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Home Care Chronic Disease Prevention Program. Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine. Homework review. What did you do? What happened as you did that? Why do you think that happened?

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home care chronic disease prevention program

Home Care Chronic DiseasePrevention Program

Melanie S. Bunn RN,MS

A collaboration of Duke University,

Division of Community Health and

University of South Carolina, School of Medicine

homework review
Homework review
  • What did you do?
  • What happened as you did that?
  • Why do you think that happened?
  • Here’s what might have happened.
  • How does this impact the next time you try this?
chronic disease management
Chronic Disease Management

Module 1:Health/Illness, Vital Signs, Exercise, Nutrition

Module 2: Motivational Interviewing

Module 3: End of Life

Module 4: Heart Attack

Module 5: COPD

Module 6: Stroke

Module 7: Hypertension

Module 8: Diabetes

Module 9: Congestive Heart Failure

objectives
Objectives
  •  Identify different types of stroke and how each occurs
  • Describe healthy lifestyle choices for the person who’s had a stroke
  • Demonstrate use of motivational interviewing with the person who’s had a stroke
stroke6
Stroke
  • Third leading cause of death in the United States
  • Sometimes referred to as a “CVA”
  • Think of it as a “Brain Attack”
what is a stroke
What is a stroke?

1. Blood vessels that supply blood to the brain become blocked or leak

2.The part of the brain fed by this blood supply no longer gets oxygen and nutrients

3.When the cells in the brain are deprived of blood, they die

4.Then the brain does not function as it did before and the person may lose control of parts of the body (movement, speech, vision…)

types of stroke
Types of stroke
  • Ischemic
  • Embolic
  • Hemorrhagic
  • TIA (transient ischemic attack)
ischemic stroke
Ischemic stroke
  • Most common type; ischemic = blockage
  • Accounts for more than 80% of strokes
  • Blood clots form in blood vessels that have fatty build up (atherosclerosis)
  • Often preceded by a “mini-stroke” of short duration
embolic stroke
Embolic stroke
  • Clot travels from elsewhere in the body to the brain
  • Most common cause is atrial fibrillation where blood stagnates in the chamber of the heart and clots form that break loose and travel to the brain
hemorrhagic stroke
Hemorrhagic stroke
  • Blood vessel in the brain ruptures and there is bleeding into the brain
  • Less common but most likely type to lead to death
mini stroke mild form of stroke
“Mini-stroke” - Mild Form of Stroke
  • Transient (short) Ischemic (blockage) Attacks.
  • Symptoms same as those for stroke but very short-lived – rarely more than 20 min
  • Occurs when blood supply to the brain is blocked temporarily and then is corrected
tia mini stroke
TIA (“Mini-stroke”)
  • But, over 1/3 all persons who have a TIA will go on to have a full stroke in the following days, weeks, or months if risk factors aren’t improved.
  • TIAs should be treated as an emergency. Quick diagnosis is the best way to reduce the risk of a full blown stroke.
risk factors for stroke 1
Risk factors for stroke (1)
  • High blood pressure
  • Tobacco smoke
  • High cholesterol
  • Diabetes
  • Other blood vessels that are “clogged”
risk factors for stroke 2
Risk factors for stroke (2)
  • Carotid artery stenosis (blockage causes decrease in diameter of main artery that goes to the head)
  • Atrial fibrillation
  • TIA
  • Blood disorders such as sickle cell anemia
  • Cocaine use
risk factors for stroke 3
Risk factors for stroke (3)
  • Obesity and inactivity
  • Family history
  • Race
  • Gender
  • Age
  • Prior stroke
warning symptoms
Warning symptoms
  • Difficulty seeing
  • Difficulty speaking
  • Difficulty with motor skills
  • Severe headache
  • Dizziness
  • Numbness
warning signs
Warning signs*
  • Decreased blood pressure (less than 90/60)
  • Increased blood pressure ( greater than 160/100)
  • Increased pulse (greater than 100)
  • Decreased pulse (less than 60)
  • Increased respiratory rate
  • Decreased respiratory rate

*ALL vital parameters are determined by RN supervisor and are patient specific

other warnings
Other warnings
  • Not taking medications
signs that stroke is happening
Signs that Stroke is Happening
  • Sudden numbness or weakness 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.
brain attack stroke is an emergency
BRAIN ATTACK!!!Stroke is an emergency
  • Call 911 immediately if there is concern for a stroke as every second counts
diagnosis
Diagnosis
  • History
  • Thorough physical exam
  • CT or MRI of the brain
  • Other studies to look at blood vessels and the heart
hospital treatment
Hospital treatment
  • Medications to break up clots
  • Aspirin
  • Other blood thinners
outpatient treatment
Outpatient treatment
  • Eat well and exercise
  • Healthy weight
  • Control blood pressure, cholesterol, diabetes
  • Do not smoke
  • Aspirin may be recommended
life after stroke
Life after stroke
  • Physical effects
    • Weakness, inability to walk or to use limbs
  • Behavioral effects
    • Moods may change, at risk for depression
  • Communication
    • Difficulty with understanding or producing speech
other therapies
Other Therapies
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Support groups for patient and family
  • Home assistance (aide)
references
References
  • Neal, LJ. & Guillett, SE .Care of the adult with a chronic illness or disability. Mosby, St. Louis, Missouri, 2004.

pp. 328-336.

  • Kennedy – Malone, L. et al. Management guidelines for gerontological nurse practitioners. F.A. Davis Company, Philadelphia, PA, 2000.

pp 352-355.

  • Lippincott, Williams and Wilkins. Managing chronic disorders. Lippincott Williams and Wilkins, USA, 2006.

pp 307-312.

  • http://www.strokeassociation.org/presenter.jhtml?identifier=1200037
case study
Case study
  • 70 year old male who smokes, has high blood pressure, and is overweight
  • You have known him for six months
  • He is usually lively and talkative
  • When you arrive to see him you have a hard time understanding his speech but he tells you that his right leg and arm are weak
case study30
Case study
  • What should you do?
  • What is possibly going on?
case study31
Case study
  • What should you do?
    • Call 911
  • What is possibly going on?
    • Stroke
case study32
Case study
  • What are his risk factors for a stroke?
case study33
Case study
  • What are his risk factors for a stroke?
    • Smoker
    • High blood pressure
    • Age
    • Overweight
case study34
Case study
  • He comes home from the hospital and rehabilitation center and luckily does not have any weakness anymore
  • His strength is back to normal
  • His doctor has told him that at 250 pounds, he needs to lose weight
motivational interviewing
Motivational interviewing
  • How do you as the Nurse Aide motivate him to take steps needed to lose weight?
    • Now that you’ve gained his trust you can start asking questions that will begin the change talk.
starting the change talk
Starting the Change Talk
  • What questions can we ask that could start him thinking about losing weight?
    • Tell me about your weight?
    • What do you think about your weight?
willing able ready
WILLING, ABLE, READY
  • In the next few slides, put yourself in this client’s shoes. Try to write down answers to the questions from his point of view.
find out how willing he is to change
Find Out How WILLING He is to Change
  • Ask open ended questions so he can:
    • State his reasons for not continuing to be overweight and for not being willing to make changes in diet or physical activity
    • State the reasons he has for losing weight
  • Have him write down his answers to the following questions
explore his reasons fully
Explore His Reasons Fully
  • Ask him how keeping an unhealthy weight could be good for any of these aspects of his life:
    • Health
    • Lifestyle
    • Emotions
    • Relationships
    • Coping abilities (stress, for example),
    • Work
    • Social life
    • Spiritual life
explore his reasons fully43
Explore His Reasons Fully
  • Ask him how losing weight could be good for any of these aspects of his life:
    • Health,
    • Lifestyle,
    • Emotions,
    • Relationships,
    • Coping abilities (stress, for example),
    • Work,
    • Social life, and
    • Spiritual life
next how important is it for him to change
Next, How Important is It for Him to Change?
  • Ask him to compare his reasons for not changing with his reasons for changing
  • Have him assign a number to the Ruler of Change in the next slide.
  • This will show how important it is for him to change
how important is it for you to change
How Important is It for You to Change?
  • On a scale of 0 to 10, how important is it to you to lose weight?

The “Ruler of Change”

willing
WILLING
  • This number on the Ruler of Change will show how WILLING he is to change
  • It will show how willing he is to start doing the things needed to lose weight (mainly eating smarter and moving more)
willing continued
Willing (continued)
  • If his Ruler of Change number is below 3 or 4:
    • He is not willing to consider change.
    • He has lots of resistance to change
    • His reasons for not losing weight are STONGER THAN his reasons for losing weight.
sample question to help decrease resistance
Sample Question to Help Decrease Resistance
  • What would have to change to decrease the importance you give to your reasons for not losing weight?
questions to decrease resistance
Questions to Decrease Resistance
  • A low number on the ruler of change says he does not think that losing weight is important and he does not want to change
  • But, look at his number on the Ruler of Change
  • If he’s not at zero, he must have at least a small interest in change.
decreasing resistance
Decreasing Resistance
  • If this is the case, Ask:
      • Why are you at ___ and not zero?
      • What would it take for you to go from__ to__ ?
    • His answers might get him to start thinking that change might be a good thing
willing continued52
Willing (continued)
  • If the number the client gives for the importance of changing is around 5:
    • He is “on the fence.”
    • He is split between wanting to take action and not being able to take the first step.
    • In this condition, he can’t change.
sample question to help increase motivation
Sample Question to Help Increase Motivation
  • What would have to change to increase the importance of your reasons for losing weight?
willing continued54
Willing (continued)
  • If the number he gives for the importance of change is greater than 6 or 7:
    • He is not resistant to change
    • He is not “on the fence”
    • He is READY to take some action
next find out if he is able
Next, Find out if He is ABLE
  • Measure his Confidence and Ability to lose weight
  • Use the Confidence and Ability “Rulers of Change” in the next slide
assessing confidence and ability to make a change
Assessing Confidence and Ability to Make a Change
  • Score your confidence to lose weight.
  • Score your ability to lose weight.
for scores of below 6
For Scores of Below 6
  • Ask, “What would it take to increase your confidence to lose weight?”
    • What encourages you to believe that you can achieve your goals for change?
  • Ask, “What would it take to increase your ability to lose weight?”
increasing confidence and ability about change
Increasing Confidence and Ability About Change
  • Other questions to ask”
    • What else could help you lose weight?
    • Who else could help you lose weight?

Adapted from Miller and Rollnick, Motivational Interviewing, 2002

for low confidence and ability scores
For Low Confidence and Ability Scores
  • Maybe the goal is not realistic, it exceeds his confidence and ability. Ask:
    • What would happen if you reduced the size of your goal?
    • What would you be willing to try?
    • Maybe if you reduced your goal for changing, you would be more likely to try.
role of the nurse aide
Role of the Nurse Aide
  • Find out what is important to the client and use this to motivate him/her to change
  • Help the client identify an activity that he/she has the ability and confidence to achieve
the next step being ready
The Next Step: Being READY
  • If he’s WILLING (Importance Score 5 and above)
  • If he’s ABLE (Confidence and Ability Scores are 5 and above)
  • Then he’s READY
being ready means
BeingREADY Means:
  • Being READY to set a goal and make a plan
  • Keeping track of progress toward the goal
  • Being prepared for setbacks with the right attitude and a Plan “B”
class exercise goal setting
Class Exercise – Goal Setting
  • Put yourself in the shoes of the client who has recently suffered a stroke and who is overweight
  • Using your current goal setting skills, write a goal for losing weight on the next slide
setting and planning a goal smart method
Setting and Planning a Goal – SMART Method
  • A useful method for setting goals, SMART.
  • To be effective, Goals need to be:
    • Specific
    • Measurable
    • Action oriented
    • Realistic
    • Time
smart method some examples
SMART method – Some Examples
  • A goal that is not SMART will probably fail.
    • “I am going to stop eating at fast food restaurants.”
set and plan a goal smart method some examples continued
Set and Plan a Goal – SMART method – Some Examples (continued)
  • A SMART goal would be,

“Instead of eating 4 times per week at a fast food restaurant, I’ll reduce it to 3 times. In 4 more weeks I will reduce to 2 weekly visits. At the same time when I go, I will select food that is low in fat and added sugar by learning to read the nutrition information provided at the store. After 4 more weeks, I’ll start walking at a leisurely pace 20 minutes per day around my neighborhood first thing in the morning and try to do this at least 5 times per week. After 4 weeks I’ll increase this to 30 minutes.”

set and plan a goal smart method
Set and Plan a Goal – SMART method
  • Now use the SMART method to rewrite the activity you chose that would support the client’s goal for losing weight
  • Write this SMART goal on the next slide from the viewpoint of the stroke survivor client in the case study
ready
READY
  • READY also includes tracking progress in a written log or on a calendar
    • Seeing concrete progress helps build confidence
    • Adding comments can also identify what helped, what was difficult, what you learned, how you can get better
progress check sample
Progress check (sample)
  • My goal was_____________
  • I was______ successful in reaching my goal
  • What helped______________
  • ______________was difficult
  • I learned that__________________

Adapted from HIP CHA training, 2005

ready72
READY
  • READY also includes being prepared for setbacks and relapses back to old habits
  • Plan for recovery from setbacks – have a “Plan B”
  • Remember,
    • Setbacks are chances for learning how to do things better,
    • Setbacks are not failures.
ready staying ready and motivated
READY - Staying Ready and Motivated
  • When you make your goal, Don’t Forget to Reward Yourself
  • A reward provides an incentive to stay motivated.
  • “After I do this, I’ll...”
final word
Final word
  • This person has a lot of areas he could work on.
  • Work with and communicate with the team so everyone is working on the same issue together, including the patient
what did you learn
What did you learn?
  • What are the different types of stroke and how does each occur?
  • What are healthy lifestyle choices for the person who’s had a stroke?
  •  How would you use motivational interviewing with the person who’s had a stroke?
slide76
How will what you’ve learned change the way you do your job?How will what you’ve learned change your life?
references77
References
  • HIP CHA training, 2005
  • Miller, W.R. and Rollnick, S. Motivational Interviewing. New York: Guilford Press,2002
  • Botelho, R. 2002. Motivate Healthy Habits.
homework assignment
Homework Assignment
  • Think of another of your own personal health improvement goals and fill out Handouts #1 to #5 and turn in next session:
    • Handout #1: Reasons for staying the same and changing
    • Handout #2: How important is change to me?
      • Answer the question: How could I increase the strength of my reasons for changing and decrease those for staying the same?
    • Handout #3: How confident and able am I?
    • Handout #4: Answer the question: What could increase my confidence and ability?
    • Handout #5: My health improvement goal using the SMART method
handout 2 measuring importance of change
Handout #2 – Measuring Importance of Change
  • On a scale of 0 to 10, how important is it for you to make a change in this health behavior?
  • Write down how you think you could increase the importance of reasons for changing and decrease the importance of those reasons for not changing
handout 3 confidence and ability to make a behavior change
Handout #3 Confidence and Ability to Make a Behavior Change
  • Score your confidence to make the behavior change.
  • Score your ability to make the behavior change.
slide84

This training aid was produced with the generous support of

The Fullerton Foundation, Inc.

For information on continuing programs that support CNA learning contact:

Duncan Howe, University of South Carolina,

School of Medicine

Duncan.Howe@uscmed.sc.edu or

Claudia J. Graham, Duke University Medical Center, Department of Community and Family Medicine, Division of Community Health Claudia.Graham@duke.edu