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Home Care Chronic Disease Prevention Program


Quick diagnosis is the best way to reduce the risk of a full blown stroke. ... What are your fears, concerns about taking the actions needed to lose weight? ... – PowerPoint PPT presentation

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Title: Home Care Chronic Disease Prevention Program

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?
  • Heres what might have happened.
  • How does this impact the next time you try this?

Chronic Disease Management
  • Module 1Health/Illness, Vital Signs, Exercise,
  • 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

  •  Identify different types of stroke and how each
  • Describe healthy lifestyle choices for the person
    whos had a stroke
  • Demonstrate use of motivational interviewing with
    the person whos had a 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?
  • 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
  • Ischemic
  • Embolic
  • Hemorrhagic
  • TIA (transient ischemic attack)

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

Embolic stroke
  • Clot travels from elsewhere in the body to the
  • 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

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
  • 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)
  • 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 arent improved.
  • TIAs should be treated as an emergency. Quick
    diagnosis is the best way to reduce the risk of a
    full blown stroke.

What are risk factors for stroke?
Risk factors for stroke (1)
  • High blood pressure
  • Tobacco smoke
  • High cholesterol
  • Diabetes
  • Other blood vessels that are clogged

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)
  • Obesity and inactivity
  • Family history
  • Race
  • Gender
  • Age
  • Prior stroke

Warning symptoms
  • Difficulty seeing
  • Difficulty speaking
  • Difficulty with motor skills
  • Severe headache
  • Dizziness
  • Numbness

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
  • Not taking medications

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
  • 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
  • Call 911 immediately if there is concern for a
    stroke as every second counts

  • History
  • Thorough physical exam
  • CT or MRI of the brain
  • Other studies to look at blood vessels and the

Hospital treatment
  • Medications to break up clots
  • Aspirin
  • Other blood thinners

Outpatient treatment
  • Eat well and exercise
  • Healthy weight
  • Control blood pressure, cholesterol, diabetes
  • Do not smoke
  • Aspirin may be recommended

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
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Support groups for patient and family
  • Home assistance (aide)

  • 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?i

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 study
  • What should you do?
  • What is possibly going on?

Case study
  • What should you do?
  • Call 911
  • What is possibly going on?
  • Stroke

Case study
  • What are his risk factors for a stroke?

Case study
  • What are his risk factors for a stroke?
  • Smoker
  • High blood pressure
  • Age
  • Overweight

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
  • How do you as the Nurse Aide motivate him to take
    steps needed to lose weight?
  • Now that youve gained his trust you can start
    asking questions that will begin 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?

  • In the next few slides, put yourself in this
    clients shoes. Try to write down answers to the
    questions from his point of view.

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

What are His Reasons for Not Losing Weight? 2
Good Questions to Ask
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

Here are Some Sample Reasons for Continuing to
Stay at an Unhealthy Weight
Next, What Reasons Does He Have for Losing Weight?
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

Here are Some Sample Reasons for Losing Weight
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

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

  • 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)
  • 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
  • What would have to change to decrease the
    importance you give to your reasons for not
    losing weight?

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 hes not at zero, he must have at least a
    small interest in change.

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 (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 cant change.

Sample Question to Help Increase Motivation
  • What would have to change to increase the
    importance of your reasons for losing weight?

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
  • 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
  • Score your confidence to lose weight.
  • Score your ability to lose weight.

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
  • 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
  • Maybe the goal is not realistic, it exceeds his
    confidence and ability. Ask
  • What would happen if you reduced the size of your
  • 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
  • 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
  • If hes WILLING (Importance Score 5 and above)
  • If hes ABLE (Confidence and Ability Scores are 5
    and above)
  • Then hes READY

Being READY 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
  • 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

Using Your Own Words Write Down a Goal and Plan
(an Activity) for Losing Weight
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
  • A goal that is not SMART will probably fail.
  • I am going to stop eating at fast food

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, Ill 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, Ill 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 Ill increase this to 30 minutes.

Set and Plan a Goal SMART method
  • Now use the SMART method to rewrite the activity
    you chose that would support the clients goal
    for losing weight
  • Write this SMART goal on the next slide from the
    viewpoint of the stroke survivor client in the
    case study

What is Your Smart Goal?
  • S
  • M
  • A
  • R
  • T

  • 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)
  • My goal was_____________
  • I was______ successful in reaching my goal
  • What helped______________
  • ______________was difficult
  • I learned that__________________
  • Adapted from HIP CHA training, 2005

  • 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
  • When you make your goal, Dont Forget to Reward
  • A reward provides an incentive to stay motivated.
  • After I do this, Ill...

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 are the different types of stroke and how
    does each occur?
  • What are healthy lifestyle choices for the person
    whos had a stroke?
  •  How would you use motivational interviewing with
    the person whos had a stroke?

How will what youve learned change the way you
do your job? How will what youve learned
change your life?
  • 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
  • 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
  • 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 1
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
  • Score your confidence to make the behavior
  • Score your ability to make the behavior change.

Write Down How You Think you Could Increase Your
Confidence and Ability
  • Handout 4

Handout 5 Re-Write Your Goal Using SMART
  • S
  • M
  • A
  • R
  • T

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_at_uscmed.sc.edu or
Claudia J. Graham, Duke University Medical
Center, Department of Community and Family
Medicine, Division of Community Health
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