STROKE: WHAT YOU NEED TO KNOW. Patient Education. Guide

Transcription

1 STROKE: WHAT YOU NEED TO KNOW Patient Education Guide

2 Contents Introduction...2 What is a stroke?...2 What can I expect while in the hospital for a stroke?...5 What else will happen while I am in the hospital?...6 What kinds of deficits are common after a stroke?...8 What medications will I need to take after a stroke?...11 How do I make sure I don t have another stroke?...14 What are the signs of a stroke?...18 When should I get help?...19 Continuing recovery, getting support...20 Common stroke terms...21 Notes

3 Introduction When you or a loved one suffers a stroke, many questions or concerns arise. This guide will help you understand what stroke is and the changes you may expect. Not all strokes are the same and you may read about things that do not apply to your type of stroke. We want you to be informed so that you can make the best choices about your care or the care of your family member. At the Henry Ford Macomb Stroke Center, members of our multi-disciplinary team will work with you to help you regain as much function as possible. We will explain what we are doing, answer your questions and help you plan for your recovery. What is a stroke? There are two kinds of stroke: ischemic and hemorrhagic. Ischemic Stroke Narrowing or clogging of the blood vessels to the brain causes an ischemic stroke. The blood flow is cut off to the brain cells. This type of stroke is the most common, occurring in more than 80 percent of all people who have strokes. Ischemic stroke has three causes thrombotic, embolic and systemic hypoperfusion, or low blood flow, to the brain. A thrombotic stroke is caused by a blood clot, or thrombus, that blocks an artery going to the brain. This clot blocks the blood flow to part of the brain. The clot forms in arteries damaged by arteriosclerosis, or hardening of the arteries. An embolic stroke is caused by a clot that forms somewhere else in the body (usually in the heart or arteries in the neck). This clot is carried in the bloodstream and plugs a blood vessel in the brain or leading to the brain. 2

4 Hemorrhagic Stroke Not all strokes are caused by blood clots that block an artery. Fifteen to 20 percent happen when a blood vessel ruptures in or near the brain. This is called a hemorrhagic (hem-o-rayg-ik) stroke. You may have many diagnostic tests before your doctor determines that you had a hemorrhagic stroke. Hemorrhagic strokes are different from ischemic strokes in many ways: The fatality rate is higher and overall prognosis poorer. Patients are younger. It is often associated with a very severe headache, nausea and vomiting. The symptoms usually appear suddenly A transient ischemic attack (TIA) or other stroke warning sign may not preced this type of stroke. There are two types of hemorrhagic stroke. In both, a blood vessel ruptures, disrupting blood flow to part of the brain. When blood spills into the brain tissue, it kills cells. Other brain cells die because blood does not reach them. Subarachnoid hemorrhage This type of stroke occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull. A ruptured aneurysm, often caused by high blood pressure, is the most common cause. An aneurysm is a blood-filled pouch that balloons out from an artery wall. Intracerebral hemorrhage This type of stroke occurs when a blood vessel bleeds into the deep tissue within the brain. This type of hemorrhage is responsible for about 10 percent of all strokes. Chronically high blood pressure or aging blood vessels are the main causes of this type of stroke. Increasing the risk of hemorrhagic stroke are: Smoking Use of oral contraceptives, especially those with a high estrogen content Excessive alcohol intake Use of illegal drugs conitnued on page 5 3

5 Sensory Function Motor Function Vision Hip Leg Trunk Trunk Arm Neck Arm Fingers Hand Language Face Hand Face Hearing Speech Smell Emotions Posture Balance Coordination Spinal Cord Brain Regions and Functions The brain is divided into regions that control the functions of the body. If a region of the brain is damaged by a stroke, symptoms related to that region may occur. These symptoms may include loss of movement or coordination, impaired sight, and trouble speaking or understanding speech. Sensory functions relate to sensation of body parts, such as feeling heat from a stove or pain from a sharp object on the foot. Motor functions relate to movement. Certain regions of the brain direct specific body movements. Regions of the brains also control vision, language, hearing, emotions, speech, smell, posture and balance. 4

6 Because hemorrhages may be life-threatening, hospital care is required in an Intensive Care Unit (ICU). Medication can control further bleeding as well as control high blood pressure. Other medicines may be prescribed to reduce the brain swelling that follows a stroke. Surgery may be needed, depending on the cause of the hemorrhage. Surgery can be done to repair an aneurysm or remove a blood clot. What can I expect while in the hospital for a stroke? Many activities will take place while you are in the hospital. Your doctor or healthcare provider should take a complete history and do a thorough physical examination including the neurological system. A neurologist may also perform the neurology exam. A neurologist is a physician who specializes in the neurological system. This exam may include checking your vision, ability to move your arms and legs, muscle strength, balance and speech. In order to further treat you, a series of diagnostic tests are usually ordered, including: CT scan: This is an imaging test of the brain. Radiation is used to create a picture of the brain and is one of the first tests you will have. The test will give valuable information about the cause of the stroke, the area in the brain affected and how much your brain has been injured by the stroke. You may have more than one CT scan while hospitalized. MRI: This also is an imaging test of the brain. Unlike the CT scan, however, the MRI uses a large magnetic field to produce an image of the brain. It, too, can show the location and extent of brain injury. The picture given by the MRI is sharper and more detailed than a CT scan so it is often used to diagnose small, deep injuries. Sometimes a MRI cannot be done if you have a metal fragment in your body or a pacemaker. The magnet of the MRI can interfere or interact with the metal in your body. 5

7 Blood tests: Many blood tests will be ordered, including a check of your cholesterol. Carotid duplex: An ultrasound (sound wave) test that shows the blood flow of the carotid arteries. If there is blockage, further testing may be needed. Echocardiogram: An ultrasound test that shows the heart chambers, valves and function of the heart. TEE (transesophageal echocardiogram): TEE detects problems with the heart chambers and valves of the heart. It also can detect an irregular heartbeat or defect in the septum wall of the heart that may cause blood clots to form in the heart, break off and travel to the brain. Angiogram: It is used to detect: Blood clots in the arteries of the brain Weak spots, called aneurysms, in the lining of blood vessels Defects of the blood vessel walls The amount of blockage in a vessel What else can I expect while I am in the hospital after a stroke? Treating a stroke involves diagnosis and immediate care, rehab therapy to improve functioning from resulting defects and care for risk factors. This often includes medication and changes in lifestyle. After your medical condition has stabilized, a group of professionals will evaluate you to see if you can benefit from a rehabilitation program. At Henry Ford Macomb Hospitals, rehabilitation can take place on a special unit of the hospital. You also may be eligible to receive rehabilitation at an outpatient rehabilitation facility or in your own home depending on your individual needs at the time you are discharged 6

8 from the hospital. Your rehabilitation may include physical therapy, occupational therapy, and speech and language therapy. Physical therapists and physical therapy assistants are trained to treat people with neurological, orthopedic and geriatric problems. The primary goal is to help restore each person to normal movement at the highest possible level. An evaluation will be performed followed by a treatment program designed just for you for walking, balance and strength. Education will be discussed with you and your family. An occupational therapist provides treatment to maximize independence in all aspects of your life. Occupational therapy provides the opportunity for people to acquire skills for the job of living necessary for safe, independent and satisfying lives. This therapist will help you to rebuild your daily living activities like bathing, dressing and cooking. Their treatment focuses on: Neurology rehabilitation Energy conservation and work simplification Adaptive equipment usage and training Training for family members and caregivers Visual and perceptual problems Low vision Speech and language therapists are specialists who help patients regain speaking skills or to develop different ways to communicate by working on understanding and using spoken and written language. The speech therapist also will work with you on cognition, which are thinking skills including attention, memory, problem solving and reasoning. They also treat voice and voice box disorders, motor speech and swallowing problems. You also may see a physical medicine and rehabilitation doctor, who is specially trained in supervising your rehabilitation. 7

9 What kinds of deficits are common after a stroke? Understanding the deficits that you or your family member have is the first step in dealing with them. Each part of the brain has a role in controlling the body. Damage to any part of the brain limits its ability to carry out its role. This results in lost skills, problems with thought processes and movement, or changes in personality traits. Having a stroke does not mean you will have all of these changes. Your doctor and healthcare team will explain your deficits and the treatment plan to minimize them. Cognitive changes Cognitive changes may include not being able to: Recognize family members, friends or familiar places Remember how to do daily activities Recall such things as the date, the season or your age Follow simple commands Act in a manner that seems appropriate to a situation Emotional changes You may have trouble controlling your emotions. This often involves rapid mood changes that include laughing or crying at inappropriate times. This is called emotional lability. Depression is common after a stroke. It can slow down recovery from a stroke and needs be treated if it occurs. Motor deficits Movement problems usually happen on only one side of the body. These range from mild weakness to the inability to move the arm or leg at all. If muscles in the face are weakened, there may be drooping of an eyelid, the mouth or a whole side of the face. 8

10 Neglect Neglect involves: Ignoring the side of the body that has been affected Dividing things at the midline eating only from one side of the plate and leaving the rest Not turning to see if something has been missed Sensory deficits Sensory deficits usually occur on one side of the body. When the sense of touch is involved, there may be tingling or numbness in the face, arm or leg. Being able to feel or sense hot or cold may be decreased or missing. Sight deficits may be present as blurred vision or loss of vision in one or both eyes. Blindness or vision on one half of the field of vision is called hemianopia or hemianopsia. Dysphagia Difficulty with swallowing is called dysphagia. It can affect eating, drinking and taking medication. If your doctor suspects a swallowing problem, a speech-language pathologist will test your swallowing. Language deficits These may include: Inability to express things correctly Inability to name objects or people (anomia) Knowing what you want to say, but having the wrong words come out Not understanding spoken language Slurred or garbled speech 9

11 Aphasia Aphasia results in difficulty using and understanding language. This includes speaking, understanding, reading and writing. The severity of aphasia varies widely. Most people with aphasia have not lost intelligence or common sense. Instead, understanding and use of language have been changed. This makes aphasia very frustrating. People with aphasia may: Struggle to produce sounds or words Have trouble repeating words or imitating simple sounds Speak in short phrases or broken sentences Use constant jargon or nonsense speech Swear, without really meaning to use that language Have trouble with reading, writing or simple calculation Not be able to understand what others are saying even though it may appear that they do When talking to someone with aphasia: Include him/her in conversations Speak slowly and clearly Give information in small amounts Allow extra time for processing Use gestures, pictures or drawings Avoid constant quizzing or testing Offer encouragement and support without pressure to perform Dysarthria Dysarthria is slurred speech that is caused by weakened muscles and nerves in the tongue, voice box (larynx), or mouth. A person with dysarthia may be able to say words and understand language, but may not be able to speak the words clearly enough to be understood by others. Someone with dysarthia may: Not be able to control and manage breathing to clearly produce sounds Sound monotone, nasal, or strained, or have a different voice than before the stroke Have problems with chewing food or drinking liquids 10

12 To help someone with dysarthia encourage him or her to: Take a deep breath before speaking Slow down when speaking Exaggerate tongue and mouth movements when speaking Sing songs Recovering from a stroke You and your family are the most important people on the team. You will be working with many staff members in your recovery. It is hard to predict how long it will take to recover from a stroke. Recovery can be a slow process and many decisions may need to be made about treatment options. Your doctor and the staff will offer guidance to your and your family. Let your family know that doing these things will help you: Be patient with the evaluation process. This is an important part of treatment since a stroke affects each person differently. Keep a list of questions, phone numbers and appointments. You may also want to record progress as it occurs. Check when it is best to visit. Once therapy begins, your loved one may spend a lot of time in therapy. The therapist may need you to attend some sessions but often it is best for the patient to work with the therapist without an audience. This is often a stressful time for family members. You will be better able to support and care for your loved one when you take care of yourself. Try to rest when you can, eat healthfully and do things that you enjoy. What medications will I need to take after a stroke? Two types of medications called anticoagulants and antiplatelets, are commonly used to prevent future ischemic strokes. Depending upon your history and risk for future strokes, you may be asked to take one or both of these types of medications. Because these medications thin the blood, their most common side effect is bleeding. Nosebleeds and other minor bleeding (such as from the gums after brushing the teeth) are not considered 11

13 life threatening. However, if you bump your head or notice a dark black stool after using the bathroom you should contact your doctor. Anticoagulants: Anticoagulants are frequently used for patients that have atrial fibrillation. In this condition, the upper chambers of the heart do not pump blood effectively. As a result, the blood in the heart has a tendency to clot. Once formed, these clots can enter the blood stream, increasing the risk for stroke. Anticoagulants make it harder for these clots to form. They also keep existing clots from getting bigger. Warfarin and Coumadin are examples anticoagulant medications. If you are taking Coumadin, you need to have a blood test called an INR on a regular basis to make certain that the drug is working appropriately. You should never take aspirin with Coumadin unless your healthcare provider tells you to do so. In addition, always tell any healthcare provider that you are taking Coumadin before you have any procedures done including dental work. You should talk with your healthcare provider about any other medications or food supplements that you take, including antibiotics, sleeping pills, cold medicine, herbal medicines and vitamins because these medicines can change the effectiveness of Warfarin. Certain foods, especially green-leafy vegetables can also affect Warfarin. These foods contain large amounts of vitamin K, a vitamin that blocks Warfarin s effects. It is fine for you to eat these foods in moderation. You should notify your healthcare provider if: Your urine turns pink or red Your stools turn red, dark brown or black You bleed more than normal when you have your period You have bruises or purple-blue areas on the skin that are unexplained You suffer a significant blow to the head Antiplatelet medications: Antiplatelet medications are medicines that keep blood clots from forming by preventing blood platelets from sticking together. The platelets are the body s first defense against abnormal 12

14 bleeding. They stick together and form a plug over the injured area. Antiplatelet drugs block this effect and reduce the risk for future strokes. Drugs in this category include aspirin, ticlopidine (Ticlid ), clopidogrel (Plavix ) and dipyridamole (Aggrenox ). Cholesterol-lowering medications statins: The term statins refers to a group of cholesterol-lowering medications that have been shown to significantly reduce the risk for heart attack and stroke. No other class of cholesterol medications has been shown to provide such a benefit. Statins reduce the amount of cholesterol produced by the liver, especially the bad cholesterol (LDL) and they can modestly increase the amount of good cholesterol (HDL). Statins include simvastatin (Zocor), atorvastatin (Lipitor), rosuvastatin (Crestor), pravastatin (Pravachol), fluvastatin (Lescol) and lovastatin (Mevacor). Most patients don t experience side effects with statins. Those who do usually report gastrointestinal effects such as bloating, diarrhea, constipation and upset stomach. These problems generally go away in a short time. On rare occasions, statins can cause muscle pain, tenderness or weakness. Your doctor will decide if you should continue taking the medication if you experience these effects. Your physician may be checking your liver function while your are taking a statin. This is a precaution to make certain that the medication does not damage the liver. This type of side effect is very rare, but is monitored closely. Contact your physician if you experience any adverse effects or if you have any questions regarding your therapy. While you are taking statins, your physician measures the amount of cholesterol your liver produces. Usually the goal is to have a bad cholesterol reading of 100 unless you have diabetes or other risk factors for heart disease. In that case, the goal for LDL is 70 or less. For the good cholesterol, the values should be greater than 45 for women and greater than 50 for men. 13

15 It is generally recommended that you take your medication in the evening because you will get more effect from the drug. If you forget to take your dose, take it as soon as you remember, unless it is too close to your next dose. The following medications/food can prevent the liver from breaking down most statins, causing higher levels of statins in the blood and more side effects: Clarithromycin (Biaxin) Cyclosporine (Neoral) Fluconazole (Diflucan) Voriconazole (Vfend) Diltiazem (Cardizem) Verapamil (Calan) Amiodarone (Cordarone) Erythromycin Grapefruit juice especially more than 8 ounces per day Most patients who have had a stroke will go home on one of the drugs in these groups. It is very important to use these medications just as your doctor prescribes them. Hemmorrhagic stroke patients will not take these medications until their neurosurgeon or neurologist says it is OK to do so. Your blood pressure medications are very important and help control your blood pressure and prevent future strokes. How do I make sure I don t have another stroke? The best way to prevent another stroke from occurring is to take the medications prescribed by your physician and to control your risk factors, including: High blood pressure High cholesterol and lipids Diabetes Smoking Being overweight and not physically active Heart disease Sometimes people have risk factors that cannot be controlled such as: 14

16 Age Gender Racial make-up Family history Having had a stroke in the past Knowing your risk factors and working to reduce them can help prevent you from having another stroke. Here s how: High blood pressure: This is the most important risk factor for stroke. Have your blood pressure checked on a regular basis. Talk to your doctor or healthcare provider to see how often you should check your blood pressure. If you are overweight, losing even a few pounds will help lower your blood pressure. In general, limit your alcohol intake. Take your blood pressure medication as ordered. If you don t feel well on your medication or are having side effects from the medication, notify your doctor. Your diet should be low in salt, saturated fat and cholesterol. Most food products now have labels to help you make good decisions about healthy food. Exercise regularly. 15

17 High cholesterol and lipids: Changing eating habits can be helpful in lowering cholesterol and lipids. First, ask your doctor or a dietitian for help. Second, avoid foods like egg yolks, fatty meats, butter and cream, which are high in fat and cholesterol. Then, try to eat moderate amounts of food and cut down on saturated fat, sugar and salt. Bake, broil, roast and boil your food. Avoid fried foods and limit alcohol intake. Eat more fruits, vegetables, cereals, dried peas and beans, pasta, fish, poultry and lean meats. Read the labels on the food products. Avoid fast food restaurants and be sure to take your medicine as prescribed by your doctor. Diabetes: Diabetes is a chronic disease requiring a lifetime of selfmanagement that affects men and women equally. If it is not managed, diabetes can result in an unhealthy build-up of glucose, or sugar, in the body. This can lead to heart and kidney disease and can affect every part of the body. Your diabetes treatment plan usually includes: a meal plan, a plan for staying active, instructions on how and when to check your blood glucose and your personal blood glucose goals (or target range). If you take diabetes medicine, your plan also should include the types, dosages, and the timing of doses of medicine. Managing your weight and blood pressure are part of this plan, too. Keeping your blood glucose levels at or near normal may help to reduce your risk of diabetes-related problems. Smoking: Stop smoking. Of course this is not an easy task. Ask your doctor or healthcare professional for information and programs to help you quit. Over-the-counter and prescription medications are available that can help you reach your goal. Ask your family and friends to support you. Try to avoid people who smoke and situations that make you want to smoke. Keep busy doing things that make it hard to smoke. You should receive information while you are in the hospital to assist you. 16

18 Being overweight and inactive: Follow the ideas in the high cholesterol and lipids section to help you lose weight. Start an exercise program slowly and increase to 30 minutes a session at least three to four times a week. Exercise also improves your mood. Try new ways of exercising like dancing and weight training. Walking, swimming and riding a stationary bike are all good ways to exercise. Check with your doctor before you begin an exercise program. Heart disease: Atrial fibrillation is a condition where the upper chambers of the heart quiver rather than beat effectively. This causes the blood to pool and clot, increasing the risk of stroke. If you have had a heart attack, you are at higher risk for a stroke. Anticoagulant medication or blood thinners are used to treat atrial fibrillation. Follow-up: It is very important that you follow up with your primary care doctor and neurologist after you go home. These doctors need to monitor you closely after you have had a stroke. Life s simple seven Remember these seven lifestyle choices that support cardiovascular health: You never smoked or quit more than a year ago Body mass index (BMI) less than minutes of moderate of 75 minutes of vigorous exercise weekly Total cholesterol of less than 200 Eat between five and nine servings of fruits and vegetables daily Blood pressure below 120/80 Fasting glucose less than

19 What are the signs of a stroke? A stroke can present in many different ways. The most common signs of a stroke are: Sudden weakness or numbness 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 (hemorrhagic stroke) You may also hear the term TIA (transient ischemic attack). Strokes and TIAs differ in key ways. Stroke symptoms usually last longer than 24 hours. The symptoms of a TIA last minutes to hours, but usually less than 24 hours. Most strokes result in some problems that may go away in time or may remain; there are no lasting effects with a TIA. TIAs are strong warning signs that a stroke could occur in the future. Risk factors need to be managed to help prevent a stroke. 18

20 When should I get help? Stroke can be a life-threatening event. This is most important because treatment needs to start right away. As soon as any signs or symptoms occur, call 911. Do not drive yourself to the hospital or have anyone else drive you to the hospital. There are treatments that can reduce the risk of damage from the most common type of stroke, but only if you get help quickly within three hours of your first symptoms. tpa (tissue plasminogen activator) is a clot-busting medication that is given through a vein in the arm of through an artery in the groin. tpa is designed to break up a clot that is blocking the blood flow to the brain. Before it can be given, a special type of CT scan is done to detect a blood clot or any bleeding in the brain. tpa cannot be given if bleeding is present or with certain other conditions. A checklist will be done before the tpa is given. The doctor will explain the risks and the benefits, and an informed consent must be signed. 19

21 Continuing recovery, getting support Once you leave the hospital, you will likely continue physical, occupational and possibly speech therapy on an outpatient basis. Henry Ford Macomb Hospital offers these services in several locations, including Warren, Fraser, Clinton Township, Chesterfield Township, Shelby Township, Washington Township, Bruce Township and Richmond. Support groups for patients and their caregivers are available. Super Survivor Stroke Group offers stroke patients and caregivers educational resources, outings and a chance to socialize. The group meets every 3rd Friday of the month from 12:30-2 p.m. in the Rehabilitation Conference Room on the 4th floor of Henry Ford Macomb Hospital in Clinton Township. For more information, call Julie Klocke at (586) New Beginnings is a support group for patients with aphasia. It gives patients a chance to gather and practice speaking skills. The group meets Fridays from 10 a.m.-noon on the second floor of the Macomb Intermediate School District Building, Garfield, Clinton Township, For more information, call Julie Klocke at (586)

22 Common stroke terms Activities of daily living (ADLs): functions that are done on a daily basis such as dressing, walking, personal hygiene and communication Aneurysm: a bulging of an arterial wall, which forms a thin walled bubble Anticoagulants: medicine that keeps platelets from sticking together to help prevent blood clots from forming Aphasia: the inability to express and/or understand speech or language Aspiration: the inhalation of food or fluids into the lungs instead of going down to the stomach Arterial fibrillation (A-Fib): an irregular heartbeat that can allow blood in the heart to form a clot, break off and travel to the brain, causing a stroke Carotid arteries: arteries that run up each side of the neck into the brain, which may become blocked by plaque, causing decreased blood flow to the brain and resulting in a stroke Coagulation: the process of blood clotting in the blood vessels Cognition: the ability to think Deficits: a lost skill such as talking or walking Depression: prolonged feeling of sadness that may be caused by brain damage from a stroke or by the response to the losses caused by the stroke Dizziness: sensation of lightheadedness or spinning Dysarthia: slurred speech due to weakness of certain muscles in the mouth, face, neck or throat 21

23 Embolism: a blood clot that forms outside of the brain that breaks away and travels to the brain Emotional lability: uncontrollable mood changes such as crying, laughter or anger Gait: ambulation or walking Hemianopia: blindness or defective vision in one or half of the field of vision Hemiparesis: weakness of the arm and/or leg on the same side of the body Hemorrhage: bleeding into the brain tissue caused by either leakage of blood from a blood vessel or from a ruptured aneurysm Magnetic resonance imaging (MRI): a type of test that uses radio waves and a strong magnetic field to detect problems in the brain Neglect: condition where the patient ignores or is unaware of one side of the body or their surroundings Occupational therapist (OT): a therapist who works with patients on restoring hand and arm function, thinking skills and activities of daily living Physical therapist (PT): a therapist who helps patients to regain strength, coordination, balance, endurance and walking ability Rehabilitation: the process of gaining function through the use of various therapies Speech therapist (ST): a therapist who works with patients on improving swallowing, speaking, listening, reading and thinking skills Stroke: decreased blood flow to the brain which usually results in some type of damage to the nerve centers in the brain Sub-acute rehabilitation: program that works with people who need to gain strength and endurance but are not able to do a more intense program Thrombus: clot Transient ischemic attack (TIA): decreased blood flow to the brain, causing a mini-stroke usually lasting a few minutes to a few hours, but can last up to 24 hours 22

24 Notes 23

25 Notes 24 Revised June 2010

26 Henry Ford Macomb Hospital is recognized as a Primary Stroke Center by The Joint Commission. The certification means Henry Ford Macomb s stroke program has demonstrated it follows national standards and guidelines that can significantly improve outcomes for stroke patients. HenryFordMacomb.com , 500, Lee