HMJ1 12.07

1. PALOMAR POMERADO HEALTH SPECIALIZING IN YOU After your stroke HMJ1 12.07

2. Table of Contents • Welcome 3 • Contact Information 4 • What is a Stroke 5 • Types of Stroke 6 • Warning Signs of a Stroke 7 • Stroke Diagnosis 8 • Treatment of Acute Stroke 9 • Who is at Risk 10 • Personal Risk Factors 11 • Smoking 12 • High Blood Pressure 14 • High Cholesterol 16 • Physical Inactivity and Obesity 17 • Atrial Fibrillation 18 • Diabetes 19 • Dietary Tips 21 • Medications 27 • Life after a Stroke 30 • Aphasia 31 • Dysarthria 33 • Swallowing Difficulties 34 • Life after Stroke 35 • Rehabilitation 36 • Being a Caregiver 39 • Anxiety and Depression 41 • Prevention of a Stroke 42 • Energy Conservation 44 • “Dial, Don’t Drive 45 • Notes 46

3. Welcome to Palomar Pomerado Health (PPH). The mission of PPH is to heal, comfort, and promote health in the communities we serve. Our vision is that PPH will be the health system of choice for patients, physicians, and employees and be recognized nationally for the highest quality of clinical care and access to comprehensive services. Our goal is to provide you with excellent healthcare. Our visiting policy is individualized and flexible based on the needs of our patients and family members. The packet you are receiving has general information you may find helpful in dealing with your condition, or your loved one’s condition. Additional handouts will be given to you for any other risk factors that may be present. Handouts are available for medications you may be taking or will take at home. These handouts will be given to you when you are admitted and others may be added before you are discharged. Your nurse or your primary healthcare provider can answer any questions you may have. We encourage you to write down your questions or comments on the “Notes” pages provided at the back of this booklet. Please use these pages to speak to your nurse or primary healthcare provider about anything regarding your hospital stay with PPH. We want your experience to be as pleasant as possible. If we can help you with anything, please do not hesitate to ask. For any questions, comments, or concerns, please call the nurses’ station directly for immediate assistance. Palomar Medical Center All prefixes are: 1-760-739 Surgical, 8th Floor: 3840 Medical/Oncology, 7th Floor: 3740 Intermediate Care, 7th Floor: 3790 Telemetry, 6th Floor: 3640 Critical Care, 6th Floor: 3655 Orthopedic/Stroke, 5th Floor: 3540 Pomerado Hospital All prefixes are: 1-858-613 Medical/Surgical/Telemetry, 4th floor: 4340 Medical/Surgical/Telemetry, 3rd floor: 4442 Critical Care/Intermediate Care, 2nd Floor: 4339

4. Contact Information Please write down important contact information in the spaces below. You may want to share this information with family members and friends. • Doctor Treating Me for Stroke Issues Name: ________________________________ Address: ______________________________ City: _______________ State: _____ Zip code: _________ Phone number: _________________________ • Other Important Phone Numbers • Ambulance, fire department, or emergency services: 911 Pharmacy: _____________________________ Other doctors or nurses: ____________________________________________________________________________________________________________

5. What is a Stroke? A 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 cannot function and die within minutes. When these nerve cells die, the parts of the body they control cannot function either. These devastating effects are often permanent because brain cells cannot be replaced. Other names for a stroke include: • Cerebral Vascular Accident (CVA) • Ischemic Stroke • Transient Ischemic Attack (TIA) • Intracranial Hemorrhage (ICH) • Cerebral Thrombosis

6. Types of Stroke There are three types of strokes: • An Ischemic Stroke is a stroke caused by a blocked artery. This is the most common type of stroke and can sometimes be treated with clot busting drugs. • A Hemorrhagic Stroke is a stroke caused by bleeding into the brain tissue. This stroke is caused by a ruptured blood vessel. • A TIA, or a Transient Ischemic Attack, is also called a “mini stroke” and 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 % of strokes are preceded by TIAs and are a very strong predictor of stroke risk. TIAs are a medical emergency and should be treated immediately. Ask your doctor► The type of stroke I have had is: _______________________________________________

7. Warning Signs of a Stroke Warning signs of a stroke can include: • 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 If you recognize any of these symptoms, act FAST. • "F" stands for Face. Ask the person to smile. If the face is droopy on one side, that is a sign of a stroke. Call 9-1-1 immediately. • "A" stands for Arm. Ask the person to raise both arms. If one arm drifts down or has no resistance to it, that is a sign of a stroke. Call 9-1-1 immediately. • "S" stands for Speech. Ask the person to say a simple phrase. If the person's speech is slurred or not able to be understood. Call 9-1-1 immediately. • "T" stands for Time. Diagnosis and treatment of an ischemic stroke must be within 3 hours of the time of onset of symptoms. Call 9-1-1 immediately. • If your recognize any of these symptoms in yourself, or someone around you, a stroke could be happening…CALL 911 IMMEDIATELTY.

8. Stroke Diagnosis It is critical to diagnose a stroke in progress because the treatment of stroke depends on the type, source, and even the location of the injury in the brain. The type of stroke also must be determined because treatment is different for an ischemic versus a hemorrhagic stroke. Timing is extremely important when it comes to diagnosing a stroke. Different types of diagnostic tests that your physician may order to diagnose a stroke includea: • CT Scan (Computerized Tomography) • An imaging test that uses radiation to create a picture of the brain. It is usually the first test ordered for a patient with stroke symptoms. This test will give the stroke team valuable information about the cause and location of the stroke and the extent of the injury to the brain. • MRI scan (Magnetic Resonance Imaging) • MRI scans use a large magnetic field to produce an image of the brain that also show the location and extent of the stroke. The image that is created is sharper and more detailed than a CT scan so it is often used to diagnose small, deep injuries of the brain.

9. Treatment of Acute Stroke Once the diagnosis of stroke is suspected or confirmed, treatments to try to restore blood flow to the brain are started. Timing is everything and will affect what treatments are used. Treatment options can include medications and medical procedures. Thrombolytic Medications These medicines (also called clot busters) are used to dissolve blood clots that are blocking the arteries in the brain. To be most effective, these medicines must be given within 3 hours after the start of stroke symptoms. Many new procedures are being developed for treating acute stroke but all these therapies are time dependent. Therefore, the need for determining the exact onset of the stroke symptoms is extremely important. Since timing is everything, it is important to call 911 if you or someone around is experiencing the signs of a stroke. Do not drive yourself, or let someone else drive him/herself to the hospital. Emergency Medical Services (EMS) will notify the Emergency Department of your symptoms and the stroke team will be activated before you arrive. Remember to Dial, Don’t Drive….

10. Who is at Risk? Certain risk factors make it more likely that you will develop artery disease and have a stroke. Some risk factors for stroke can be controlled, while others can't. Major risk factors for a stroke that you can control include: • Smoking • High blood pressure • High blood cholesterol • Overweight and obesity • Physical inactivity • Diabetes (high blood sugar) • Atrial Fibrillation Risk factors that you cannot change include: • Age: Stroke affects all ages but the older you are, the greater your risk of stroke • Heredity: The risk of a stroke is greater in people whose close blood relatives have had a stroke. • Race: African Americans have a higher risk of death and disability from a stroke because they have a greater incidence of high blood pressure. Hispanic Americans are also at an increased risk for stroke due to complications of diabetes. • Prior Stroke: Someone who has had a stroke is at higher risk of having another one. • Gender: While more men have strokes each year, over half of the stroke deaths occur in women.

11. My Personal Risk Factors Risk Factors are different for each person. Check the risk factors below that apply to you. • Remember that some of your risk factors cannot be changed but others can be managed successfully working with your health care team. • High blood pressure • Obesity • High Cholesterol • Atrial fibrillation • Diabetes • Smoking • Sedentary lifestyle • Previous heart attack or stroke Your nurse or primary care provider will give you information to help you modify your risk factors. More helpful information can also be found in this book.

12. Smoking Tobacco use is the number one preventable cause of serious illnesses such as heart disease, stroke, lung cancer, and emphysema. An estimated 25.1 million men and 20.9 million women smoke cigarettes. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. Some helpful tips to quit smoking include: • Making an agreement with yourself to quit. • Asking your nurse or physician about quit smoking aids (Chantix, Zyban, Nicoderm). • Attending a smoking cessation class. • Avoiding people who smoke.

13. Stop Smoking Now Smoking can make cardiovascular disease worse, so if you smoke, you should stop immediately. Quitting takes hard work and a lot of effort, but you CAN quit smoking. For counseling or to register for PPH Kick the HabitProgram, please call the Cancer Resource Center at (760) 739-3943 or (858) 613-4044.

14. Relapse Prevention for New Non-smokers Think of yourself as a non-smoker. • Decide that cigarettes, or any tobacco products, are not an option! • Refer to yourself as a non-smoker, not as an ex-smoker Watch out for the top 3 triggers. • Being around smokers • Alcohol • Highly emotional situations • (Remember to watch yourself for your personal triggers as well.) You can manage your weight when you quit. • Stay active • Drink water and eat healthy meals • Keep low-fat, low-calorie snacks on hand • (Remember to follow the specific dietary or fluid guidelines and/or restrictions that your primary healthcare provider has discussed with you.) You can manage stress when you quit. • Incorporate stress reducing activities in your new lifestyle • Use stress management techniques If you “slip” (smoke or use tobacco products), do not let it turn into a relapse. • Ask yourself what went wrong • Fine tune your strategies and recommit to quitting • One cigarette does not mean that you are a smoker again! If you have a relapse, you can get back on track. • Ask yourself if you still want to quit • Find a NEW reason to quit • Revise your strategies, commit to quit, and set a new date • Join, or rejoin, a support group to help you stay a non-smoker For more information, or to register for PPH Kick the Habit Program, contact the PPH Cancer Resource Center at 760.739.3943 or 858.613.4044.

15. High Blood Pressure High blood pressure (BP), or hypertension (HTN) is the single most important risk factor for stroke. Many people believe control of high blood pressure is a key reason for the decrease in death rates for stroke. It is estimated that the prevalence of high blood pressure in adults over the age of 20 is approximately 72 million in the United States alone. Up to 95 % of high blood pressure are from unknown causes, but the condition is easily detectable and treatable. In addition to medications, diet, exercise, and weight loss can assist in controlling your blood pressure. • Please ask to see a dietitian to assist you with healthy meal planning to lower both your blood pressure and your cholesterol. • Normal blood pressure is 120/80. • High blood pressure is 140/90 or higher. • If you are diabetic, you are considered to have high blood pressure if your blood pressure is 130/85. My blood pressure is: _____________________

16. High Cholesterol About 36 million American adults have total cholesterol levels above 240 mg/dL. • Your total cholesterol should be below 200 mg/dL. • Your triglyceride level should be below 150mg/dL. • Your HDL, or good cholesterol, should be 40 mg/dL or higher. • Your LDL, or bad cholesterol, should be less than 100 mg/dL In addition to medications, diet, exercise, and weight loss can help control you cholesterol levels. • Please ask to see a dietitian for healthy meal planning to assist you in lowering both your high blood pressure and cholesterol. My cholesterol levels in the hospital are: Total Cholesterol: ________ Triglyceride: ________ HDL: _______ LDL: __________

17. Physical Inactivity and Obesity About 65 % of Americans age 20 and older are overweight or obese. Data from the Centers for Disease Control and Prevention show that only 30.1% of American adults engage in light-moderate physical activity for at least 30 minutes on five or more days a week. • If you are overweight, losing even 5 to 10 pounds will help lower your blood pressure and cholesterol and improve your overall health. Physical activity will build endurance, control blood pressure, reduce cholesterol levels, help with weight loss, and reduce your risk for developing diabetes. The key is finding activities that fit your lifestyle and abilities. The American Heart Association/American Stroke Association recommend 30 minutes a day 5 to 7 days per week. This can be broken up in to three 10 minute brisk walks during the day! Ideal body weight is determined calculating your Body Mass Index (BMI). • Your nurse or dietitian can assist you in calculating your BMI during your stay. The ideal BMI is 20 – 25. My BMI is: __________ Before beginning any exercise program, consult your physician to discuss what is right for you and your health.

18. Atrial Fibrillation Atrial fibrillation is a condition that causes the upper chambers of the heart, the atria, to quiver instead of beating effectively to move blood into the ventricle. This causes blood flow to slow and pool and can increase the risk of clotting. If a clot breaks lose from the atria and enters the bloodstream, it can lodge in an artery leading to the brain and can cause a stroke. About 15 to 20 percent of people who have had a stroke have this heart arrhythmia. People with atrial fibrillation have an increased stroke risk of about five percent per year. Treatment for atrial fibrillation includes medications such as coumadin or warfarin, aspirin, plavix. Your physician may chose to perform a cardioversion. During a cardioversion, the atria are electrically converted back into a regular rhythm. My doctor has prescribed the following medication(s) for my atrial fibrillation: _________________________________________________ _________________________________________________ _________________________________________________

19. Diabetes Diabetes is an independent risk factor for stroke. Many people with diabetes also have high blood pressure, high cholesterol, and are overweight. Diabetes is manageable with medications such as insulin, glipizide, and/or glyburide. Diet and exercise can also help manage diabetes. Your physician may perform a lab test called a hemoglobin A1c which will let them know how well your diabetes has been controlled in the last 90 days. The goal is to have a number less than 7.0%. My hemoglobin A1c (HgbA1c) is: __________

20. Know Your Diabetes Risk • Type Two Diabetes Mellitus (Type 2 Diabetes) is a metabolic disorder characterized by the body’s inability to produce enough insulin and/or the body cells being resistant to insulin. This results in an abnormal elevation of blood sugar. • Why should I be concerned to know if I have Type 2 Diabetes? • Type 2 Diabetes rarely occurs alone. People that are newly diagnosed with Type 2 Diabetes usually already have a disease such as High Blood Pressure and/or Abnormal Cholesterol levels. High blood sugar is not just high blood sugar. If left untreated, high blood sugar will harm large and small blood vessels – every cell of your body is affected. • What are the risk factors of Type 2 Diabetes? • Diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, and Pacific Islanders (however, Type 2 Diabetes is seen across all race / ethnic groups). • Age over 45 (the older one gets the higher the risk – however children as young as 8 years of age are being diagnosed with Type 2 Diabetes). • First-degree relative (sibling or parent) with Type 2 Diabetes. • Overweight, especially being overweight around the ‘belly’ (apple shape). • Sedentary (inactive) lifestyle. • Women who had gestational diabetes or gave birth to at least one baby weighing more than 9 pounds (if your mother had gestational diabetes while pregnant with YOU, you are at risk). • Having other health problems such as: High Blood Pressure, Abnormal Cholesterol, and other Cardiovascular Diseases. • Other co-existing factors that could increase your risk – smoking, continual high stress levels, and depression. • The more risk factors you have, the more at risk you are of developing or having Type 2 Diabetes. • Don’t Ask – Don’t Tell – Absolutely NOT! • Uncontrolled diabetes is the leading cause of blindness, renal failure, and limb amputations (not associated with injuries). • The leading cause of death in the United States is heart disease (68% of these people had diabetes). • Two out of three people with diabetes die from heart disease and stroke. • It is estimated that once a person is diagnosed with Type 2 Diabetes, he or she likely had diabetes for at least 5 to 7 years before being diagnosed. • Ask Your Primary Healthcare Provider for Further Evaluation to See If You Have Diabetes or Are at Risk. Prevention and Early Diagnosis and Treatment To help Prevent the Complications of Uncontrolled Diabetes is Crucial! • For more information, contact PPH Diabetes Health • at 760.739.2865 or 858.613.4164.

21. DASH Diet(Dietary Approaches to Stop Hypertension) The DASH diet is simply what the name implies, a diet to stop hypertension or high blood pressure. It is based on research that has shown that eating a low fat, low sodium diet rich in whole grains, low fat dairy foods, fruits and vegetables lowers blood pressure significantly. While it may seem difficult or overwhelming to change a lifetime of eating habits, making a few changes over a couple of days or weeks is often easier than changing your entire diet overnight. • Add a serving of vegetables at lunch one day and dinner the next, and add a fruit at one meal or snack. • Increase your use of fat free and low fat milk products to three servings a day • Limit lean meats to 6 ounces a day –three ounces a meal which is about the size of a deck of cards. • Include two or more vegetarian-style, or meatless meals each week.

22. DASH Diet US Department of Health and Human Services, National Institute of Health. www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

23. Following the DASH Eating Plan US Department of Health and Human Services, National Institute of Health. www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

24. US Department of Health and Human Services, National Institute of Health. www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

25. DASH Eating Plan: Number of Daily Servings for Other Calorie Levels US Department of Health and Human Services, National Institute of Health. www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

26. Dietary Tips to Reduce Cholesterol • Eat less saturated fat and cholesterol • Eat less total fat, even “good” fats such as olive oil. Avoid fried foods, fatty meats and whole milk products, including cheese and ice cream. • Select foods low in cholesterol. Cholesterol is found only in foods from animals. Foods from plants contain no cholesterol. • Choose foods low in saturated fat. Saturated fats are usually found in animal fats. But you should not eat the three plant oils (coconut, palm and palm kernel) that are high in saturated fat. These oils are often added to packaged foods. • Use as little hydrogenated and partially hydrogenated fats as possible. Select tub or liquid margarine rather than stick margarine. • Special “spreads” • Special spreads, such as Benecol and Take Control are made from plants and have been shown to lower cholesterol. Talk with your dietitian about adding these foods to your diet.

27. Medications Anticoagulants and Antiplatelet Medications Medicines such as aspirin and clopidogrel, and aggrenox stop platelets (a blood cell related to clotting) from clumping together and forming unwanted clots. Aspirin is recommended for preventing a first stroke in some patients. Along with other antiplatelet agents it also has an important role in preventing recurrent strokes. These medications should not be stopped without first talking to your physicians. It is also important to tell all physicians treating you that you take these medicines. Medications such as coumadin (or warfarin) thin the blood and prevent clots from forming in your arteries. They are different from antiplatelet agents and are recommended primarily for patients with a high risk of stroke and people with atrial fibrillation. While these drugs are more effective preventing clots in people with atrial fibrillation, they may have side effects including bruising and bleeding. Careful follow up with one’s primary care physician, including blood tests to measure warfarin effect, is essential for people taking these drugs. Again, please be sure to tell any physician treating you that you take these drugs. Beta Blockers These medicines decrease the workload on your heart. Beta blockers also are used to relieve chest pain or discomfort and to help prevent additional heart attacks. Beta blockers also are used to correct arrhythmias (irregular heartbeats).

28. Medications Angiotensin-Converting Enzyme Inhibitors (ACE-I) These medicines (such as captopril, benazapril, and lisinopril) lower blood pressure and reduce the strain on your heart. They also help slow down further weakening of the heart muscle. Studies have also shown that in certain patients, use of ACE-I’s may reduce subsequent stroke incidence even if blood pressure is normal. In diabetics, these drugs may preserve renal function. In patients with kidney disease, these drugs slow decline in renal function and prolong time till dialysis is required. Angiotensin Receptor Blockers (ARB) These drugs are very similar to the ACE-I’s in terms of function, but instead of blocking formation of angiotensin as ACE-I’s do, they block the effect of angiotensin on the arteries themselves.Most of the positive effects of ACE-I’s as listed above are also noted with ARB’s. Statins These medicines, (such as lovastatin or simvastatin and others) help lower cholesterol in the body. Statins also need to be monitored by your primary care physician and the dose adjusted to provide maximum benefit. Side effects can include muscle soreness and weakness which should be brought to the attention of your physician immediately. Other Medicines Medicines may also be given to relieve pain, anxiety, and depression which often occur during and after a stroke If you need help paying for any of your medications, please talk to your nurse, case manager, or pharmacist for assistance.

29. Taking Medications Here are a few tips for taking your medications. Most medicines need to be taken every day even if you feel fine. Ask your doctor or nurse about any special issues you should be aware of concerning your medications. • Have a routine: Take your medications at the same time each day and use reminders to help you stay on track • Take all your medicines: Some work better when used together with others. Don’t take one and skip another. • Plan ahead: Refill your prescriptions before you run out. • Be sure you have them when you travel. • Never change your dosage or stop taking a medicine without talking to your primary care physician, and if you miss a pill, don’t take two when it is time for the next dose. • Tell your primary care physician if you think you are having a side effect to a medication: Your physician may change the dose or give you a new prescription • Carry an up to date list of your medicines and bring the list with you each time you visit your primary care provider. The pharmacy where you fill your prescriptions should also know about all the medications you take even if you do not have the prescriptions filled at the same pharmacy. This will help to prevent any potential medication reactions. • Use a pill box to be sure you take all your medications properly every day. If you have difficulty filling the box correctly, ask a friend or relative to help. • Consult your physician if you are having difficulty swallowing pills, for example, coughing or ”getting stuck”.

30. Life After a Stroke When brain cells injured by a stroke cannot work, the part of the brain they control cannot work either. This is why a stroke can be so devastating. Brain injury from a stroke can affect the senses, motor activity, speech and the ability to understand speech. Brain injury can also affect a person’s behavior and thought patterns, memory and emotions. Paralysis or weakness on one side of the body is common. These effects may be temporary or lasting depending on the area of the brain affected and the extent of the brain injury. Injured and dead brain cells cannot heal or replace themselves. Recovery from a severe stroke usually takes months or years of medical treatment, rehabilitation therapy and determined effort by the stroke survivor. Many survivors never regain all their lost functions but despite these losses, many go on to lead full, productive lives. Almost everyone feels tired after a stroke and while feeling fatigued is normal at first, you will probably start to feel less tired in a few months. It is important to plan your activities to conserve your energy.

31. Aphasia Aphasia is a language disorder that affects the ability to communicate. Aphasia is most often caused by a stroke that affects the left side of the brain which controls language. Aphasia does not affect intelligence. Many stroke survivors remain mentally intact even though their speech may be jumbled, fragmented or impossible to understand. Aphasia may manifest itself as trouble speaking, trouble finding words, understanding what others say, difficulty with reading , writing, or math, and/or the inability to process long words and infrequently used words. People with aphasia are often frustrated and confused because they cannot speak or understand things the way they did before the stroke. They may act differently because of these changes in their brain. They report feeling isolated and alone. While these feelings are normal, they should be reported to your physician so they can determine if short term medications will help the situation.

32. Types of Aphasia Receptive Aphasia: A patient with receptive aphasia is not able to follow directions or has difficulty understanding questions. Some tips to make communicating with your loved one easier include: • Using visual cues • Using simple gestures • Simplifying instructions even to one word • Speaking slowly • Asking to perform tasks one step at a time • Checking for comprehension frequently (don’t assume that he or she understands) Expressive Aphasia: Patients with expressive aphasia have limited ability to use words. The patient may say words that they do not mean, for example, “no” for “yes.” Some tips to make communicating easier include: • Using a communication board. • Giving extra time for the patient to answer • Giving auditory/visual/ written choices • Using yes/no questions • Asking the patient to point or gesture • Using writing if appropriate • Having the patient fill in the blank (e.g. Would you like a cup of ----------?” • Sometimes their words and sentences may not make sense. My communication strategies include: ______________________

33. Dysarthria Dysarthria is another communication and speech problem that can occur with stroke. Dysarthria is characterized by slow, “slurred,” or unintelligible speech. In other words dysarthria affects how words are spoken. While this often occurs with aphasia, a language problem, it is not the same and can occur alone. Patients may experience weakness of the lips and tongue affecting speech clarity. Some tips for improving communication with the patient with dysarthria include: • Sitting the patient up, if possible, for better breath support • Asking the patient to slow down and speak up. • Asking the patient to over-articulate or pretend they are speaking for a lip reader. My Speech strategies are:__________________ If you have any questions regarding communication between you and your loved ones, please talk to your speech therapist of nurse for more helpful tips.

34. Swallowing Difficulties Immediately following a stroke, patients sometimes have difficulty swallowing or may not be able to swallow at all. This disorder is called dysphagia. People with this problem often cough or choke when or immediately after they eat or drink. Food particles or liquid can then go into the lungs and cause aspiration pneumonia. Safe eating or drinking guidelines may be recommended by a speech therapist. Please follow the provided directions when feeding yourself or your loved one. While in the hospital, do not feed your loved one unless the staff has given you permission to. The speech therapist working with your physician will develop a treatment program to help you with any swallowing difficulties. The therapist may recommend special consistencies for food and liquids to decrease the risks of aspiration and pneumonia. Please ask your speech therapist, nurse or a dietitian for specific details on the special food consistency that you may need. My swallowing guidelines are: ___________________________________________________ ___________________________________________________ ____________________________________________________ My diet is: ___________________________________________

35. Life After a Stroke Treatment After You Leave the Hospital Most people spend several days in the hospital after a stroke. When you leave the hospital, treatment does not stop. At home, your treatment may include daily medicines and rehabilitation (rehab). Your doctor may recommend lifestyle changes including quitting smoking, losing weight, changing your diet, and increasing your physical activity, to lower your chances of having another stroke. Your care team may feel you are not strong enough to go directly home after your hospital stay and may suggest that you go to a skilled nursing facility for more rehab and strengthening. Your case manager will assist you and your family with these arrangements.

36. Rehabilitation After a Stroke Rehabilitation is a critical part of the recovery of a stroke survivor. The effects of stroke may mean that you must relearn, change or redefine how you live. While rehab does not reverse the effects of the stroke, it can help you return to your optimum level of function. Rehabilitation begins when your physicians determine you are medically stable, you have the stamina to tolerate the therapy, and that you will benefit from it. Rehabilitation services are started in the hospital, but can be continued in various settings such as an acute rehab unit, skilled nursing facility, at home with home health, or in out-patient facilities. What you will do in rehab depends on what you need to become independent. The rehab team will assess your needs and determine a plan which may include: • Self-care skills such as feeding, grooming, bathing and dressing • Mobility skills such as transferring, walking or use of a wheelchair • Speech and language skills to improve communication • Memory and problem-solving skills • Social skills for interacting with others

37. Rehabilitation After a Stroke The Rehabilitation Team consists of several specialists. They include: • Rehab physician • Rehab nurses • Physical, occupational, and speech therapists • Dietitians • Social workers • Support group members • Chaplains The services you may require from each will be determined by your physician and the team members working together with you to develop an individual rehab plan. Palomar Pomerado Health has an Acute Rehabilitation Unit (ARU) located within Palomar Medical Center (PMC). Your physician may ask the staff to come and evaluate you to determine if you are strong enough for this intense program. If you are not a candidate immediately after your stroke, you may be later after a short stay at a skilled nursing facility (SNF) for strengthening.

38. PMC: Acute Rehabilitation Program The ARU at PMC is a hospital-based, comprehensive physical and cognitive rehabilitation program dedicated exclusively to treating those individuals who have experienced a disabling injury or illness. Services are provided for patients who have suffered functional loss due to a stroke as well as other rehabilitation diagnoses. Our goal is to ensure an optimum level of recovery from a CVA while providing cost-effective outcomes for each patient. To reach our goal, the Medical Director works with and coordinates the efforts of a team of professionals focusing on improving the function of each patient, in an effort to restore the patient to his/her fullest potential.  The ARU at PMC accepts referrals from physicians, social workers, rehabilitation nurses, case managers, patients, and their families. Candidates for admission will receive an assessment at no cost to determine their appropriateness for the program. You can discuss whether or not your diagnosis meets criteria for admission to the ARU with your physician.

39. Being a Caregiver When a loved one is disabled, it changes the family system by changing how each of the members relate to each other. Being a caregiver can be a satisfying experience but can also be stressful. Family roles become confused. Some members may not feel comfortable in their new roles or the caregivers new role. Some may not want to “interfere” with what has already been planned or decided. Family meetings can be uncomfortable and awkward especially for people who have not talked openly about family matters before. Talking about feelings or asking for help is difficult for many people. Case managers, social workers, physicians, and nursing staff at Palomar Pomerado Health are available it assist you, your family and caregivers through this difficult time. Chaplaincy services are also available. Please notify your nurse or physician if you would like to speak to anyone about this new role in your life.

40. Caregivers Bill of Rights I have the right to: • Take care of myself. • This is not an act of selfishness, it will enable me to take better care of my loved one. • Seek help from others even though my loved one may object. • I recognize the limits of my own endurance and strength. • Maintain facets of my own life that do not include the person I care for, just as I would if he or she were healthy. • Get angry, be depressed, and express other difficult emotions. • Reject any attempt by my loved one to manipulate me through guilt, anger, or depression. • Receive consideration, affection, forgiveness, and acceptance from my loved one as long as I offer these qualities in return. • Take pride in what I am accomplishing and to applaud the courage it sometimes takes to meet the needs of my loved one. • Protect my individuality and my right to make a life for myself that will sustain me when my loved one no longer needs my full-time help. • Expect and demand that as new strides are made in finding resources to aid physically and mentally impaired persons in our country, similar strides will be made towards aiding and supporting caregivers. Author unknown: http://www.americanheart.org/downloadable/heart/1196275052136CaregiversRights.pdf

41. Life After a Stroke Anxiety and Depression After a Stroke Immediately after a stroke a survivor may respond one way and weeks later respond entirely different. These emotional reactions may occur due to biological causes resulting from the stroke or psychological causes. Emotional changes such as rapid mood changes, crying or laughing that does not match a person’s mood or that lasts longer than seems appropriate and depression are common. Psychological changes including frustration, anxiety, anger or apathy are common and often helped by talking to someone and acknowledging these feelings. These feelings are normal and let you cope without feeling guilty about them. Depression is common after a stroke and can be treated with a variety of medicines. Depression often occurs within two weeks of the event and may seriously affect your rehabilitation and recovery. Depression also affects people who care for you during your recovery. If you think you or your loved one is suffering from depression, please talk to your physician or nurse about possible treatments available to you.

42. Prevention Modifying your personal risk factors is a very important step in preventing another stroke. It is also important for your friends and loved ones to know their risk factors to prevent their first stroke. Healthy Lifestyle Choices Healthy lifestyle choices to help prevent a stroke include: • Following a low-fat diet rich in fruits and vegetables. Pay careful attention to the amounts and types of fat in your diet. Lower your salt intake. These changes can help lower high blood pressure and high blood cholesterol. • Losing weight if you are overweight or obese. • Quitting smoking. • Doing physical activity to improve heart fitness. Ask your doctor how much and what kinds of physical activity are safe for you.

43. Prevention Treat Related Conditions In addition to making lifestyle changes, you can help prevent a first or recurrent stroke by treating your modifiable risk factors such as: • High blood cholesterol. • You may need medicine to lower your cholesterol if diet and exercise are not enough. • High blood pressure. • You may need medicine to keep your blood pressure under control. • Diabetes. If you have diabetes, control your blood sugar levels through diet and physical activity (as your physician recommends). • Take your medications as prescribed by your physician. • Quit Smoking now!

44. Suggestions for Energy Conservation • Plan Ahead and Organize Your Work • change storage of items to reduce trips or reaching • delegate when needed • combine motions and activities and simplify details • Schedule Rest • balance periods of rest and work •  rest before fatigue • frequent, short rests are beneficial • Pace Yourself • moderate pace is better than rushing through activity •  reduce sudden or prolonged strains • alternate sitting and standing • Practice Proper Body Mechanics • when sitting, use well-supporting chair • adjust work heights-work without bending over • bend at knees and hips, not at back • carry several smaller loads or use a cart • Limit Overhead Work • use long handled tools •  store items lower • delegate • Limit Isometric Work • breathe evenly, do not hold your breath • Identify Effects of Your Environment • avoid extremes of temperature • eliminate smoke or noxious fumes • avoid long, hot showers or baths • Reduce Stress • learn relaxation techniques •  physical exercise reduces stress • anticipate fatigue and stress and plan ahead to reduce stress • Prioritize • decide what activities are important to you, and what could be delegated •  use your energy on important tasks

45. “Dial, Don’t Drive” Use of Emergency Services, Dial 911 • Learn the signs, but remember that even if you are not sure it is a stroke, have it checked out. • Minutes matter! Fast action can save lives, maybe your own. Do not wait more than five minutes to call 911. • Calling 911 is almost always the fastest way to get lifesaving treatment. Emergency medical services staff can begin treatment when they arrive — up to an hour sooner than if someone gets to the hospital by car. The staff are also trained to revive someone whose heart has stopped. Patients with stroke symptoms who arrive by ambulance usually receive faster treatment at the hospital, too. • If you cannot access the emergency medical services (EMS)/911, have someone drive you to the hospital right away. If you are the one having symptoms, do not drive yourself, unless you have absolutely no other option.  Palomar Pomerado Health: http://dialdontdrive.org/

46. Make This Plan a Permanent Part of Your Life Living with the effects of a stroke is a chronic condition and requires continuous follow up with a primary care physician. If you do not have a physician you see on an ongoing basis, please ask the physician treating you here to assist you in finding a solution. The case manager and social worker can also assist you with this process. If you are having trouble sticking to your treatment plan, please do not change anything. Talk with your nurse or primary healthcare provider for help! The Hurdles People Often Experience Are: Cost of medicines Communication issues Depression Caregiver issues We can help and we want to help. Talk with your nurse or primary healthcare provider about these barriers and we can work out solutions together! We are here for you!

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