultry: Skinless chicken & turkey, Cornish hen, duck or goose (drained of fat); low-sodium chicken or turkey deli meat Poultry: Fried chicken, chicken & turkey with skin Fish: Include 2 or more servings per week of fresh, frozen or canned fish & shellfish (watch sodium content of canned items) Fish: Fried fish or shellfish, commercially breaded or processed fish Pork: Lean & choice cuts such as fresh ham, tenderloin, center loin chop, Canadian bacon Pork: Spare ribs, ground pork, pork sausage, bacon Lamb: Lean & choice cuts such as chop, leg & roast Lamb: Rib roast, ground lamb, organ meats Game: Duck, goose or pheasant (without skin & drained of fat), venison, buffalo, ostrich, rabbit, emu Game: Duck, goose or pheasant with skin Processed Meats: Choose processed & deli meats with <3g fat per oz. Processed Meats: Bologna, pimento loaf, salami, sausage, bratwurst, knockwurst, hot dogs, bacon Eggs: Limit egg yolks to 2-4 per week, egg whites (2 whites can be used in place of 1 whole egg in most recipes), cholesterol-free egg substitutes Eggs: More than 2-4 whole eggs per week (include those used in baking)
  16. 16. Stroke Guidebook Food Group: Low-Fat Dairy Products (2-3servings per day) Food Group: Breads, Cereals, Rice & Pasta (6-11servings per day/1 serving = 1oz.) Choose Most Often Avoid or Choose Less Often Milk: Fat-free/skim or 1% milk (liquid, powdered & evaporated), fat-free or low-fat buttermilk, soy milk Milk: Whole or 2% milk (liquid, powdered & evaporated Yogurt: Fat-free or low-fat yogurt, yogurt drinks, soy yogurt Yogurt: Whole-milk yogurt or yogurt drinks Cheese: Low-fat natural or processed cheeses such as mozzarella, parmesan, cottage cheese, ricotta Cheese: Regular cheeses high in saturated fat, whole-milk cottage cheese Ice Cream: Low-fat or fat-free ice cream & frozen yogurt Ice Cream: Regular ice cream Sour Cream: Low-fat or fat-free sour cream Sour Cream: Regular sour cream Coffee Creamer: Low-fat coffee creamer Coffee Creamer: Cream, half & half, whipping cream, nondairy creamer, whipped topping Choose Most Often Avoid or Choose Less Often Breads: Whole-grain bread, buns, bagels & pita; English muffins, corn or flour tortillas, homemade corn muffins & other homemade baked goods using unsaturated oils, low-fat milk & egg substitute Breads: Croissants, biscuits, pastries, processed white bread, high-fat bakery bagels, commercially prepared muffins & other bakery items Rice: Brown rice & whole grains such as barley, quinoa, millet, oats Rice: Instant rice & rice mixes high in sodium Cereals: Whole-grain wheat, rice, bran, oats cereals, low-fat granola Cereals: Processed cereals not made from whole grain, most granolas 14
  17. 17. Stroke Guidebook Food Group: Vegetables (3-5servings per day) Food Group: Fruit (2-4servings per day) Food Group: Fats & Oils (6-8tsp. per day) Choose Most Often Avoid or Choose Less Often Fresh, frozen or canned without added fat or sodium Canned with sodium/salt, fried or prepared with butter, cheese or cream Choose Most Often Avoid or Choose Less Often Fresh, frozen, dried or canned in own juice; 100% fruit juice Fruit in heavy syrup or served with butter or cream Choose Most Often Avoid or Choose Less Often Monounsaturated Fats: Canola, olive & peanut oils; avocado, almonds, cashews, pecans, peanut butter & other nut butters; olives, sesame seeds, Tahini paste Butter, lard, shortening, bacon grease, stick margarine, ghee; coconut, palm & palm kernel oils; macadamia & Brazil nuts, pistachios, pine nuts; salad dressings made with egg yolk, cheese, sour cream or whole milk; coconut; chocolate Polyunsaturated Fats: margarines (tub or spray) made from heart-healthy oils; corn, sunflower, safflower, sesame & soybean oils; salad dressings made from heart-healthy oils; walnuts, sunflower & pumpkin seeds 15
  18. 18. Stroke Guidebook Too Tired to Eat or Cook? Meal planning, grocery shopping and cooking require a lot of energy. But, being tired does not mean you should give up on healthy eating. Planning ahead can help you get the nutrition you need for your stroke recovery. • Eat your biggest meal early in the day when you have the most energy. The last meal of the day can be simple, such as a sandwich or cereal. • Look for pre-washed, pre-cut fruits and vegetables at the grocery store. Most places offer apple slices, baby carrots, broccoli florets, celery sticks, mixed vegetables, salad greens, and spinach. • If preparing and eating three meals a day takes too long or takes too much energy, eat six small meals per day instead. • Many communities offer a “Meals on Wheels” program. Check with your local social services to see how you can get healthy meals delivered to your home through this program. • Seniors can often get healthy, low-cost meals at senior center. Check your local newspaper for locations, times and menus. Have you Lost Your Appetite? Many survivors do not feel as hungry as they used to and forget to eat during the day. • Try eating smaller healthy meals throughout the day. • Be sure to plan three meals a day plus snacks to maintain your health and energy—even when you are not so hungry. • Eat high-calorie foods in your meal first. • Sometimes, poor appetite is caused by depression. Your appetite is likely to improve after depression is treated. • Walk or do some light exercise to stimulate your appetite. Challenges When Eating It is hard to eat healthy when you have trouble swallowing, chewing, or using eating utensils. Swallowing and Chewing Problems A stroke can weaken or paralyze muscles that help you swallow or chew. About 40-60% of stroke survivors have dysphagia (swallowing difficulties). Dysphagia can lead to serious medical problems such as dehydration (not enough water), malnutrition (not enough vitamins and minerals), choking or coughing, aspiration (when food or liquid goes into the lungs) and pneumonia. The speech-language therapist can test for dysphagia and make suggestions to improve swallowing and eating. Talk to your doctor if you have any of these signs of dysphagia: • Coughing, choking, or sputtering when eating or drinking. • An unusually hoarse voice or the need to clear your throat often. • Food, liquids, or saliva escape from your mouth or nose when you try to eat or drink. 16
  19. 19. Stroke Guidebook What can help? If the speech-language pathologist says you are safe to eat by mouth: • Cut foods into smaller pieces before chewing. • Use a blender or food processor to puree foods to the texture of baby food. • Choose soft foods such as cooked cereal, mashed potatoes, eggs, cottage cheese, applesauce, canned fruits and soups. • Thicken liquids so you can control them better in order to keep from going down the wrong way. Natural thickeners include cornstarch, tapioca, flour, instant potato flakes, oats, and matzo meal. • Keep your mouth moist with ice chips and small sips of water. • Place foods and liquids on the stronger side of the mouth (the opposite of the drooping side). • If you wear dentures, see your dentist to check how they fit. Loose dentures can interfere with chewing and swallowing. Dentures that do not fit well can also cause pain, which can decrease your appetite. Medicines, mouth dryness and other medical changes can affect denture fit. Have your dentist check them at least once a year. Eating Utensils After your stroke, you may have trouble grasping or holding utensils. Take advantage of special products that can help you: • Flatware with larger handles or Velcro straps can be easier to grasp. • Knives with curved blades can help you cut food with one hand. • Plate guards can help keep food on the plate when using one hand. • Rubberized pads under the plate can keep it from sliding around. Meals and Social Outings Eating out is common in the United States. It can also be good for your recovery. Eating out on occasion relieves you of many household duties. It also can help you connect socially with others. But, many stroke survivors shy away from restaurants and social outings because they have problems getting around, filtering out noises, or have difficulty eating and swallowing. Some of the following tips may help: • Call ahead to see if the place has parking, entry ramps, eating space and bathrooms needed to host guests in wheelchairs. • Avoid busy times and noisy places. • Request a booth or table where you can sit across from others but face a wall; this can reduce distractions in the restaurant. • Go to a familiar restaurant where you know the menu. • Mentally rehearse what you want to order. • Have family and friends help you order items that are safe. • Bring a card that says, “I have aphasia” and show it to the restaurant staff. For more information, go to 17
  20. 20. Going Home Most stroke survivors are able to return home and continue doing what you were involved in before the stroke. You may need intensive therapy and may be discharged to a rehabilitation facility; or therapy can be completed from home. The rehabilitation process will be determined by the severity of your stroke. Some survivors need few services, while others need months of rehabilitation. Social workers and other hospital staff can help prepare you for the move home or to a rehabilitation facility upon leaving the hospital. For those who have had a more severe stroke, going home depends on many factors: • Ability to care for oneself. • Ability to follow medical advice . • Mobility and speech (Stroke survivors not independent in these areas may be at risk in an emergency or feel isolated.) • Availability of a caregiver. Managing life at home is an important part of stroke recovery. Stroke affects each survivor differently. To live well after stroke, you may need to make some changes in your home and daily routine. What changes do I need to make at home? Living at home successfully also depends on how well the home can be adapted to meet your needs. • Safety – Take a good look around and get rid of anything that might be dangerous. This might be as simple as taking up throw rugs, testing the bath water temperature prior to getting in or wearing rubber-soled shoes to prevent slipping. You may have to get handrails in the bath or shower. • Accessibility – You need to be able to move freely within your home. You may have to rearrange the furniture or build a ramp to go up steps. • Independence – Your home should be modified so that you can be as independent as possible. Often this means adding adaptive equipment, such as grab bars or transfer benches. Preparing to Go Home • If needed, ask your doctor to help you plan a home visit by an occupational therapist (OT). They are trained to help you manage daily activities and regain you independence. The OT will check your home and may suggest simple changes to make everyday living easier and safer. • A social worker can help you make decisions about your rehabilitation plan. Stroke Guidebook 18
  21. 21. Stroke Guidebook Going Places Getting out is good for you. It gives you a chance to be with other people. Each time you successfully go places, you build your confidence to do it again. Getting out of the house allows stroke survivors a chance to regain a sense of freedom, control and independence. Going to the places you want to go, doing the things you enjoy, and spending time with other people will help the recovery process. Accept that your body has changed and realize you can still be active, productive, and have a good quality of life. How Do I Know if I Can Drive Safely? Driving involves many skills that can be affected by a stroke. Fortunately, most stroke survivors can regain the ability to drive safely. • Talk to your doctor or occupational therapist for a professional opinion. • Contact the State Department of Motor Vehicles. Ask for the Office of Driver Safety and find out requirements for people who have had a stroke. • Have your driving tested. • Enroll in a drivers training program. Signs of Unsafe Driving • Drives too fast or too slow for the road conditions or posted speed. • Needs help or instructions from passengers. • Does not observe sign or signals. • Often gets lost, even in familiar areas. • Has accidents or close calls. • Gets easily frustrated or confused. Tips for Safe Driving • Always make sure you and your passengers wear seatbelts. • Drive in familiar areas. • Drive on roads that are not busy. • Combine trips. Plan your errands and appointments. • Turn off the radio, phone, and other things that can take your attention away from driving. • Avoid driving at night. • Plan your travel so that you are off the road during rush-hour traffic or during bad weather. 19
  22. 22. Recurrent Stroke and Stroke Prevention After stroke, survivors tend to focus on rehabilitation and recovery. But preventing another (or recurring) stroke should be a key concern. Of the 750,000 Americans who have a stroke each year 5-14 percent will have a second stroke within one year. Stroke prevention is also important for those who have had transient ischemic attacks (TIAs) or mini-strokes. TIAs are brief episodes of stroke-like symptoms that last from a few minutes to 24 hours. TIAs usually do not cause permanent damage or disability. But TIAs can be a serious warning sign of impending stroke. Up to one third of people who have a TIA are expected to have a stroke. Strokes and TIAs can be prevented through lifestyle changes, surgery, medicine, or a mix of all three. Your Personal Modifiable Risk Factors/Lifestyle Changes There are two types of stroke risk factors. One type you cannot control, the other you can. Stroke risk factors you cannot control include: • Being over the age 55. • Being a man. • Being African American. • Someone in your family has had a stroke. • Having diabetes. Having one or more of these factors doesn’t mean you will have a stroke. By making simple lifestyle changes, (listed below), you may be able to reduce the risk of a first or recurrent stroke. These simple lifestyle changes can greatly reduce your chance of having a stroke. You can control these risk factors: 1. Quit smoking. 2. Control your blood pressure. 3. Maintain a healthy weight. 4. Eat foods low in sodium (salt) and fat. 5. Avoid excessive alcohol. 6. Exercise often. 7. Stay hydrated. 8. Monitor your cholesterol levels. 9. Manage your diabetes. 10. Control atrial fibrillation (if present). 20 Stroke Guidebook
  23. 23. Stroke Guidebook 1. Quit smoking Smoking and tobacco use are the most preventable cause of serious illness. How do I quit and free myself? • Quitting takes hard work and a lot of effort, but you can quit smoking. • Millions of people quit smoking every year and most quit on their own. • Quit when you are ready to quit. • List your reasons for wanting to quit. • Consider the benefits of quitting, better physical health and energy, peace of mind and control, better social life, preventing harm to those around you and saving money. • Talk to your health care provider about how to stop smoking and set a quit date. • Plan the way you will quit—do not leave it to chance. There is no “best” way to quit. “Cold turkey,” Cutting down gradually, Nicotine gums or patches are some options. Do what you and your health care provider think will work best for you. • If you can not stop right now, cut down on the number of cigarettes you smoke each day. • Seek support and encouragement from you friends and family. • Use stress management techniques. Here are some suggestions to stay smoke free. • Plan how you will deal with tempting situations such as: Social situations that involve alcohol, relaxing after a meal, emotional upsets, loneliness, boredom, depression, anger or anxiety at work, conflicts with people. • Avoid old activities that trigger the urge to smoke. • If coffee is a trigger, change to juice or tea. Hold your cup in the opposite hand. • Review the list of reasons you want to quit often. • Clean out and put away ashtrays. Throw out lighters, matches, and cigarettes. • Become more active in your leisure time. Exercise. • Keep healthy cigarette substitutes around like carrot or celery sticks, sunflower seeds, etc. • Reinvest in yourself. You will have 5-10 percent more time. Develop new skills, hobbies, or ways to relax. • Mark your success on the calendar and reward yourself. • Start saving the cash you would have spent on cigarettes. Buy something special. 21
  24. 24. Talk to your doctor about smoking cessation programs or products that might work for you. Baptist Health has resources that can help. The Quit Smart Program is an individualized, multi-method program based on research conducted at Duke University Medical Center. For more information, call 904.202.7069. 2. Control your blood pressure High blood pressure is one of the most important and easily controlled stroke risk factors. Know your blood pressure and control it. Because there are no symptoms, many people do not know that they have high blood pressure. Blood pressure is given two numbers, for example 120/80. The top number, the systolic blood pressure, is a measurement of the forces your blood puts on blood vessel walls as your heart pumps. The bottom number, diastolic blood pressure is a measurement of the force your blood puts on the blood vessel walls when your heart is at rest. • For people over age 18, normal blood pressure is lower than 120/80. A blood pressure reading consistently 120/80-139/89 is pre-hypertension. If yours is in this range, you are more likely to develop high blood pressure. Also called hypertension, high blood pressure is a reading of 140/90 or higher. • Have your blood pressure checked at least once each year—more often if you have high blood pressure, have had a heart attack, stroke, are diabetic, have kidney disease, have high cholesterol or are overweight. For blood pressure readings check the pharmacy/drug/grocery store or fire station. • If you are at risk for high blood pressure, ask your doctor how to manage it more aggressively. Many times blood pressure can be controlled through diet and exercise. Even light exercise—a fast walk, bicycle ride, swim or yard work—can make a difference. Adults should do some form of moderate physical activity for at least 30 minutes five or more days per week, according to the Centers for Disease Control and Prevention. Regular exercise may reduce your risk of stroke. Before you start an exercise program, check with your doctor. For some people who have high blood pressure, losing weight, reducing sodium or other lifestyle changes will not lower high blood pressure as much as needed. These people will probably need to take medication. 3. Maintain a healthy weight If you are overweight, especially if you carry a lot of weight around your waist, you are at higher risk for health problems such as high blood pressure, high blood cholesterol, diabetes, heart disease, and 22 Stroke Guidebook
  25. 25. Stroke Guidebook stroke. If you are overweight, start eating a healthy diet and exercise regularly. Quick-weight loss diets do not work. Body Mass Index (BMI) looks at height-to-weight ratio. It can tell if you are obese. Discuss it with your doctor. For more information and to calculate your BMI online visit the American Heart Association’s website and search BMI. 4. Eat foods low in sodium (salt). Too much sodium (salt) in the diet can cause high blood pressure, which can lead to stroke. Foods high in saturated fat and cholesterol can cause fatty deposits on the walls of your arteries (blood vessels). This causes atherosclerosis (hardening of the arteries). Atherosclerosis can cause poor blood flow in certain areas of your body, and put you at higher risk for health problems such as stroke and heart disease. For more information on eating right and for some tasty healthy recipes visit the American Heart Association’s Web site 5. Avoid excessive alcohol. One or two drinks a day may help increase HDL (“good”) cholesterol, but more than that can contribute to high blood pressure, heart disease, and stroke. Alcohol can also increase dehydration. 6. Exercise often. Be physically active. Exercise can help with blood pressure control, reduce cholesterol levels, reduce risk of developing diabetes, and aid in weight control. 7. Stay hydrated. It is very important to keep blood liquid and flowing. A general rule of thumb is to drink enough to keep from getting thirsty. This is especially important when exercising and during the summer or early winter when dehydration is the most likely. 8. Manage your cholesterol levels. High amounts of dietary cholesterol may increase blood cholesterol in some people. Eat less than 300 milligrams (mg) of cholesterol per day. The body needs some cholesterol to stay healthy. The body needs cholesterol to build cell walls and make hormones. However, too much cholesterol in your body may be bad for your health. Elevated cholesterol (particularly “bad” cholesterol, or LDL) is a risk factor for heart disease and stroke. 23
  26. 26. Cholesterol readings are divided into two types. Low-density lipoprotein (LDL) cholesterol is commonly called the “bad” cholesterol, and is a type of fat in the blood that contains the most cholesterol. It can contribute to the formation of plaque (or fatty deposits) buildup in the arteries, known as atherosclerosis. You want your LDL to be low, generally less than 130 milligrams/per deciliter (mg/dL), but if you have had a stroke/TIA or heart attack your goal is less than 100 and if you have diabetes you want your LDL to be less than 70. High-density lipoprotein (HDL) is known as the “good” cholesterol, and is a type of fat in the blood that helps to remove cholesterol from the blood, preventing the fatty buildup and formation of plaque. You want your HDL to be as high as possible, generally higher than 40 mg/dL for men and above 50 for women. Some ways to raise HDL and lower LDL are: • Decreasing body weight. • Avoiding foods high in saturated fat, dietary cholesterol, and excess calories. • Exercising for at least 20 minutes three times a week. • Stop smoking. • Taking appropriate medications. 9. Manage your diabetes Some people are more likely to develop diabetes. Diabetes increases the risk of heart disease and stroke. During regular check ups your doctor should screen for diabetes. If you have diabetes, you can manage it by carefully following your doctor’s recommendations. A blood test called Hemoglobin A1c should be done every three months and should be below 7mg/dL. Hemoglobin A1c is used to determine your average blood sugar levels over the last three months. 24 Stroke Guidebook
  27. 27. 10. Controlling atrial fibrillation Many forms of heart disease can increase your stroke risk. Atrial fibrillation (Afib) is an irregular heartbeat. Afib is when the top chambers of the heart fibrillate (quiver) and do not empty effectively. This fibrillation can cause blood clots to form. The clot can travel from the heart to the brain and cause a stroke. Warfarin (Coumadin) and aspirin are often prescribed to treat atrial fibrillation. You and your doctor should monitor taking warfarin carefully. Work with your doctor to manage atrial fibrillation. Following up after discharge Be sure to follow your personal discharge instructions. Make sure you understand and agree with them. Know your personal modifiable risk factors from the list above. It is very important to have regular checkups and work with your doctor to reduce or control your personal modifiable risk factors. Your doctor can monitor your risk factors and suggest treatments. Stroke Guidebook 25
  28. 28. Stroke Guidebook 26 National American Stroke Association, a division of the American Heart Association 888.478.7653 Ask for the Stroke Family Warmline to talk with a stroke survivor or caregiver, get a list of stroke support groups in your area or ask for Stroke Connection magazine National Stroke Association 1-800-STROKES 1-800-787-6537 Information on stroke, including prevention, treatment, rehabilitation, and support for stroke survivors and their families or subscribe to Stroke Smart magazine. National Institute of Neurological Disorders and Stroke 800.352.9424 Government information available on a variety of stroke-related topics. Local First Call, a division of the United Way 904.632.0600 or 211 Can refer you to community resources. Independent Living Resource Center of Northeast Florida 904.399.8484 Advice, information, and referrals for disabled individuals. Jewish Family and Community Services 904.448.1933 Multiple services, including counseling Baptist Behavior Health 904.376.3800 Psychological and psychiatric counseling services Resources for stroke survivors and their families* *This information is provided by Baptist Health as a resource and should not be considered an endorsement.
  29. 29. Compiled by Michelle Silver, MSN, ARNP, FNP-BC Clinical Outcome Specialist Stroke Nursing Clinical Practice Division Baptist Health Summer 2008 Stroke Guidebook 27 Contributions The Stroke Center Team The Neuroscience Nurses The Clinical Practice Division Note: This guide was compiled from medical information that is available to the general public. It should not be considered recommended treatment for any particular individual. Stroke survivors should check with their doctors about any personal medical concerns. The information in this patient guide was gathered from the following resources: American Heart Association National Stroke Association American Stroke Association The Centers for Disease Control Thompson MICROMEDEX National Institute of Neurological Disorders
  30. 30. Stroke Guidebook Notes 28
  31. 31. Stroke Guidebook Notes 29
  32. 32. BAPTIST HEALTH 800 Prudential Drive Jacksonville, Florida 32207 904.202.CARE (2273) BAPTIST MEDICAL CENTER DOWNTOWN 800 Prudential Drive Jacksonville, Florida 32207 904.202.2000 BAPTIST MEDICAL CENTER BEACHES 1350 13th Avenue South Jacksonville Beach, Florida 32250 904.627.2900 BAPTIST MEDICAL CENTER NASSAU 1250 South 18th Street Fernandina Beach, Florida 32034 904.321.3500 BAPTIST MEDICAL CENTER SOUTH 14550 Old St. Augustine Road Jacksonville, Florida 32258 904.821.6000 WOLFSON CHILDREN’S HOSPITAL 800 Prudential Drive Jacksonville, Florida 32207 904.202.8000