Home Care Chronic Disease Prevention Program

1. Home Care Chronic DiseasePrevention Program Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine

2. Homework review • What did you do? • What happened as you did that? • Why do you think that happened? • Here’s what might have happened. • How does this impact the next time you try this?

3. Chronic Disease Management Module 1:Health/Illness, Vital Signs, Exercise, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Module 9: Congestive Heart Failure

4. Stroke

5. Objectives •  Identify different types of stroke and how each occurs • Describe healthy lifestyle choices for the person who’s had a stroke • Demonstrate use of motivational interviewing with the person who’s had a stroke

6. Stroke • Third leading cause of death in the United States • Sometimes referred to as a “CVA” • Think of it as a “Brain Attack”

7. What is a stroke? 1. Blood vessels that supply blood to the brain become blocked or leak 2.The part of the brain fed by this blood supply no longer gets oxygen and nutrients 3.When the cells in the brain are deprived of blood, they die 4.Then the brain does not function as it did before and the person may lose control of parts of the body (movement, speech, vision…)

8. Types of stroke • Ischemic • Embolic • Hemorrhagic • TIA (transient ischemic attack)

9. Ischemic stroke • Most common type; ischemic = blockage • Accounts for more than 80% of strokes • Blood clots form in blood vessels that have fatty build up (atherosclerosis) • Often preceded by a “mini-stroke” of short duration

10. Embolic stroke • Clot travels from elsewhere in the body to the brain • Most common cause is atrial fibrillation where blood stagnates in the chamber of the heart and clots form that break loose and travel to the brain

11. Hemorrhagic stroke • Blood vessel in the brain ruptures and there is bleeding into the brain • Less common but most likely type to lead to death

12. “Mini-stroke” - Mild Form of Stroke • Transient (short) Ischemic (blockage) Attacks. • Symptoms same as those for stroke but very short-lived – rarely more than 20 min • Occurs when blood supply to the brain is blocked temporarily and then is corrected

13. TIA (“Mini-stroke”) • But, over 1/3 all persons who have a TIA will go on to have a full stroke in the following days, weeks, or months if risk factors aren’t improved. • TIAs should be treated as an emergency. Quick diagnosis is the best way to reduce the risk of a full blown stroke.

14. What are risk factors for stroke?

15. Risk factors for stroke (1) • High blood pressure • Tobacco smoke • High cholesterol • Diabetes • Other blood vessels that are “clogged”

16. Risk factors for stroke (2) • Carotid artery stenosis (blockage causes decrease in diameter of main artery that goes to the head) • Atrial fibrillation • TIA • Blood disorders such as sickle cell anemia • Cocaine use

17. Risk factors for stroke (3) • Obesity and inactivity • Family history • Race • Gender • Age • Prior stroke

18. Warning symptoms • Difficulty seeing • Difficulty speaking • Difficulty with motor skills • Severe headache • Dizziness • Numbness

19. Warning signs* • Decreased blood pressure (less than 90/60) • Increased blood pressure ( greater than 160/100) • Increased pulse (greater than 100) • Decreased pulse (less than 60) • Increased respiratory rate • Decreased respiratory rate *ALL vital parameters are determined by RN supervisor and are patient specific

20. Other warnings • Not taking medications

21. Signs that Stroke is Happening • 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 cause.

22. BRAIN ATTACK!!!Stroke is an emergency • Call 911 immediately if there is concern for a stroke as every second counts

23. Diagnosis • History • Thorough physical exam • CT or MRI of the brain • Other studies to look at blood vessels and the heart

24. Hospital treatment • Medications to break up clots • Aspirin • Other blood thinners

25. Outpatient treatment • Eat well and exercise • Healthy weight • Control blood pressure, cholesterol, diabetes • Do not smoke • Aspirin may be recommended

26. Life after stroke • Physical effects • Weakness, inability to walk or to use limbs • Behavioral effects • Moods may change, at risk for depression • Communication • Difficulty with understanding or producing speech

27. Other Therapies • Physical therapy • Occupational therapy • Speech therapy • Support groups for patient and family • Home assistance (aide)

28. References • Neal, LJ. & Guillett, SE .Care of the adult with a chronic illness or disability. Mosby, St. Louis, Missouri, 2004. pp. 328-336. • Kennedy – Malone, L. et al. Management guidelines for gerontological nurse practitioners. F.A. Davis Company, Philadelphia, PA, 2000. pp 352-355. • Lippincott, Williams and Wilkins. Managing chronic disorders. Lippincott Williams and Wilkins, USA, 2006. pp 307-312. • http://www.strokeassociation.org/presenter.jhtml?identifier=1200037

29. Case study • 70 year old male who smokes, has high blood pressure, and is overweight • You have known him for six months • He is usually lively and talkative • When you arrive to see him you have a hard time understanding his speech but he tells you that his right leg and arm are weak

30. Case study • What should you do? • What is possibly going on?

31. Case study • What should you do? • Call 911 • What is possibly going on? • Stroke

32. Case study • What are his risk factors for a stroke?

33. Case study • What are his risk factors for a stroke? • Smoker • High blood pressure • Age • Overweight

34. Case study • He comes home from the hospital and rehabilitation center and luckily does not have any weakness anymore • His strength is back to normal • His doctor has told him that at 250 pounds, he needs to lose weight

35. Motivational interviewing • How do you as the Nurse Aide motivate him to take steps needed to lose weight? • Now that you’ve gained his trust you can start asking questions that will begin the change talk.

36. Starting the Change Talk • What questions can we ask that could start him thinking about losing weight? • Tell me about your weight? • What do you think about your weight?

37. WILLING, ABLE, READY • In the next few slides, put yourself in this client’s shoes. Try to write down answers to the questions from his point of view.

38. Find Out How WILLING He is to Change • Ask open ended questions so he can: • State his reasons for not continuing to be overweight and for not being willing to make changes in diet or physical activity • State the reasons he has for losing weight • Have him write down his answers to the following questions

39. What are His Reasons for Not Losing Weight? – 2 Good Questions to Ask

40. Explore His Reasons Fully • Ask him how keeping an unhealthy weight could be good for any of these aspects of his life: • Health • Lifestyle • Emotions • Relationships • Coping abilities (stress, for example), • Work • Social life • Spiritual life

41. Here are Some Sample Reasons for Continuing to Stay at an Unhealthy Weight

42. Next, What Reasons Does He Have for Losing Weight?

43. Explore His Reasons Fully • Ask him how losing weight could be good for any of these aspects of his life: • Health, • Lifestyle, • Emotions, • Relationships, • Coping abilities (stress, for example), • Work, • Social life, and • Spiritual life

44. Here are Some Sample Reasons for Losing Weight

45. Next, How Important is It for Him to Change? • Ask him to compare his reasons for not changing with his reasons for changing • Have him assign a number to the Ruler of Change in the next slide. • This will show how important it is for him to change

46. How Important is It for You to Change? • On a scale of 0 to 10, how important is it to you to lose weight? The “Ruler of Change”

47. WILLING • This number on the Ruler of Change will show how WILLING he is to change • It will show how willing he is to start doing the things needed to lose weight (mainly eating smarter and moving more)

48. Willing (continued) • If his Ruler of Change number is below 3 or 4: • He is not willing to consider change. • He has lots of resistance to change • His reasons for not losing weight are STONGER THAN his reasons for losing weight.

49. Sample Question to Help Decrease Resistance • What would have to change to decrease the importance you give to your reasons for not losing weight?

50. Questions to Decrease Resistance • A low number on the ruler of change says he does not think that losing weight is important and he does not want to change • But, look at his number on the Ruler of Change • If he’s not at zero, he must have at least a small interest in change.