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Management of Adult Stroke Rehabilitation Care

References: . Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline Stroke 2005;36 Pamela Duncan et alComprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient. A Scientific Statement from the American Heart Association Sept. 2010

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Management of Adult Stroke Rehabilitation Care

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    1. Management of Adult Stroke Rehabilitation Care

    2. References: Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline Stroke 2005;36 Pamela Duncan et al Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient. A Scientific Statement from the American Heart Association Sept. 2010 Elaine Miller et al

    3. Clinical Practice Guideline Recommendations

    4. Key Points Primary goals of Rehab are to prevent complications, minimize impairments and maximize function Secondary prevention is fundamental to prevention of recurrent stroke Early assessment and intervention are critical to optimize rehabilitation Standardized evaluation and vital assessment tools are essential to development of a comprehensive treatment tool Evidence-based intervention should be based on functional goals

    5. Key Points Every patient should have access to an experienced interdisciplinary rehab team to ensure optimal outcomes Patient and family members and/or caregiver are essential members of the rehabilitation team Interdisciplinary team should utilize community resources for community re-integration Ongoing medical management of risk factors and co-morbidities is essential to ensure survival Effective Rehabilitation improves functional outcomes

    6. Outcome Measures Functional status Re-hospitalizations Community dwelling status Mortality

    7. Measuring Outcomes Primary outcome measure for assessment of functional status is FIM (Functional Independence Measure Score) Measures burden of care Increase in score means increase in independence

    8. Rehabilitation Depends On Stroke Severity and ability of stroke patient to participate Availability of Family/Caregiver Patient and Family preference Insurance coverage

    9. Types of Rehabilitation Inpatient Rehab Facilities—Most intense type of program with requirement of at least 3 hours of therapy /day Outpatient Rehab—therapies delivered in an outpatient setting Home Health– therapy delivered in the home Nursing Home– therapies delivered in a less intense manner as patient tolerates

    10. Provision of Rehabilitation Care Post Acute Stroke Care best delivered in a formally organized and coordinated program Rehabilitation teams are made up of disciplines experienced in delivering post stroke care. An organized team should be available either inpatient, outpatient or skilled nursing facility

    11. Education/Patient and Families Patient/Families/Caregivers are involved in decision making and treatment planning from the beginning Education is provided in an interactive an written manner and documented in patient medical record Rehabilitation Team should be aware of and recognize possible caregiver stress Current list of Community, State and National Resources should be maintained and available for patients and families

    12. Scientific Statements

    13. Interdisciplinary Approach to Stroke Management Across Care Settings Holistic, Comprehensive, Interactive Stroke patient and caregivers are central participants in the rehab process A comprehensive and individualized assessment and treatment plans are formulated with collaborative input from the Rehab team, survivors and family Nurses play a central role in care coordination throughout the recovery continuum

    14. WHO’s International Classification of Functioning (ICF) WHO’s ICF model is an organizational framework that acknowledges Recovery after stroke is a multifactorial process that encompasses: --Pathophysiological processes directly related to the stroke and associated comorbidities --impact stroke has on individual --contextual variables such as each survivor’s personal and environmental resources

    15. AHA Classes and Levels of Evidence Class I Agreement the treatment is useful and effective Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a treatment. - Class IIa Weight of evidence is in favor of the treatment. - Class IIb Usefulness/efficacy is less well established by evidence Class III Evidence and/or general agreement that the treatment is not useful/effective and in some cases may be harmful. Levels of Evidence A :Data derived from multiple randomized trials. B : Data derived from a single randomized trial or nonrandomized studies. C :Consensus opinion of experts.

    16. WHO ICF—Impact of Stroke Domains to Address Body Structure and Function—Primary (hemiparesis, cognitive dysfunction) or Secondary (contractures) Activities Limitations (ADLs and IADLs) Participation Limitations (reestablishing previous or new life, return to work, mobility, cognition) Personal and environmental factors (Comorbidities, sex, cultural background, family support, social attitudes, architectural barriers, healthcare resources)

    17. Recommendations Many recommendations under each domain Each recommendation is identified by class and level of evidence The following is a sampling of some recommendations

    18. Body Structure & Function Use of Standardized, valid and reliable test procedures to measure severity of UE & LE impairment (Class 1, LOE B) Routine and specific assessment of bowel function (Class 1, LOE B) Assessment of major post-stroke complications (DVT/PE, skin breakdown, spasticity, aspiration, etc.) using reliable, valid and widely accepted assessment methods (Class 1, LOE A) Assessment of major medical post stroke complications (Class 1 LOE A) Document communication and cognitive disorders (Class 1, LOE B) Document the impact of cognitive and communicative disorders have on activities and participation (Class 1, LOE C)

    19. Activities and Limitations Use standardized, valid and reliable tools to facilitate: Interdisciplinary assessment of mobility and self care needs to facilitate discharge to home as well as improve quality of life. Class IIa: (LOE B) Assessment of IADLs, leisure and participation for maintained functional independence and optimal participation. Class IIa: (LOE B) Assessment of level of assistance needed for mobility, transfers, ambulation and self care. Class IIa: (LOE B)

    20. Family and Caregiver Assessment of caregiver needs Detailed assessment of caregiver needs from caregiver’s perspective in inpatient and outpatient settings Class 1; (LOE C) Consider the entire family system, with appropriate referral for treatment or counseling Class IIa; (LOE C) Follow up contact with family caregivers should be arranged and performed after discharge Class 1; (LOE A)

    21. Family and Caregiver Areas of caregiver knowledge should be assessed and reinforced (Warning signs of stroke, risk factors for secondary prevention, lifestyle changes, medication management, etc.) Class 1; (LOE B) Caregivers should be asked about survivors’ depressive symptoms, emotions so that strategies can be provided for caregivers and treatment or counseling can be sought for the survivor. Class 1; (LOE C) Caregivers should be asked about their own health and encouraged to seek regular health checkups. Class 1; (LOE C)

    22. Conclusions Healthcare advances have greatly contributed to improved stroke survival Majority of stroke survivors continue to deal with residual physical, cognitive, communicative and/or emotional deficits There is strong evidence that stroke rehabilitation initiated at the time of admission and sustained across the continuum significantly reduces the likelihood of death and disability within the first year

    23. Conclusions The WHO ICF model of disease is being used to provide a common framework to deliver and study the efficacy of rehab outcomes across rehab settings ICF can be used to facilitate decision making, collaboration and communication among all interdisciplinary team members US Centers for Medicare and Medicaid Services are looking closely at adopting ICF as a framework for documenting care and determining payment for services

    24. In the End This scientific statement is an initial effort to reframe complexities of interdisciplinary, post acute care of Stroke survivors The goal is to optimize the potential for the highest achievable outcomes and quality care.

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