Understanding Your Stroke

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1 Understanding Your Stroke 8383 North Davis Highway Pensacola, Florida (850)

2 This booklet on Understanding Your Stroke was developed utilizing the following documents: Teaching sheets from the American Stroke Association, 2001, American Heart Association CareNotes System, from

3 table of contents Home Instructions Quick Reference What is Stroke? Risk Factors for Stroke Signs & Symptoms of Stroke What Causes a Stroke? Types of Strokes How Is a Stroke Treated? Tests Complications After Stroke Driving After a Stroke What Are My Responsibilities? General Rules about Medications? Understanding Your Medications How Active Can I Be? What Do I Do In Case Acknowledgement of Receipt Notes Where Do I Find Support & More Info? Back Cover Will I Get Better? Stroke Rehabilitation Particular Problems After Stroke Living at Home After a Stroke West Florida Healthcare 1

4 Home Instruction Quick Reference If you have been diagnosed with stroke, it s important to follow your doctor s advice exactly. Following your treatment plan can help you feel better, stay out of the hospital, and live longer. Activity Remain physically active following your doctor s instructions about exercise and activity. Rest often. Any time you become even a little tired or short of breath, SIT DOWN and rest. Keep your feet and legs elevated while sitting. Do not dangle them. Plan your activities to include rest periods. Take note of your breathing pattern and how well you tolerate activity. Diet / Nutrition Follow any diet instructions given to you by your doctor or the dietitian including how much salt (sodium) you are allowed each day. If you are overweight, talk to your doctor about a weight reduction plan. Medications Your doctor may prescribe one or a combination of medications for you. You MUST take your medicine as prescribed. Be sure to take you medicines exactly as your doctor tells you: no more, no less. Skipping doses or not refilling a prescription could cause serious problems. Do not stop taking your medicine without talking to your doctor. Medicines sometimes cause side effects like causing you to cough or go to the bathroom more often. If you have side effects or questions or believe the medicine is not helping you call your doctor. Follow-up Be sure and schedule a follow-up appointment with your primary care doctor or any specialists as instructed. Weight Monitoring If you notice any unexplained weight loss or weight gain, tell your doctor. Tell Your Doctor If Alert your doctor any time you notice a change in your body or your symptoms, but be especially aware of the following and call your doctor if any of these signs or symptoms occur or if you experience any other new sudden symptoms: numbness or weakness of the face, arm or leg, especially on one side of the body confusion, trouble speaking or understanding trouble seeing in one or both eyes trouble walking, dizziness, loss of balance or coordination severe headache with no known cause If you experience chest pain, go to the nearest emergency room immediately. Smoking Do not smoke or use other tobacco products. Tobacco is probably the single most dangerous thing you can do to your health. Nicotine robs the heart of oxygen and contracts blood vessels, which raises heart rate and blood pressure. If you smoke or use tobacco products, discuss alternatives with your doctor. The most important thing is that you continue to try to quit until you are successful! Additional Instructions Keep all appointments. Work with your doctor. To get the most benefit from your health care, you need to take an active role. Visit your doctor regularly, take notes, and ask questions. 2 Understanding Your Stroke

5 What is Stroke? Stroke is the number 3 cause of death and a leading cause of serious, long-term disability in America. Stroke is a disease that affects the arteries of the brain. A stroke occurs when a blood vessel bringing blood to the brain gets blocked or ruptures so brain cells don t get the flow of blood that they need. Deprived of oxygen, nerve cells can t function and die within minutes. And when nerve cells don t function, the part of the body controlled by these cells can t function either. The devastating effects of stroke are often permanent because dead brain cells can t be replaced. Other names for stroke are CVA (Cerebrovascular Accident) and Brain Attack. The good news about stroke is that it s largely preventable. Research has shown that you can take steps to prevent stroke by reducing and controlling your risk factors. The other good news is that more than 4 million people who have had strokes are alive today! Much is being done to treat strokes and stop them in their tracks. A new clot-dissolving drug (t-pa), approved by the FDA, to treat stroke, represents a major advance in the fight against stroke. If you act fast and seek emergency treatment right away, you could prevent a major stroke, reduce disabilities caused by stroke or save your life. Risk Factors for Stroke Knowing your risk is the key to stroke prevention. There are steps you can take to reduce your risk of stroke, including having regular medical checkups. Risk factors fall into three broad categories: Those that you can modify with your doctor s help Those you can modify by changing your lifestyle Those you cannot control Risk factors you can treat, modify or control with medical treatment: High Blood Pressure. This is the single most important risk factor for stroke. Know your blood pressure and have it checked at least once every 2 years. If it s high (140/90 or above), speak with your doctor about medical treatment. Diabetes Mellitus (high blood sugar). While diabetes is treatable, having it increases a person s risk of stroke. Work with your doctor to manage your diabetes and reduce other risk factors. Heart Disease. People with heart disease have a higher risk for stroke. Atrial Fibrillation (irregular heartbeat) is a significant risk factor for stroke. It involves the heart s electrical impulses losing their regular pattern. AF is not usually, itself, life-threatening, but it can lead to other problems like heart muscle disease, heart failure and stroke. It can cause stroke because during AF the atria of the heart beat too rapidly and ineffectively and the blood pools in these chambers and tends to form clots. If a clot breaks loose, enters the bloodstream and travels to your brain, it can plug an artery that supplies blood to the brain and cause a stroke. About 15% of all strokes occur in people with AF, and AF is the most common cause of stroke in the elderly. TIAs. Transient ischemic attacks (TIA s) are mini-strokes that produce stroke-like symptoms but no lasting effect. Recognizing and treating TIA s can reduce the risk of a major stroke. Know the warning signs of a TIA (discussed below) and seek emergency medical treatment immediately. Carotid Artery Disease. The carotid arteries in your neck supply blood to your brain. A carotid artery damaged by a fatty buildup of plaque in the artery wall may become blocked by a blood clot, which may result in a stroke. West Florida Healthcare 3

6 Risk Factors You Can Modify By Making Lifestyle Changes Tobacco use. Don t smoke cigarettes or use other forms of tobacco. Physical inactivity and obesity. Being inactive, obese or both can increase your risk of cardiovascular disease. Excessive alcohol intake. Drinking an average of more than one drink per day for women or more than two drinks a day for men raises blood pressure. Binge drinking can lead to stroke. Illegal drug use. Intravenous drug abuse carries a high risk of stroke. Cocaine use has also been linked to stroke. Risk Factors You Can't Control Increasing age. Stroke affects all ages. The older you are, the greater your stroke risk. Gender. Men are at higher risk for stroke when compared to women. Heredity and race. The risk of stroke is greater in people whose close blood relatives have had a stroke. African Americans have a higher risk of death and disability from a stroke than whites, because they have a greater incidence of high blood pressure. Hispanic Americans are also at higher risk of stroke. Prior stroke. Someone who has had a stroke is at higher risk of having another one. signs and symptoms of stroke Your brain controls how you move, feel, think and behave. Brain injury from a stroke may affect any of these abilities. Signs and symptoms of a stroke depend upon the part of the brain affected and how much damage occurred. You may have some or all of these signs. During a stroke you may have sudden: Numbness (no feeling), tingling, weakness (hemiparesis), or paralysis (hemiplegia) (cannot move) on one side of the body (face, arm or leg) Trouble swallowing (dysphagia) Confusion, trouble speaking (aphasia) or understanding Trouble seeing in one or both eyes, or double vision Trouble walking, dizziness, loss of balance or coordination Severe headache with no known cause Remember FAST F A S Speech slurred T Time to call 911 Face (numb / weak) Arm (numb / weak) These signs and symptoms, noted above, may appear within minutes or hours. Note the time symptoms started and call 911 or the emergency medical number in your area. Don t ignore these warning signs, even if they go away. An emergency medical doctor must treat you within 3 hours of the onset of symptoms. Other, perhaps more long-term changes that may be caused by a stroke are: Loss of emotional control and changes in mood (depression, apathy or lack of motivation, tiredness, emotions may change rapidly and sometimes not match the mood, frustration, anger, sadness, and denial of the changes caused by the brain injury). Cognitive changes (problems with memory, judgment, problem solving or a combination of these Behavior changes (personality changes, improper language or actions) 4 Understanding Your Stroke

7 What Causes a Stroke? A stroke may be caused by any of the following: A piece of fatty plaque (debris) that is formed in a blood vessel breaks away and flows through the blood stream going to the brain. The plaque blocks an artery which causes a stroke. This is called an embolic stroke. A thrombus (blood clot) formed in an artery (blood vessel) and blocks blood flow to the brain. This is called a thrombotic stroke. A torn artery in the brain, causing blood to spill out. This is called a cerebral hemorrhage or hemorrhagic stroke. It often results from high blood pressure. Blockage of certain small blood vessels inside the brain. Types of Strokes TIA, or Transient Ischemic Attack (TRAN-see-ynt) (is-ke-mik) is a mini stroke that occurs when a blood clot blocks an artery for a short time. The symptoms of a TIA are like the warning signs of a stroke, but they usually last only a few minutes. About 10 percent of stokes are preceded by TIAs. TIAs are strong predictors of stroke risk. Don t ignore the signs. Call 911 or seek emergency medical attention immediately. Ischemic Strokes a stroke caused by lack of blood reaching the brain due to the blood vessels in the brain becoming narrowed or clogged, cutting off blood flow to brain cells. High blood pressure is the most important risk factor for ischemic stroke that you can change. Ischemic Strokes are the most common type of stroke and account for about 70 to 80 percent of all strokes. Symptoms develop over a few minutes or worsen over hours. They are typically preceded by symptoms or warning signs that may include loss of strength or sensation in one side of the body, problems with speech and language or changes in vision or balance, as discussed above. Ischemic strokes usually occur at night or first thing in the morning. Often a TIA may give some warning of a major ischemic stroke. There Are Three Types of Ischemic Strokes Thrombotic strokes, caused by a blood clot (thrombus) in an artery going to the brain. The clot blocks blood flow to part of the brain. Blood clots usually form in arteries damaged by artheriosclerosis (hardening of the arteries). This type of stroke accounts for about 60% of all strokes. Embolic strokes account for about 20% of all strokes. They re caused by a wandering clot (embolus) that s formed elsewhere (usually in the heart or neck arteries). Clots are carried in the bloodstream and clog a blood vessel in or leading to the brain. Systemic hypoperfusion (low blood flow) occurs because of circulatory failure caused by the heart itself. The heart s pumping action fails and too little blood reaches the brain. This is how a heart attack may cause a stroke. West Florida Healthcare 5

8 Hemorrhagic Strokes (hem-o-ray G-ik) 15 to 20 percent of strokes occur when a blood vessel ruptures in or near the brain. This rupture stops oxygen supply to the surrounding areas of the brain. Hemorrhagic strokes are different from ischemic strokes in many ways: The fatality rate is higher and overall prognosis poorer for those who have hemorrhagic strokes People who have these strokes are generally younger Usually the symptoms appear suddenly This kind of stroke is often associated with a very severe headache, nausea and vomiting TIA or any other stroke warning sign may not precede this type of stroke There Are Two Kinds of Hemorrhagic Stroke In both, a blood vessel ruptures, disrupting blood flow to the brain. Increasing the risk of hemorrhagic strokes are: Cigarette smoking Use of oral contraceptives (particularly those with high estrogen content) Excessive alcohol intake Use of illegal drugs Subarachnoid Hemorrhage (sub-ah-rak-noid) 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 Occurs when a blood vessel bleeds into the tissue deep within the brain. This type of hemorrhage is responsible for about 10% of all strokes Chronically high blood pressure or aging blood vessels are the main culprits of this type of stroke How is a Stroke Treated? Treatment of a stroke depends upon the type of stroke but the main goals are: 1. To limit the size of the brain infarct 2. To institute measures that protect surrounding brain tissue Ischemic Stroke An ischemic stroke includes strokes caused by a blockage in a blood vessel. Anticoagulant medicine Treatment for an ischemic stroke includes anticoagulant medicines which are also called blood thinners. This medicine group keeps clots from forming in the blood. Antiplatelet aggregating medicine These medicines interact with platelets to prevent blood clots from forming. Platelets are a type of blood cell that join to form clots Thrombolytic medicine (clot busters) This medicine group is used in a stroke caused by a clot in a blood vessel. Thrombolytics break apart clots and restore blood flow. T-PA must be given within 3 hours of the onset of symptoms Carotid Endarterectomy (kah-rot-id-en-dar-ter-ek-tome) is surgery that removes harmful plaque (plak) from your carotid arteries. These two arteries are located in the neck and supply your brain with blood and oxygen. If plaque obstructs one of these arteries, it reduces the blood flow to the brain, leading to stroke. This surgery may reduce your risk of further major strokes. Hemorrhagic (bleed) stroke This type of stroke is caused by a rupture of a blood vessel that has caused there to be no blood flow to the brain. This may require surgery Antihypertensive Medications may be administered, especially if it was caused by high blood pressure A drain may be need to be inserted to help drain excess fluid in the brain 6 Understanding Your Stroke

9 tests Blood Tests You may need blood taken for different tests. We will check your bleeding times and cholesterol. Chest x-ray This is a picture of your lungs and heart. Doctors use it to see how our lungs and heart are doing. Doctors may use the x-ray to look for signs of infection, like pneumonia, or to look for collapsed lungs. Chest x-rays may show tumors, broken ribs, or fluid around the heart of lungs. Imaging Tests You may have any of the following tests to diagnose a stroke: Computerized Axial Tomographic Scan (CT or CAT Scan) This is also called a CAT scan. A special x-ray machine uses a computer to take pictures of your brain. It may be used to look at the skull, brain tissue, and blood vessels. You may be given dye before the pictures are taken. The dye is usually given in your IV. The dye may help your doctor see the pictures better. People who are allergic to iodine or shellfish (lobster, crab, or shrimp) may be allergic to some dyes. Tell the doctor if you are allergic to shellfish, or have other allergies or medical conditions. Magnetic resonance imaging scanning (MRI) Using magnetic waves, this test, also called an MRI, takes pictures of your head. An MRI can provide very accurate images of the brain and is used to determine the presence, location and size of aneurysms and ischemic strokes. You will need to lie still during an MRI. Never enter the MRI room with an oxygen tank, watch, or any other metal objects. This can cause serious injury. Tell your caregiver if you have an metal implants in your body. Blood Flow Tests Carotid ultrasonography (Carotid Doppler) This test uses sound waves to show the blood flow in your carotid arteries. The carotid arteries are the blood vessels in your neck that carry blood to your brain. A carotid Doppler test will check if there is a narrowing or blockage of the carotid arteries that may lead to a stroke. Arteriography (also called angiography) Blood flow tests that give detailed information about the condition of arteries in your head and neck that supply blood to your brain. Special substances are injected into the blood vessels and an x-ray is taken. This gives a picture of the blood flow through these vessels. This allows the size and location of the blockages to be evaluated. This test is especially valuable in diagnosing aneurysms and malformed blood vessels and providing valuable information before surgery. Tests That Show Electrical Activity Electrocardiogram (ECG) or (EKG) This test measures the electrical activity of your heart. It tells if you have had a past heart attack, have enlargement or are currently having a heart attack. It is painless, and involves sticky tabs being placed on your chest, and maybe on your arms and legs. Each sticky pad has a wire that is hooked to a machine or TV-type screen. A short period of electrical activity in your heart muscle is recorded. Doctors look closely for certain problems or changes in how your heart is working. This test takes about 5 to 10 minutes. It is important that you lie as still as possible during the test. You may need this test more than once. Electroencephalogram (EEG) In this diagnostic procedure, small metal disks (electrodes) are placed on a person s scalp. These electrodes can detect electrical activity in the form of impulses that is recorded. A Neurologist can interpret the EEG and have valuable information about underlying problems in the brain. West Florida Healthcare 7

10 Complications After Stroke Your doctor s highest priorities after a stroke are to prevent complications from the present stroke and to prevent another stroke. Your doctor must determine that you are medically stable and able to resume some self-care activities. This means that all complications must be treated and under control. Some complications happen as a direct result of injury to the brain due to stroke, or because of a change in the patient s abilities; for example, being unable to move freely can result in bedsores. Clinical depression can also occur with a stroke. The Most Common Complications Edema (eh-de-mah) brain swelling after injury Seizures abnormal electrical activity in the brain causing convulsions Clinical Depression a treatable illness that often occurs with stroke and causes unwanted emotional and physical reactions to changes and losses Bedsores pressure ulcers that result from decreased ability to move Limb Contractures shortened muscles in an arm or leg from reduced range of motion or lack of exercise Shoulder Pain stems from lack of support or exercise of an arm Blood Vessel Problems blood clots form in veins Urinary Tract Infection & Bladder Control urgency and incontinence Pneumonia causes breathing problems and is a complication of many major illnesses. Medical treatment often involves medical supervision, monitoring and drug therapies Physical treatment usually involves some type of activity that can be done by you, a healthcare professional or by both of you working together. Types of treatment may include: Range of motion exercises and physical therapy to avoid limb contracture and shoulder pain, blood vessel problems and pneumonia Frequent turning, good nutrition and skin care to avoid bedsores; sometimes use of a special mattress called an egg crate or air mattress may be put on your bed. Bladder training programs for incontinence Swallowing and respiratory therapy and deep breathing exercises, all of which help to decrease the risk of pneumonia Use of 4 prong cane or walker when walking may be needed to keep from falling; use of chairs with arms to ease getting up and down Psychological treatment can include counseling or supportive therapy for feelings that result from clinical depression. Types of treatment may include antidepressant medication, psychotherapy or a combination of both. You may also be referred to a local stroke support group. Will I Get Better? In most cases people recovering from a stroke do get better. The effects of a stroke are the greatest immediately after the stroke occurs. From then on, you may start to get better. How fast and how much you improve depends on the extent of the brain injury and the success of rehabilitation. Recovering your abilities begins after the stroke is over and you re medically stable. Some improvement occurs spontaneously and relates to how the brain works again after it s been injured. Stroke rehabilitation programs help you improve your abilities and learn new skills and coping techniques. Depression after stroke can interfere with rehabilitation. It s important that it be treated. Improvement often occurs most quickly in the first months after a stroke, then continues over years with your continued efforts. 8 Understanding Your Stroke

11 stroke rehabilitation When the immediate crisis of a stroke has passed and you ve been stabilized medically, it s time to consider rehabilitation therapy. The effects of stroke may mean that you must change or relearn how you live day-to-day. Rehabilitation may reverse some of these effects. Who will be a part of my rehabilitation program? Your rehabilitation team may include: Physiatrist A medical doctor who specializes in rehabilitation Physical Therapist A healthcare provider who specializes in maximizing a stroke survivor s mobility and independence to improve major motor and sensory impairments, such as walking, balance and coordination Occupational Therapist A therapist who focuses on helping stroke survivors rebuild skills in daily living activities such as bathing, toileting and dressing Rehabilitation Nurse A nurse who coordinates the medical support needs of stroke survivors throughout rehabilitation Speech Therapist A specialist who helps restore language skills and also treats swallowing disorders Recreational Therapist A therapist who helps to modify activities that the survivor enjoyed before the stroke or introduces new ones Psychiatrist or Psychologist Specialists who help stroke survivors adjust to the emotional challenges and new circumstances of their lives Vocational Rehabilitation Counselor A specialist who evaluates work-related abilities of people with disabilities. They can help stroke survivors make the most of their skills to return to work. What Will I Do in Rehab? Improve your independency by including: Activities of daily living such as eating, bathing and dressing Mobility skills such as transferring, walking or self-propelling a wheelchair Communication skills in speech and language Cognitive skills such as memory or problem solving Socialization skills in interacting with other people Psychological functioning to improve coping skills and treatment to overcome depression if needed. West Florida Healthcare 9

12 particular problems after stroke Aphasia (ah-fa-ze-ah) A language disorder that affects the ability to communicate. It s most often caused by a stroke that affects the left part of the brain, which controls language. Aphasia does NOT affect intelligence. Stroke survivors remain mentally alert, even though their speech may be jumbled, fragmented or impossible to understand. Some survivors continue to have Trouble speaking Trouble finding words Problems understanding what others say Problems with reading, writing or math Inability to process long words and infrequently used words People with aphasia are often frustrated and confused because they can t speak or understand things the way they did before their stroke. They may act differently because of changes in their brain. There Are Different Forms of Aphasia Global Aphasia Someone with this type of aphasia may be completely unable to speak, name objects, repeat phrases and unable to understand commands. Broca s Aphasia The person knows what they want to say, but can t find the right words Wernicke s Aphasia A person with this aphasia can seldom comprehend what is being said or control what they re saying. Feeling Tired After a Stroke After a stroke, almost everyone complains of feeling tired at some point. While fatigue is common at first, you ll probably start feeling less tired after a few months. For some people, tiredness may continue for years after a stroke, but they usually find ways to make the most of the energy they have. It s important to pinpoint what s causing you to be tired. When you know what s causing your tiredness, you can take action to manage it. You should consult our doctor to rule out any medical conditions that might cause tiredness or make it worse. You may feel tired after a stroke for 3 major reasons: You have less energy than before. This can be because of sleeping poorly, not getting enough exercise, poor nutrition or the side effects of medicine. You have as much energy as before, but you re using it differently. Due to the effects of your stroke, many things, like dressing, talking or walking, take a lot more effort. Changes in thinking and memory take more concentration. You have to stay on alert all of the time and this takes energy. You also may feel more tired due to emotional rather than physical changes. Coping with frustration, anxiety, anger, and sadness can be draining. Depressed feelings are common after a stroke. Often loss of energy, interest or enthusiasm occurs along with a depressed mood. How Can I Increase My Energy? Tell your doctor how you feel and make sure you have had an up-to-date physical. This can help determine any medical reasons for your tiredness or side effects of your medication. Celebrate your successes. Give yourself credit when you accomplish something. Look at your progress, not at what s left to be done. Try naps, or schedule rest periods throughout the day. Rest as long as you need to feel refreshed. Learn to relax. Sometimes the harder you try to do something, the harder it is to do. You become tense, anxious and frustrated. All this take more energy. Being relaxed lets you use your energy more efficiently. Every day do something you enjoy. A positive attitude or experience helps a lot to boost energy levels. Physical activity is important. With permission from your doctor, consider joining a health and wellness program. 10 Understanding Your Stroke

13 Emotional Changes after Stroke Immediately after a stroke, a survivor may respond one way, yet weeks later respond entirely differently. Some may react with understandable sadness; others may be amazingly cheerful. These emotional reactions may occur because of biological causes due to stroke or because of the effects of a stroke (psychological causes). These changes may vary with time and can interfere with rehabilitation. What Emotional Changes are Biological? Emotions may be difficult to control, especially soon after a stroke. There are two common emotional responses caused by biological changes. Emotional Liability also called reflex crying or labile mood, can cause: Rapid mood changes a person may spill over into tears and then quickly stop crying or may start laughing Crying or laughing that doesn t match a person s mood Crying or laughing that lasts longer than seems appropriate Post-stroke Depression is characterized by: Feelings of sadness Hopelessness or helplessness Irritability Changes in eating, sleeping and thinking What Emotional Reactions are Psychological? Post-stroke psychological emotions are natural. They re just part of adjusting to the changes brought by the stroke. Often talking about the effects of the stroke and acknowledging these feelings helps stroke survivors deal with these emotions. Some common psychological reactions to stroke are: Frustration Anxiety Anger Apathy or not caring what happens Lack of motivation Depression or sadness Treatment for post-stroke depression may be necessary. Don t hesitate to take antidepressant medications prescribed by your doctor. Treatment for post-stroke depression may be necessary. Don t hesitate to take antidepressant medications prescribed by your doctor. How Can I Cope with My Changing Emotions? Improve your independency by including: Tell yourself that your feelings aren t good or bad. Let yourself cope without feeling guilty about your emotions. Find people who understand what you re feeling. Ask about a support group Get enough exercise and seek out enjoyable activities Give yourself credit for the progress you ve made. Celebrate the large and small gains. Learn to talk to yourself in a positive way. Allow yourself to make mistakes. Ask your doctor for help. Ask for a referral to a mental health specialist for psychological counseling or antidepressant medication if needed for depression. West Florida Healthcare 11

14 living at Home after a stroke How Do I Know If Going Home is the Right Choice? Going home poses few problems for people who have had a minor stroke and have few lingering effects. For those whose strokes were more severe, going home depends on these four factors: Ability to care for yourself. Rehabilitation should be focused on daily activities Ability to follow medical advice. It s important for medication to be taken as prescribed and medical advice followed. A caregiver. Someone who is willing and able to help when needed should be available. Ability to move around and communicate. If stroke survivors aren t independent in these areas, they may be at risk in an emergency or feel isolated. Most stroke survivors are able to return home and resume many of the activities they were involved in before the stroke. Leaving the hospital may seem scary at first because so many things may have changed. The hospital staff can help prepare you for the move home or perhaps to another setting that can better provide for your needs when you leave the hospital. What If I Can t Go Home? Your doctor may advise a move from the hospital to another type of facility that can meet your needs either temporarily or permanently. It s important that the living place you choose is safe and supports your continued recovery. Your case manager at the hospital can give you information about alternatives that might work for you. Possibilities include: Nursing Facility This can be a good option for someone who has ongoing medical problems Skilled Nursing Facility This is for people who need medical attention, continued therapy and more care than a caregiver can provide at home. Intermediate Care Facility This is for people who don t have serious medical problems and can manage some level of self-care. Assisted Living This is for people who can live somewhat independently, but need to have some assistance with things like meals, medication and housekeeping. What Changes Do I Need to Make at Home? Living at home successfully also depends on how well your home can be adapted to meet your needs. Safety Take a good look around and eliminate anything that might be dangerous. This might be as simple as taking up throw rugs, testing the temperature of bath water or wearing rubber-soled shoes. Or it may be more involved, like installing handrails. Accessibility You need to be able to move freely within the house. Modifications can be as simple as rearranging the furniture or as involved as building a ramp. Independence Your home should be modified so that you can be as independent as possible. Often this means adding adaptive equipment like grab bars or transfer benches. 12 Understanding Your Stroke

15 driving after a stroke Driving is often a major concern after a stroke. It s not unusual for stroke survivors to want to drive. Being able to get around after a stroke is important. While safety is always an issue when a person gets behind the wheel, it s even more important after a stroke. The reason is that the injury to the brain may change how you do things. Before you drive again, think carefully about how these changes may affect your own, your family s and other people s safety. What are Some Warning Signs of Unsafe Driving? Often survivors are unaware of the difficulties that they might have driving again after a stroke. Some may not realize all of the effects of their stroke. They may feel that they re able to drive, when it s a bad idea. Driving against your doctor s advice can be dangerous and may be illegal. In some cases, your doctor may have the legal responsibility to notify your state that you ve been advised not to drive. There are some warning signs of unsafe driving. If you or someone you know has experienced some of these warning signs, please consider having your driving tested. Driving too fast or too slow for road conditions or posted speeds Needs help or instructions from passengers Doesn t observe signs or signals Makes slow or poor distance decisions Gets easily frustrated or confused Often gets lost, even in familiar areas Has accidents or near misses Drifts across lane markings into other lanes How Can I Tell If I Can Drive? Talk to your doctor or occupational therapist. He or she can tell you about your stroke and whether it might change your driving. You ll also get a professional opinion based on experience. Contact your State Department of Motor Vehicles in your area. Ask for the Office of Driver Safety. Ask what requirements apply to people who ve had a stroke. Have your driving tested. There are professionals such as driver rehabilitation specialists who can evaluate your driving ability. You ll get a behind-the-wheel evaluation and be tested for vision perception, functional ability, reaction time, judgment and cognitive abilities (thinking and problem solving). Call community rehabilitation centers of your local Department of Motor Vehicles. Enroll in a Driver s Training Program. For a fee, you may receive driving assessment, classroom instruction and suggestions for modifying your vehicle (if necessary). These programs are often available through rehabilitation centers. Ask you family if they have noticed changes in your communication, thinking, judgment or behavior that should be evaluated before you drive again. They often have many more opportunities to observe changes than others do. West Florida Healthcare 13

16 WHat are my responsibilities? You can make an impact on your health by following these general guidelines for people with Stroke. Stop Smoking It is essential that you not use tobacco in any form. We will provide assistance in the form of Referrals to smoking cessation support groups. We will also discuss nicotine patches and oral medications to find a method that works for you and assist you in the success of quitting smoking. Cholesterol Keep your blood cholesterol level in a normal range. Eat foods low in fat to decrease the risk of developing plaque (fatty deposits) in your blood vessels. If you have hyperlipidemia (high blood cholesterol level), talk to your doctor about ways to lower it. Blood Sugar Monitor and control your blood sugar level if you have diabetes. Follow Your Prescribed Diet Monitor Your Weight Weighing too much can make your heart work harder and can cause serious health problems. Talk to your caregiver about a weight loss plan if you are overweight. Notify your physician if you experience unexpected weight loss or gain. Report Changes in Your Symptoms Call with profound changes. Call your physician. Stay Active Exercise reduces your risk of heart attack and stroke and makes your heart stronger. It helps to control your weight and blood pressure, helps you relax and can improve your mood. Talk to your doctor before you start exercising; together you can plan the best exercise program for you. It is best to start slowly and do more as you get stronger. Follow the guidelines in the Activity and Exercise section of this booklet. Look for even small chances to be more active; take the stairs instead of an elevator and park farther from you destination. Remember a great rule is that you have been too active if you are weaker than usual the next day. You may be given a diet to assist you in eating right for any other conditions you may have such as obesity, high cholesterol, or diabetes. Special cookbooks can make it easier to plan low fat, low salt, or low sugar meals. Avoid foods like egg yolks, fatty meats, butter and cream, which are high in fat and cholesterol. Eat moderate amounts of food and cut down on saturated fat, sugar and salt. Bake, broil roast and boil (don t fry foods). Avoid most fast food and read nutrition labels on packaged meals. Eat a variety of healthy foods every day. Your diet should include fruits, vegetables, breads, dairy products, and protein (such as chicken, fish, and beans). Eating healthy foods may help you feel better and have more energy No Alcohol/No Drugs Alcohol is found in beer, wine, liquor, like vodka or whiskey, and other adult drinks. Different people have different ideas about what too much means. It is important to remember that how often you drink is as important as how much you drink. 14 Understanding Your Stroke

17 Blood Pressure High blood pressure means that the pressure in your arteries is consistently in the high range, leading to stroke, heart attack, heart failure or kidney failure. Two numbers represent blood pressure; the higher (systolic) number represents the pressure when the heart is beating and the lower (diastolic) number represents the pressure when the heart is resting between beats. The systolic number is always listed first and the diastolic number is second. A blood pressure of less than 120 over 80 is considered normal for adults. A blood pressure reading equal to or higher than 140 over 90 is considered high. Blood pressure between / is considered prehypertension and requires lifestyle modifications to reduce the risk of cardiovascular disease. Even is you have had a prior stroke or heart attack, controlling high blood pressure can help prevent another one. Lost weight if you re overweight Eat a healthy diet that s low in salt, total fat, saturated fat and cholesterol Eat enough fruits and vegetables, and fat-free or low-fat dairy products Be more active Limit alcohol to no more than 2 drinks a day if you re a man, and 1 drink a day if you re a woman Take your blood pressure medicine the way your doctor tells you Know what your blood pressure should be and try to keep it at that level; have it checked regularly Take Your Medications Take Your Medications, please. The medications your doctor has prescribed have shown to help people with stroke live longer, stay out of the hospital, and feel better. Bring all your medications with you to your appointment with your physician. Sometimes confusion arises about drugs and how to take them. This will help us make sure you get the correct treatment. Heart Conditions If you have atrial fibrillation (an irregular or fast heart beat): your may need to take antithrombotic medicine. Having a recent heart attack may also require you to take antithrombotics.. Be Encouraged A positive attitude can help you overcome difficult times. Many people with strokes can lead active happy lives with positive changes to their lifestyle. What Do I Change About My Diet? If your doctor recommends you watch your Sodium (salt), here are some tips for reducing sodium Stay away from processed, cured and Allow your taste buds time to adapt. Your canned foods unless they are low in salt taste will change. or sodium. Read labels. Select sodium-free, low sodium, Eat fresh fruits, vegetables, grains and or very low sodium. fresh meats. Avoid prepared, quick or fast foods. Use fresh herbs and spices without salt. When you eat out ask that your food be prepared without salt. Baked, broiled, steamed Do not use salt when preparing food. Take the salt shaker off the table or poached methods are best. Do not use salt substitutes. West Florida Healthcare 15

18 General rules about medications Taking your medicines every day is extremely important to treating your stroke. Your doctor may add medications one at a time, or he may start two or more. You may need more frequent physician visits at times your medication is being adjusted for the optimal dose for you. Important Reminders About Medications Take medications exactly as your doctor ordered them. Do not skip doses, take more than ordered to make up forgotten doses, or forget to refill prescriptions. Bring all the medications you are taking each time you see the doctor along with your medication record. Understand what each medicine is for, what it looks like, and common side effects. Be patient as your doctors find the right medications for you along with the best time, amount and combination to take them. Do not take over-the-counter medications without asking your doctor or nurse. Check your medications for an expiration date. Ask your pharmacist if you have any questions. Check with your physician before taking any new medication prescribed by a new doctor or over-the-counter drugs. Let us know if you are having difficulty taking your medications due to times of doses or cost of medications. Share any problems with us. Clear your over-the-counter pain reliever with your physician. Some medications such as ibuprofen can decrease cardiac function. Please Call If You think a medicine is causing a problem. Do not just stop taking it. Some drugs have to be stopped gradually. Any physician starts you on a new medication or you begin an over-the-counter drug or herbal remedy. Keeping Track of Your Medications Stroke patients are oftentimes overwhelmed by the amount of medications they must take. Get a system that works. You need to know: Which medications to take each day What each pill looks like When to take your medications Bring your medications with you each time you come to the clinic, hospital or plan to see the doctor. Always carry a list with you of medications you are currently taking. Consider purchasing a Medic Alert bracelet. Use the medication chart provided for you in the back of this book. Bring it with you to any doctor appointments. Make sure your nurse updates this with any changes. Stroke patients generally share in being overwhelmed by the cost of medications. Shop around local pharmacies to find the best prices for each prescription. Generic forms of most medications are usually cheaper. Your doctor will generally prescribe this if possible. Remind him/her. Mail order pharmacies are also usually great sources of savings. Internet/on-line pharmacies are usually very inexpensive but you need to plan ahead. Examples are Planet Rx.com. You may qualify for some governmental or pharmaceutical company assistance programs. Ask your nurse to request a Utilization Manager to come see you while you are in the hospital. Please let us know if the cost is a problem with you taking your medications as prescribed. All medications have side effects and can interact with other drugs. It is very important that we know all drugs that you are taking. If you miss a dose, take the missed medicine at the next scheduled time. Do not go back and make up the dose. 16 Understanding Your Stroke

19 understanding your medications Taking your medications every day is essential in treating your Stroke. Common kinds of medicines prescribed for treating stroke include: Anti-Platelet Agents Antiplatelet medicines keep blood clots from forming by preventing blood platelets from sticking together. They re used as a treatment for patients with artherosclerosis or with increased clotting tendencies. Anti-Platelet Agents make your blood less likely to clot. They prevent new heart attacks, strokes and leg blockages. Side Effects The most common side effects of anti-platelet agents are stomach bleeding, belly pain, and diarrhea. Report any side effects right away. Anti-Platelet Agents include: Aspirin ASA; Aspirin is the single most important therapeutic agent for stroke prevention. It s a medicine that can save your life if you have heart problems, or if you have had a stroke or TIA. You must use Aspirin just as your doctor tells you, and not in your own way. Plavix Clopidogrel Anticoagulants These are blood thinners, which delay the clotting of blood; they make it harder for clots to form or keep existing clots from enlarging in your heart, veins or arteries. Two examples are heparin and (warfarin (brand name Coumadin). Follow your doctor s instructions when taking this. Have blood tests taken regularly so your doctor can tell how the medicine is working. Never take aspirin with anticoagulants unless the doctor tells you to. Tell your other doctors that you are on anticoagulants. Always check with your doctor before taking other medications or food 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. Tell your family how you take this medicine and carry your emergency medical ID card with you. Because blood thinners may cause you to bleed or bruise easily, do the following things: Watch for bleeding from your gums or nose, or in your urine or BMs Use a soft washcloth on your skin and a soft toothbrush to brush your teeth. Doing this can keep your skin and gums from bleeding. Tell your dentist before dental cleanings, and other caregivers before other procedures that you take blood thinning medicine. If you shave, use an electric shaver Do not play contact sports since you may bleed or bruise easier Wear a MedicAlert bracelet or necklace that says you are taking a blood thinner medicine. You may get one from your local drugstore or contact the MedicAlert Foundation listed below at the end of this document. Tell Your Doctor 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 Your gums bleed You have a very bad headache or stomach pain that doesn t go away You get sick or feel weak, faint or dizzy You think you re pregnant You often find bruises or blood blisters You have an accident of any kind West Florida Healthcare 17

20 Antihypertensives These are two examples of some medications that may be ordered by your doctor to help lower you blood pressure. Beta-Blockers These drugs take time to work. In fact, the maximal beneficial effects can take 6-8 months to occur. Types of Beta-Blockers There are many types of beta-blockers, ask your nurse or doctor what one have been prescribed for you. Just to name a few: acebutolol, betaxolol, labetalol, metoprolol, propranolol, timolol, atenolol, nadolol, and sotalol. The dose to start is very low and increased every two weeks to the maximum tolerated dose. Side Effects Beta-blockers can cause dizziness, nausea, vomiting, impaired peripheral circulation resulting in cold hands and feet, and sleep disturbances. It is very important to take your pills every day, unless your doctor tells you otherwise. Beta-blockers should be taken with food. When your heart adjusts, you should feel better. Keep track of how you feel and tell your doctor if anything bothers you. You may feel the same, or worse for 3 to 10 weeks. After that most people feel better. Do not stop taking beta-blockers suddenly. If your doctor wants you to quit, he or she will gradually reduce your dose. Calcium Channel Blockers Amlodopine (Norvasc); Verapamil (Calan); Nifedipine (Procardia); Diltiazem (Cardizem); Nicardipine (Cardene), and Nimodipine (Nimtop) are all effective antihypertensives. These drugs also help to lower blood pressure. These drugs improve oxygen delivery to the heart, decrease total peripheral resistance therefore decreasing your blood pressure. Side Effects Calcium Channel Blockers can cause dizziness, flushing, edema in your hands and feet, lethargy, headache and fatigue. Some people may also experience nausea/vomiting, anorexia, constipation, weight gain and thirst. It is also very important to take your pills every day, unless your doctor tells you otherwise. Do not stop taking calcium channel blockers suddenly. If your doctor wants you to quit, he or she will gradually reduce your dose. Anticonvulsants Phenobarbital; Phenytoin (Dilantin); Carbamazepine (Tegretol); Valproic acid (Depakote); Fosphenytoin (Cerebyx); Gabapentin (Neurontin); Levetiracetam (Keppra) Anticonvulsants can work in a few different ways but the goal of all of them is to stop seizure activity. They will limit the spread of seizure activity and reducing seizure propagation. Depending on what kind of seizures you may have will help choose the anticonvulsant you will need to control your seizure activity. Side Effects Anticonvulsants can cause various side effects but the most common of them are nausea/vomiting. Administration of the drug with food can help alleviate this common side effect. Ataxia, dizziness, fatigue, acute onset of visual impairment and/ or ocular pain and headache can also occur during therapy. Psychosis and some behavioral disturbances are unlikely but can occur. Dermatologic reactions such as skin rashes can occur and reported to your doctor. Other reportable side effects are bleeding and bruising: this may be an indication for reduction of the dosage or withdrawal of therapy. Liver problems can also occur, therefore lab draws will be ordered by your doctor while on anticonvulsant therapy. 18 Understanding Your Stroke

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