Stroke prevention and hospital management.

Abstract

Stroke is a preventable disease. Minor stroke and transient ischaemic attack (TIA) are important warning signs of the possibility of a major stroke. Worldwide, stroke is the third most common killer and the largest cause of disability. The incidence of stroke is predicted to increase with the predominance of unhealthy lifestyles and the aging population. The adoption of a healthy lifestyle can reduce many of the risk factors. This descriptive study was designed to explore patients’ understanding of modifiable risk factors of cerebrovascular disease. It investigated lifestyle changes actually made, as well as the factors affecting patients’ decisions about whether to make lifestyle changes. The two major factors considered were patients’ sources and level of knowledge and their attitudes and beliefs around making changes. A convenience sample of patients who had suffered a minor stroke or TIA was recruited through a major metropolitan hospital. Thirty-five subjects responded to a postal questionnaire. The mean age was 68 years and 37% of the subjects had sustained some disability as a result of the TIA or minor stroke. The results demonstrated that many subjects had a poor understanding of risk factors of stroke. While smoking was well recognised as a risk factor, subjects showed less awareness of other risk factors, such as excessive alcohol consumption and obesity. Subjects also reported significant confusion regarding diet. Sixty-six percent of subjects depended on doctors as their main source of health information. This may be problematic as the current shortages of General Practitioners has put pressure on doctors to keep appointment times short and reduce the time available for health education. The main barriers to lifestyle change, were lack of motivation, and inadequate, knowledge, guidance, and support and the inability to access good information. Although 83% of subjects suffered from hypertension, medication was the accepted method of control, few subjects realised the significance of lifestyle factors. Nine percent of subjects were only diagnosed with hypertension after their stroke or TIA and few monitor their own blood pressure, despite the wide availability of home monitoring devices. From the findings of this study it is concluded that health promotion and education are very important strategies in the prevention of stroke and it is recommended that this kind of education begins in childhood with tailored, age-specific programs delivered to the public over the lifespan. The role of health screening cannot be underestimated in the detection of risk factors such as hypertension and obesity. Early detection makes effective treatment possible and helps prevent the occurrence of strokes, thus reducing the cost to the community. Long-term health strategies such as improving health resource distribution and enhancing health education are needed where patients and their families participate together in comprehensive education programs. It is hoped that this may lead to a shared understanding, which may translate to patients being more supported, and therefore more able, to make the necessary lifestyle changes.

Dysphagia is a common complication following stroke, which can result in significant morbidity and mortality. Multidisciplinary collaboration facilitates management strategies, decision-making and the efficiency of rehabilitation. Nurses are responsible for coordination of management and in particular for continuous monitoring, assessment of swallowing and nutritional state, maintaining safety and preventing complications. An understanding of the issues and strategies relating to management may provide valuable information to enhance the safety, cost-effectiveness and quality of care. A retrospective review of patients’ medical records was used to collect data. A sample of ninety-five adults who were admitted to an Australian public hospital between January 2003 and April 2006, with a diagnosis of dysphagic stroke were recruited. Statistical Package for Social Sciences (SPSS) was used to analyse the quantitative data, while content analysis was used to analyse the qualitative data. All subjects were assessed by a speech pathologist, the mean age was 75 years and 50.5% were male. Except for critically ill subjects, almost all were assessed within three days. Ninety-six percent of subjects had communication problems and 81% had upper limb motor impairment. During hospitalisation almost 60% of subjects had an improvement in their oral intake including 8% resuming their premorbid diet. Eighteen percent were on enteral tube feeding upon discharge, 4% deteriorated and 16% died. It appears that oral intake of most subjects was unsatisfactory. When recorded the mean body weight lost was 2.3kg. At least 22% had malnutrition or dehydration. Forty-five percent aspirated and 22% had respiratory infection. Almost half of the subjects (48%) were discharged to aged care facilities. Eighty percent had no documented follow-up scheduled for management of their dysphagia. Early identification of dysphagia, prudent supervising of appropriate oral intake and mouth care may help to maintain safe swallowing, preventing aspiration and chest infection. Regular checks of body weight, serum albumin level, oral intake and early enteral feeding are essential to guide nutritional support, minimise malnutrition and problematic medication administration. Encouraging oral intake and providing families with support could promote recovery of swallowing skills and help patients to regain the ability to eat independently. Providing helpful information on the care options available may allay patient and family anxiety. A qualified nurse practitioner could assess patients and ensure that a tailored care plan was designed to meet patients’ needs and this may improve the outcomes considerably.