A Patient GuideStroke

What is a stroke .......................................................................1Types of stroke...............................................................................1What is a transient ischemic attack (TIA)?.................................2

Warning Signs of Stroke or TIA...............................................2

Why is Stroke an Emergency? Call 911 ....................................3

Stroke Testing and Monitoring..................................................3

Acute Stroke Treatment ...........................................................6

Stroke Medications ...................................................................6

Stroke Recovery and Rehabilitation ..........................................8Cognition (thinking) and Communication .................................9Coping with Emotions ................................................................10Social Support .............................................................................11Eating and Swallowing................................................................11Going Home................................................................................18Going Places................................................................................19

Recurrent Stroke and Stroke Prevention.................................20Personal Modifiable Risk Factor Reduction ...............................20Follow up after discharge ............................................................25

Resources ...............................................................................22

Stroke Guidebook

Dear Patient:This guidebook was written to give you and your family some information about stroke andhelp you to prepare for recovery. Please keep in mind that each person has different causes andkinds of stroke as well as needs and pathways to recovery. The guidebook will help you learn orbetter understand what a stroke is, what the warning signs are, what to do when one occurs,tests and treatment options, risk factor reduction, rehabilitation and, and resources for support.Please let us know if you have any questions or concerns.

Sincerely,Baptist Health

What is a stroke?A stroke, or a brain attack, is a type of blood vessel disease which affects the blood vesselsleading to and inside the brain. A stroke occurs when a blood vessel which carries oxygen andnutrients to the brain, is blocked or bursts. This may result in brain cell death affecting bodyfunctions and is a medical emergency. Stroke is the third leading cause of death and a leadingcause of disability in the United States.

Types of stroke• Ischemic strokes are caused by blockage of an artery that supplies blood to

the brain.• Hemorrhagic (bleeding) strokes are caused by ruptured blood vessels.

What is an ischemic stroke?Ischemic stroke accounts for about eighty-three percent of all cases. Ischemic strokes happen asa result of a blockage within a blood vessel supplying blood to the brain. The reason for thistype of blockage is the development of fatty deposits lining the vessel walls. This condition iscalled atherosclerosis which can contribute to a heart attack or stroke. These fatty deposits cancause two types of blood flow blockages to the brain.

There are generally two causes of ischemic strokes.• Cerebral thrombosis refers to a thrombus (blood clot) that develops and clogs

the vessel.• Cerebral embolism is a blood clot that forms in the bloodstream usually in the heart and

large arteries of the upper chest and neck. A part of the blood clot breaks loose, entersthe bloodstream and travels through the brains blood vessels until it reaches vessels toosmall to let it pass. A second important cause of embolism is an irregular heartbeat,known as atrial fibrillation. It creates conditions where clots can form in the heart andtravel to the brain.

1

Stroke Guidebook

Stroke Guidebook

What is a hemorrhagic (bleeding) stroke? Seventeen percent of all strokes are hemorrhagic. This happens when a blood vessel bursts andstops the oxygen supply to the surrounding areas of the brain.

Hemorrhagic strokes are different from ischemic strokes in several ways.• The death rate is higher and the overall prognosis is worse.• Usually affects younger people.• Symptoms often include a sudden severe headache, nausea, and vomiting.• May not see a TIA (mini-stroke) or other stroke warning sign first.

There are two kinds of bleeding strokes.• Subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain bursts

and bleeds into the space between the brain and the skull. The most common cause is abusted aneurysm (blood filled pouch that balloons out from an artery wall) most oftencaused by high blood pressure.

• Intracerebral hemorrhage occurs when a blood vessel bleeds into the tissue deep withinthe brain and is most often caused by high blood pressure or aging, causing about 10-20percent of all strokes.

Treatment for bleeding strokes.Because hemorrhages can be life threatening, hospital care is required in an intensive care unit.Medication can control further bleeding, control high blood pressure, or decrease brain swelling.Surgery may be needed depending on the cause of the bleeding.

What is a TIA?A transient ischemic attack (TIA), sometimes called a mini-stroke, is caused by blockage ofblood flow in the brain that occurs briefly and goes away on its own. A TIA can happen days,weeks or months before a major stroke and can be a sign that a major stroke may occur. Thesymptoms of a TIA are the same as the warning signs of a stroke, but usually last less than onehour but may last up to 24 hours. Once you have had a stroke your risk of another is higher. Itis very important to recognize the warning signs of stroke.The first step to treat a stroke is torecognize the symptoms as soon as they happen.

Warning Signs of Stroke or TIA • 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 cause2

Stroke Guidebook

Why is stroke an Emergency?Call 911Every minute counts. The longer blood flow is cut off to the brain, the greater the damage.Treatments are available to greatly reduce the damage caused by a stroke. The most commonkind of stroke, ischemic stroke, can be treated with a drug that dissolves clots blocking theblood flow.

What should you do?To receive the drug that dissolves clots you need to arrive at the hospital as soon as symptoms start.

• Know stroke symptoms• Call 911 right away• Get to a hospital that is expert in caring for stroke patients.

Do not wait for the symptoms to go away and do not ignore them. If you have any of thesewarning signs or symptoms call 911 and get help right away.

If possible, know the time the symptoms started. Because stroke injures the brain, you may notrealize that you are having a stroke. The people around you might not know it either. Yourfamily, friends, or neighbors may think you are confused. You may not be able to call 911. That is why everyone should know the signs of stroke and know how to act fast.

Stroke Testing and MonitoringFinding a stroke while it is happening is importantbecause the treatment depends on the type, cause, andlocation. Your doctors and nurses will ask questions aboutyour medical history and symptoms. Tests will beperformed to correctly diagnose a stroke. If you have hada stroke or stroke warning signs, your doctor will needadditional information to fully understand your specificproblem and plan the best treatment. In addition to bloodtests, you will need testing to examine your brain, heartand blood vessels. Here are the tests most often used instroke diagnosis and treatment planning.

Blood Tests and Procedures Used forStroke DiagnosisStroke cannot be determined by a blood test alone. However, these tests can provideinformation about stroke risk factors and other medical problems that may be important.

3

Stroke Guidebook

Blood TestsCBC (complete blood count)This is a routine test and shows the number of red blood cells, white blood cells, and plateletsin your blood. Hematocrit and hemoglobin show of the number of red blood cells. A completeblood count might be used to tell if you are anemic (too little blood) or have an infection(shown by too many white blood cells).

Coagulation (clotting) testsPT (Prothrombin time)PTT (Partial thromboplastin time)INR (International normalized ratio)These tests measure how quickly your blood clots. Anabnormality could result in excessive bleeding or excessiveclotting. If you are taking blood-thinning medicine such aswarfarin (Coumadin or similar drugs), the INR blood test isused to be sure that you receive the correct dose. It is veryimportant that you obtain regular checks. If you are takingheparin, the PTT test is used to determine the correct dose.

Blood chemistry testsThese tests measure the levels of normal chemicalsubstances in your blood. An important test in emergencystroke evaluation is to measure glucose (blood sugar) levels.Blood sugar levels which are too high or too low can cause

symptoms which may be mistaken for stroke. Fasting blood glucose is used to help in thediagnosis of diabetes, which is a risk factor for stroke. Controlling blood sugar after a stroke canimprove stroke recovery. Other blood chemistry tests measure serum electrolytes, the normalchemicals in your blood (sodium, potassium, calcium) or check the function of your liver orkidneys.

Blood lipid (fat) testsThese tests measure cholesterol, triglycerides, HDL (high density lipoprotein), and LDL (lowdensity lipoprotein). Cholesterol is a natural substance found in all living tissue, but when toomuch of it builds up in the arteries, either because of heredity or dietary factors, it can bedangerous. Cholesterol is a wax-like substance that is found in the body. It is a lipid, or a typeof fat. Cholesterol is made in your body by your liver. You also get cholesterol by eating foodsthat come from animals. Examples of foods that come from animals include meats, eggs, andwhole-fat dairy (milk) products.

Your health care provider may take a blood sample from you to see if you have too muchcholesterol in your blood. You may need to fast for 9-12 hours before your blood is drawn.

4

Fasting (going without eating) helps to make sure that the test shows your actual cholesterol orblood sugar level. When fasting, you may drink water. Food and other drinks (such as coffee ortea) consumed during this time may affect your cholesterol or blood sugar reading.

Acceptable blood cholesterol levels are specific to each individual and for that reason yourhealth care provider should have those numbers and work with you on a therapeutic plan.

In general, Normal Total Cholesterol is below 200.Normal LDL is below 100.Normal HDL is above 40 for men and 50 for women.

What are triglycerides?Triglycerides are another class of fat found in the blood stream. Elevated triglyceride levels maybe caused by medical conditions such as diabetes, hypothyroidism, kidney disease, or liverdisease. Dietary causes of elevated triglyceride levels may include obesity and high intakes offat, alcohol, and concentrated sweets. A healthy triglyceride level is generally less than150mg/dL.

Tests that check the brain, heart, and arteriesCAT Scan (Computed axial tomography, CT) is an important diagnostic test of the brain. Ituses x-rays to produce a 3-dimensional image of your head and is usually one of the first testsgiven to a patient with stroke symptoms.

MRI (Magnetic resonance imaging, MR) like a CT scan, it shows the location and extent ofbrain injury. The image is sharper and more detailed than a CT scan. It uses magnetic fields toalso produce a 3-dimensional image.

Tests that view the blood vesselsCarotid Doppler is a test that uses ultrasound waves and can show if the artery in your neckthat supplies blood to the brain is narrowed by atherosclerosis (cholesterol deposits).

MRA (Magnetic resonance angiogram/arteriogram) is a special type of MRI scans. In this test,special substances are injected into the blood vessels and an x-ray is taken to show the bloodflow through the blood vessels leading to and into the brain.

This allows the size and location of blockages to be evaluated. This test is especially valuable in diagnosing aneurysms and malformed blood vessels and providing information before surgery.

Stroke Guidebook

5

Tests that check the heartElectrocardiogram (EKG) is a standard test of the electrical activity of the heart. Electricalsensors are attached to your chests, arms, and legs. Some strokes are caused by an irregularheartbeat.

Echocardiogram (2-D echo, TTE, TEE) ultrasound waves are used to take a picture of yourheart and the circulating blood. The ultrasound probe may be placed on your chest (trans-thoracic echocardiogram, TTE) or through a tube put down your throat (trans-esophagealechocardiogram, TEE). A TEE is more accurate and can be used when problems with the chestmake TTE hard to do. Before a TEE you will be given medicine through your veins to relaxand allow for the procedure.

Acute Stroke Treatment Treatment depends on the type and cause of stroke.Surgery, medications, acute hospital care andrehabilitation are all accepted stroke treatments.

When a neck artery is partially blocked by a fattybuildup, surgery might be used to remove the plaque.This surgery is called a carotid endarterectomy.

Cerebral angioplasty is a new, experimental technique.Balloons, stents and coils are used to improve blood flowand treat some types of problems with the brain’s bloodvessels. The widespread use will require more study of itssafety and effectiveness.

Sometimes treating a stroke means treating the heart.The reason is that various kinds of heart disease can contribute to the risk of stroke. Forexample, damaged heart valves may need to be treated surgically or with anti-clotting drugs toreduce the chance of clots forming around them. Blood clots also can form in the hearts ofpeople with atrial fibrillation. Atrial fibrillation (A-fib) is a type of abnormal heart rhythm. Ifclots form, there is a chance they could travel to the brain and cause a stroke.

Stroke MedicationsStrokes caused by a blood clot are often treated with medications that work to prevent theblood’s ability to clot. These include:

• Blood clot-busting medications• Anticoagulants • Antiplatelet medications

6

Stroke Guidebook

7

Stroke Guidebook

In 1996, the Food and Drug Administration approved the clot-busting drug tissue plasminogen activator (t-PA) to treat stroke. This has had a positive impact on the treatment of ischemic strokes.

Not every stroke patient should be treated with t-PA, particularly those having a bleedingstroke. Use of t-PA can cause bleeding. Tissue plasminogin activator is effective only if givenvery soon after a stroke begins. For maximum benefit, it must be started within three hours of the onset of stroke symptoms. That is why it is so important to see stroke as a medicalemergency and respond immediately.

If you do not receive t-PA, you may receive other medicines that improve blood flow. Bothanticoagulants and antiplatelets are medicines that decrease blood clotting.

What should I know if I am taking anticoagulants?Anticoagulants are medicines given to prevent your blood from clotting or preventing clotsthat already exist from getting larger. They can keep harmful clots from forming in your heart,veins or arteries. Clots can block blood flow and cause a heart attack or stroke. Commonnames for anticoagulants are warfarin (Coumadin) and heparin.

• You must tell all of your doctors and dentists that you are taking the anticoagulantmedication.

• You must take the medication exactly the way your doctor tells you. • Have blood tests taken regularly so your doctor can see how the medication is working.• Know the level of your target Prothrombin time and International Normalizing Ratio

or PT/INR.• Tell your family you are take anticoagulant medicine and wear emergency medical

identification (i.e. bracelet).• Always check with your doctor before taking other medications or supplements such as

aspirin, vitamins, cold medicine, sleeping pills or antibiotics. These can alter theeffectiveness and safety of anticoagulants by strengthening or weakening them.

• Avoid big changes in how much vitamin K you eat. Vitamin K can inactivate someblood thinners. Limit foods high in vitamin K content, broccoli, brussel sprouts,cabbage, kale, parsley, spinach, and turnip/collard/mustard greens, to ? cup cooked or 1 cup raw vegetables daily. Discuss your diet with your doctor, dietitian, or pharmacist.

• You may bleed more easily while you are using this medication so avoid activities thatcan increase the chance of traumatic injury. Let your doctor know if you have had an injury.

• Watch for signs of internal bleeding (i.e. excessive bruising, blood in stools).

Stroke Guidebook

What should I know about antiplatelet medications?Antiplatelet medications keep blood clots from forming. They keep blood platelets fromsticking together. They are used to treat atherosclerosis or if someone has an increased risk ofblood clots. Atherosclerosis occurs when cholesterol builds up on inner walls of blood vesselsand increases the chance that blood clots will form. Antiplatelet medicine helps preventstrokes. Common names for antiplatelets include aspirin, clopidogrel (Plavix), anddipyridamole (Aggrenox).

• Antiplatelets should not be taken with anticoagulants unless your doctor tells you to do so.• You might receive directions not to take antiplatelets or anticoagulants when you are

going to have surgery.

Stroke Recovery and RehabilitationStroke is the leading cause of adult disability in the United States. There are more than 5 million stroke survivors in the United States.Rehabilitation is an important part of recovering from stroke. Throughrehabilitation, you can relearn or regain basic skills such as speaking,eating, dressing, and walking.

When the immediate crisis of a stroke has passed and you are medicallystable, it is time to consider rehabilitation therapy. Therapy begins in thehospital and often continues after being discharged from the hospital.The goal of rehabilitation is to restore as much independence as possibleby improving physical, mental, and cognitive (thinking) abilities. Not allof the negative effects of a stroke are permanent.

Appropriate and adequate rehabilitation can help you work toward thegoal of restoring your daily activities. Your rehabilitation may includeOccupational, Physical and Speech-Language Therapy.

Occupational Therapy focuses on helping stroke survivors rebuild skillsthat are needed for daily living activities such as bathing, dressing, andcooking. The Occupational Therapist also works on improving skills inmemory, judgment, and problem solving, which are necessary to performdaily living activities.

Physical Therapy works to improve stroke survivor’s movement, strength, and problems withsensation (feeling). The Physical Therapist focuses on restoring skills needed to get aroundmore independently, to improve transfers, balance, coordination, and walking.

Speech-Language Therapy focuses on improving the function and safety of swallowing, whichis often affected by a stroke. The speech-language pathologist helps improve communication

8

skills, such as listening and understanding, talking, saying words clearly, reading and writing.Therapy may also work toward improving problem solving, memory, and reasoning skills.

Because the effects of stroke vary, it is important to have an individualized therapy program to best meet your needs. You should consult a therapist who can help in selecting specificexercises that will benefit you and provide instruction for both you and your caregiver. As with any exercise program, consult your doctor and/or therapist first.

For additional information on inpatient or outpatient Stroke Rehabilitation, please call BaptistHealth Rehabilitation Services at the following locations:Baptist Medical Center Downtown: 904-202-9750Baptist Medical Center South: 904-821-6575Baptist Medical Center Beaches: 904-627-2980Baptist Medical Center Nassau: 904-277-9677

Cognition (thinking) andCommunicationStroke can cause physical problems. It can also affectcognition, or thinking abilities. Cognition is what helpspeople use their brains to talk, read, write, learn,understand, reason, and remember. Difficulty withcognition may affect how you manage your everydaytasks, your ability to participate in rehabilitation, andeven to live on your own following a stroke.

Memory Loss and CommunicatingEvery stroke is unique. The effect that stroke has on your thinking abilities depends on whereand how the stroke injured the brain and your overall health.

1. Memory lossAfter stroke memory loss is common, but not the same for everyone. For example, dependingon where the stroke occurred in the brain you may have short-term memory loss.

What may help?• Try to form a daily routine—doing certain tasks at regular times during the day.• Try not to tackle too many things at once. Break tasks down into small steps.• If a task needs to be done, make a note of it or do it right away.• Make a habit of always putting things away in the same place where they can easily be

seen or found.

Stroke Guidebook

9

2. AphasiaAfter a stroke, one of the most common problems people experience is trouble withcommunication. Stroke survivors may experience a type of communication disorder calledaphasia, which means “without language.” About one million people in the United States haveaphasia. Most cases are due to the results of a stroke. There are several types of aphasia,depending on what part of the brain has been damaged.

People with aphasia have a partial or total loss of their ability to talk, to understand what peoplesay, and to read and write. One or a combination of these skills may be affected. For example, youmay have trouble remembering the names of objects or putting words together to make sentences.

You may recover from aphasia without treatment. But most people benefit from therapy by a speech-language therapist. The goal is to improve your ability to communicate. This is done by helping youget back some of your language skills and learning new ways to get your message across.

Communication tips• Try using your hands to gesture, or nod your head, if you are unable to say words.• Draw or write things on paper.• Create a communication book that includes words, pictures and symbols that are

meaningful to you.• Take your time. Try talking to people when you have plenty of time.• Show people what works best for you.

Coping with EmotionsDealing with a flood of emotions can be hard for stroke survivors. It is common to be tired,frustrated, depressed, and unmotivated. Some emotions are normal responses to the changes inyour life after a stroke. If you suffer from depression, anxiety or emotions that are not in line

with the situation, seek help. You may be treated with medication,counseling, therapy, or all three. Joining a local stroke support groupmay also help.

Dealing with DepressionGrieving for what you lost is normal. If sadness becomes depression,talk to your doctor. Depression can surface right after a stroke, duringrehabilitation, or after you go home. It can be, but not always, causedby brain damage from the stroke. Mild or major depression is themost common emotional problem faced by survivors. Symptoms of depression include:• Feeling sad most of the time.• Feeling worthless or helpless.• Crying all the time.

Stroke Guidebook

10

Stroke Guidebook

• Loss of interest or pleasure in ordinary activities.• A change in how easily you are annoyed.• Sudden trouble sleeping or oversleeping.• Sudden loss or increase of appetite.• Being unable to concentrate, remember or make decisions like you used to.• Ongoing thoughts of death or suicide.

Social SupportSocializing with family and friends is an important part ofstroke recovery. As a stroke survivor, you may have troubledoing the things that allow you to connect with other peoplesuch as talking on the phone, writing letters, shopping, oreating out. This can make you feel disconnected and alone ata time when you need more social support that ever before.

Getting the Support You NeedStroke survivors and stroke caregivers need support. There aremany ways to get the support you need.

A support group allows you to interact with other stroke survivors and caregivers who knowwhat you are going through. People in a support group can:

• Help you find ways to solve problems related to stroke.• Share information about products that may help recovery.• Encourage you to try new things.• Listen to your concerns and frustrations.• Give you a chance to get out of the house.

Healthy Eating and SwallowingYou should eat nutritious food to get better. Many stroke survivors are malnourished. This meansthey are not getting enough vitamins and minerals because they are not eating enough healthyfoods. You need to eat healthy so you can have energy for exercise, therapy, and your favoriteactivities. Healthy eating will be easier once you learn to deal with new challenges you mighthave from a stroke.

Choosing Healthy FoodsHealthy eating is good for you. It will help you manage your weight and blood pressure as wellas diabetes and high cholesterol. These things are all crucial to prevent another stroke and stayhealthy. Most foods in the grocery store must now have a nutrition label and an ingredient list.If you are still unsure, ask your doctor to arrange a visit with a licensed dietitian. The dietitianwill teach you how to plan meals and snacks to improve your health.

11

Stroke Guidebook

Heart-Healthy EatingA diet high in saturated fat and cholesterol has been linked to chronic diseases such as heartdisease and stroke. The goal of a heart healthy eating is to decrease your risk of heart diseaseand stroke. Research shows that the amount and type of fat you eat can affect your overallhealth. A heart healthy diet low in sodium, saturated and trans fats, and cholesterol can helpreduce the risk and/or complications of heart disease and stroke. Eating fiber (ie. whole wheatbread, fresh vegetables) may help you decrease your cholesterol. Decreasing your fat intake willdecrease your calorie intake. Decreasing the amount of sodium (salt) that you eat and drinkmay help to control your blood pressure. You may also lose weight on this diet becausedecreasing your fat intake will decrease your calorie intake. Decreasing calories in your diet canhelp you to lose weight.

Nutrition Guidelines for Your Health• Plan to eat a variety of foods of a variety of colors each day.• Eat at least five servings of fruits and vegetables per day.• Reduce Sodium. Try cooking from scratch instead of using pre-prepared

foods from a box or bag. Do not use salt during cooking and at the table. • Read food labels for the amount of sodium. Keep the sodium content of a

complete meal to between 500-600mg. Keep single food items less than 240mg.• Limit Saturated Fat. Saturated fats can increase cholesterol levels, especially

low-density lipoprotein or LDL (bad cholesterol). Saturated fats are found inmeat, milk products, and in some vegetable fats such as coconut, palm, andpalm kernel oils. To lower your saturated fat intake, choose low fat meatswithout the skin and limit your daily intake to 6 ounces (3 ounces = the sizeof a deck of cards); choose low-fat or fat-free milk products.

• Avoid Trans Fat. Trans fat raises LDL levels (bad cholesterol) and lowers high-densitylipoprotein or HDL levels (good cholesterol). Trans fat can be found in vegetableshortening, some margarine, crackers, cookies, chips, cakes, doughnuts and other foodsmade with or fried in partially. hydrogenated oils. A small amount of trans fat is alsofound naturally in milk products, some meat and other foods made with animal fats.

• Reduce Cholesterol. Cholesterol can be found in animal products such as meat, egg yolks,and milk products.

• Increase Fiber and Antioxidants. Try for a minimum of 25 grams of fiber each day. Eat adiet high fiber with foods such as vegetables, fruits and whole grains such as oats, wholewheat, brown rice, whole bran and barley.

• Maintain a Healthy Weight. Lose weight if you are overweight or maintain a healthyweight. Talk with your doctor or registered dietician to determine a healthy weight foryou. Be more physically active every day to help control weight. Pay attention toserving size and eat only enough for your height and body type. Avoid foods andbeverages with added sugars, which can easily add too many calories with littlenutritional benefit.

12

Stroke Guidebook

13

Heart-Healthy Food Choices

Food Group: Lean Meat, Poultry, Seafood, Eggs & Other Protein Foods (5-6 oz. per day / 3 oz. = deck of cards)

Choose Most Often Avoid or Choose Less Often

Beef: USDA Select or Choice grades of leanbeef (trim visible fat) such as eye & top round,sirloin, flank, tenderloin, round tip, top loin,bottom round, rib, chuck & rump roast, T-bone,porterhouse, cube steak, ground round, lean &extra lean ground beef (> 90% lean); lean vealchop, roast or leg; low-sodium roast beef deli meat

Beef: Prime grades of beef, prime rib, heavilymarbled & meats with lots of visible fat, regularground beef; ground or processed veal cutlets

Poultry: Skinless chicken & turkey, Cornishhen, duck or goose (drained of fat); low-sodiumchicken or turkey deli meat

Poultry: Fried chicken, chicken & turkey withskin

Fish: Include 2 or more servings per week offresh, frozen or canned fish & shellfish (watchsodium content of canned items)

Fish: Fried fish or shellfish, commerciallybreaded or processed fish

Pork: Lean & choice cuts such as fresh ham,tenderloin, center loin chop, Canadian bacon

Pork: Spare ribs, ground pork, pork sausage,bacon

Lamb: Lean & choice cuts such as chop, leg &roast

Lamb: Rib roast, ground lamb, organ meats

Game: Duck, goose or pheasant (without skin& drained of fat), venison, buffalo, ostrich,rabbit, emu

Game: Duck, goose or pheasant with skin

Processed Meats: Choose processed & delimeats with <3g fat per oz.

Processed Meats: Bologna, pimento loaf,salami, sausage, bratwurst, knockwurst, hotdogs, bacon

Eggs: Limit egg yolks to 2-4 per week, eggwhites (2 whites can be used in place of 1whole egg in most recipes), cholesterol-free eggsubstitutes

Eggs: More than 2-4 whole eggs per week(include those used in baking)

Stroke Guidebook

Food Group: Low-Fat Dairy Products (2-3 servings per day)

Food Group: Breads, Cereals, Rice & Pasta (6-11 servings per day / 1 serving = 1 oz.)

Choose Most Often Avoid or Choose Less Often

Milk: Fat-free/skim or 1% milk (liquid,powdered & evaporated), fat-free or low-fatbuttermilk, soy milk

Milk: Whole or 2% milk (liquid, powdered &evaporated

Yogurt: Fat-free or low-fat yogurt, yogurtdrinks, soy yogurt

Yogurt: Whole-milk yogurt or yogurt drinks

Cheese: Low-fat natural or processed cheesessuch as mozzarella, parmesan, cottage cheese,ricotta

Cheese: Regular cheeses high in saturated fat,whole-milk cottage cheese

Ice Cream: Low-fat or fat-free ice cream &frozen yogurt

Ice Cream: Regular ice cream

Sour Cream: Low-fat or fat-free sour cream Sour Cream: Regular sour cream

Coffee Creamer: Low-fat coffee creamer Coffee Creamer: Cream, half & half, whippingcream, nondairy creamer, whipped topping

Choose Most Often Avoid or Choose Less Often

Breads: Whole-grain bread, buns, bagels &pita; English muffins, corn or flour tortillas,homemade corn muffins & other homemadebaked goods using unsaturated oils, low-fatmilk & egg substitute

Breads: Croissants, biscuits, pastries, processedwhite bread, high-fat bakery bagels,commercially prepared muffins & other bakeryitems

Rice: Brown rice & whole grains such asbarley, quinoa, millet, oats

Rice: Instant rice & rice mixes high in sodium

Cereals: Whole-grain wheat, rice, bran, oatscereals, low-fat granola

Cereals: Processed cereals not made fromwhole grain, most granolas

14

Stroke Guidebook

Food Group: Vegetables (3-5 servings per day)

Food Group: Fruit (2-4 servings per day)

Food Group: Fats & Oils (6-8 tsp. per day)

Choose Most Often Avoid or Choose Less Often

Fresh, frozen or canned without added fat orsodium

Canned with sodium/salt, fried or preparedwith butter, cheese or cream

Choose Most Often Avoid or Choose Less Often

Fresh, frozen, dried or canned in own juice;100% fruit juice

Fruit in heavy syrup or served with butter orcream

Choose Most Often Avoid or Choose Less Often

Monounsaturated Fats: Canola, olive &peanut oils; avocado, almonds, cashews,pecans, peanut butter & other nut butters;olives, sesame seeds, Tahini paste

Butter, lard, shortening, bacon grease, stickmargarine, ghee; coconut, palm & palm kerneloils; macadamia & Brazil nuts, pistachios, pinenuts; salad dressings made with egg yolk,cheese, sour cream or whole milk; coconut;chocolate

Polyunsaturated Fats: margarines (tub orspray) made from heart-healthy oils; corn,sunflower, safflower, sesame & soybean oils;salad dressings made from heart-healthy oils;walnuts, sunflower & pumpkin seeds

15

Stroke Guidebook

Too Tired to Eat or Cook?Meal planning, grocery shopping and cooking require a lot of energy. But, being tired does notmean you should give up on healthy eating. Planning ahead can help you get the nutrition youneed for your stroke recovery.

• Eat your biggest meal early in the day when you have the most energy. The last meal ofthe day can be simple, such as a sandwich or cereal.

• Look for pre-washed, pre-cut fruits and vegetables at the grocery store. Most places offerapple slices, baby carrots, broccoli florets, celery sticks, mixed vegetables, salad greens,and spinach.

• If preparing and eating three meals a day takes too long or takes too much energy, eatsix small meals per day instead.

• Many communities offer a “Meals on Wheels” program. Check with your local socialservices to see how you can get healthy meals delivered to your home through this program.

• Seniors can often get healthy, low-cost meals at senior center. Check your localnewspaper for locations, times and menus.

Have you Lost Your Appetite?Many survivors do not feel as hungry as they used to and forget to eat during the day.

• Try eating smaller healthy meals throughout the day.• Be sure to plan three meals a day plus snacks to maintain your health and energy—even

when you are not so hungry.• Eat high-calorie foods in your meal first.• Sometimes, poor appetite is caused by depression. Your appetite is likely to improve

after depression is treated.• Walk or do some light exercise to stimulate your appetite.

Challenges When EatingIt is hard to eat healthy when you have trouble swallowing, chewing, or using eating utensils.

Swallowing and Chewing ProblemsA stroke can weaken or paralyze muscles that help you swallow or chew. About 40-60% ofstroke survivors have dysphagia (swallowing difficulties). Dysphagia can lead to serious medicalproblems such as dehydration (not enough water), malnutrition (not enough vitamins andminerals), choking or coughing, aspiration (when food or liquid goes into the lungs) andpneumonia. The speech-language therapist can test for dysphagia and make suggestions toimprove swallowing and eating.

Talk to your doctor if you have any of these signs of dysphagia:• Coughing, choking, or sputtering when eating or drinking.• An unusually hoarse voice or the need to clear your throat often.• Food, liquids, or saliva escape from your mouth or nose when you try to eat or drink.

16

Stroke Guidebook

What can help?If the speech-language pathologist says you are safe to eat by mouth:

• Cut foods into smaller pieces before chewing.• Use a blender or food processor to puree foods to the texture of baby food.• Choose soft foods such as cooked cereal, mashed potatoes, eggs, cottage cheese,

applesauce, canned fruits and soups.• Thicken liquids so you can control them better in order to keep from going down the

wrong way. Natural thickeners include cornstarch, tapioca, flour, instant potato flakes,oats, and matzo meal.

• Keep your mouth moist with ice chips and small sips of water.• Place foods and liquids on the stronger side of the mouth (the opposite of the drooping side).• If you wear dentures, see your dentist to check how they fit. Loose dentures can interfere

with chewing and swallowing. Dentures that do not fit well can also cause pain, whichcan decrease your appetite. Medicines, mouth dryness and other medical changes canaffect denture fit. Have your dentist check them at least once a year.

Eating UtensilsAfter your stroke, you may have trouble grasping or holding utensils. Take advantage of specialproducts that can help you:

• Flatware with larger handles or Velcro straps can be easier to grasp.• Knives with curved blades can help you cut food with one hand.• Plate guards can help keep food on the plate when using one hand.• Rubberized pads under the plate can keep it from sliding around.

Meals and Social OutingsEating out is common in the United States. It can also be good for your recovery. Eating out onoccasion relieves you of many household duties. It also can help youconnect socially with others. But, many stroke survivors shy awayfrom restaurants and social outings because they have problemsgetting around, filtering out noises, or have difficulty eating andswallowing. Some of the following tips may help:

• Call ahead to see if the place has parking, entry ramps, eatingspace and bathrooms needed to host guests in wheelchairs.

• Avoid busy times and noisy places.• Request a booth or table where you can sit across from others

but face a wall; this can reduce distractions in the restaurant.• Go to a familiar restaurant where you know the menu.• Mentally rehearse what you want to order.• Have family and friends help you order items that are safe.• Bring a card that says, “I have aphasia” and show it to the restaurant staff.

For more information, go to www.aphasia.org. 17

Going HomeMost stroke survivors are able to return home and continue doing what you were involved inbefore the stroke. You may need intensive therapy and may be discharged to a rehabilitationfacility; or therapy can be completed from home. The rehabilitation process will be determinedby the severity of your stroke. Some survivors need few services, while others need months ofrehabilitation. Social workers and other hospital staff can help prepare you for the move homeor to a rehabilitation facility upon leaving the hospital.

For those who have had a more severe stroke, going home depends on many factors:• Ability to care for oneself.• Ability to follow medical advice .• Mobility and speech (Stroke survivors not independent in these

areas may be at risk in an emergency or feel isolated.)• Availability of a caregiver.

Managing life at home is an important part of stroke recovery. Strokeaffects each survivor differently. To live well after stroke, you may needto make some changes in your home and daily routine.

What changes do I need to make at home?Living at home successfully also depends on how well the home can beadapted to meet your needs.• Safety – Take a good look around and get rid of anything that might

be dangerous. This might be as simple as taking up throw rugs,testing the bath water temperature prior to getting in or wearingrubber-soled shoes to prevent slipping. You may have to get handrailsin the bath or shower.

• Accessibility – You need to be able to move freely within your home.You may have to rearrange the furniture or build a ramp to go up steps.

• Independence – Your home should be modified so that you can be asindependent as possible. Often this means adding adaptive equipment,such as grab bars or transfer benches.

Preparing to Go Home• If needed, ask your doctor to help you plan a home visit by an occupational therapist

(OT). They are trained to help you manage daily activities and regain youindependence. The OT will check your home and may suggest simple changes to makeeveryday living easier and safer.

• A social worker can help you make decisions about your rehabilitation plan.

Stroke Guidebook

18

Stroke Guidebook

Going PlacesGetting out is good for you. It gives you a chance to be withother people. Each time you successfully go places, you buildyour confidence to do it again. Getting out of the house allowsstroke survivors a chance to regain a sense of freedom, controland independence. Going to the places you want to go, doingthe things you enjoy, and spending time with other people willhelp the recovery process. Accept that your body has changedand realize you can still be active, productive, and have a goodquality of life.

How Do I Know if I Can Drive Safely?Driving involves many skills that can be affected by a stroke. Fortunately, most stroke survivorscan regain the ability to drive safely.

• Talk to your doctor or occupational therapist for a professional opinion.• Contact the State Department of Motor Vehicles. Ask for the Office of Driver Safety

and find out requirements for people who have had a stroke.• Have your driving tested.• Enroll in a drivers training program.

Signs of Unsafe Driving• Drives too fast or too slow for the road conditions or posted speed.• Needs help or instructions from passengers.• Does not observe sign or signals.• Often gets lost, even in familiar areas.• Has accidents or close calls.• Gets easily frustrated or confused.

Tips for Safe Driving• Always make sure you and your passengers wear seatbelts.• Drive in familiar areas.• Drive on roads that are not busy.• Combine trips. Plan your errands and appointments.• Turn off the radio, phone, and other things that can take your attention away from driving.• Avoid driving at night.• Plan your travel so that you are off the road during rush-hour traffic or during bad weather.

19

Recurrent Stroke and Stroke PreventionAfter stroke, survivors tend to focus on rehabilitation and recovery. But preventing another (orrecurring) stroke should be a key concern. Of the 750,000 Americans who have a stroke eachyear 5-14 percent will have a second stroke within one year.

Stroke prevention is also important for those who have had transient ischemic attacks (TIAs)or mini-strokes. TIAs are brief episodes of stroke-like symptoms that last from a few minutes to24 hours. TIAs usually do not cause permanent damage or disability. But TIAs can be a seriouswarning sign of impending stroke. Up to one third of people who have a TIA are expected tohave a stroke. Strokes and TIAs can be prevented through lifestyle changes, surgery, medicine,or a mix of all three.

Your Personal Modifiable Risk Factors/Lifestyle ChangesThere are two types of stroke risk factors. One type you cannot control, the other you can.

Stroke risk factors you cannot control include:• Being over the age 55.• Being a man.• Being African American.• Someone in your family has had a stroke.• Having diabetes.

Having one or more of these factors doesn’t mean you will have astroke. By making simple lifestyle changes, (listed below), you may beable to reduce the risk of a first or recurrent stroke.

These simple lifestyle changes can greatly reduce your chance ofhaving a stroke. You can control these risk factors: 1. Quit smoking.2. Control your blood pressure.3. Maintain a healthy weight.4. Eat foods low in sodium (salt) and fat. 5. Avoid excessive alcohol.6. Exercise often.7. Stay hydrated.8. Monitor your cholesterol levels.9. Manage your diabetes.10. Control atrial fibrillation (if present).

20

Stroke Guidebook

Stroke Guidebook

1. Quit smokingSmoking and tobacco use are the most preventable cause of seriousillness.

How do I quit and free myself?• Quitting takes hard work and a lot of effort, but you can

quit smoking.• Millions of people quit smoking every year and most quit on

their own.• Quit when you are ready to quit.• List your reasons for wanting to quit.• Consider the benefits of quitting, better physical health and energy, peace of mind and

control, better social life, preventing harm to those around you and saving money. • Talk to your health care provider about how to stop smoking and set a quit date.• Plan the way you will quit—do not leave it to chance. There is no “best” way to quit.

“Cold turkey,” Cutting down gradually, Nicotine gums or patches are some options. Dowhat you and your health care provider think will work best for you.

• If you can not stop right now, cut down on the number of cigarettes you smoke each day.• Seek support and encouragement from you friends and family.• Use stress management techniques.

Here are some suggestions to stay smoke free.• Plan how you will deal with tempting situations such as: Social situations that involve

alcohol, relaxing after a meal, emotional upsets, loneliness, boredom, depression, angeror anxiety at work, conflicts with people.

• Avoid old activities that trigger the urge to smoke. • If coffee is a trigger, change to juice or tea. Hold

your cup in the opposite hand.• Review the list of reasons you want to quit often.• Clean out and put away ashtrays. Throw out

lighters, matches, and cigarettes.• Become more active in your leisure time. Exercise.• Keep healthy cigarette substitutes around like carrot

or celery sticks, sunflower seeds, etc.• Reinvest in yourself. You will have 5-10 percent more

time. Develop new skills, hobbies, or ways to relax.• Mark your success on the calendar and reward yourself.• Start saving the cash you would have spent on cigarettes. Buy something special.

21

Talk to your doctor about smoking cessation programs or products that might work for you.Baptist Health has resources that can help. The Quit Smart Program is an individualized,multi-method program based on research conducted at Duke University Medical Center. Formore information, call 904.202.7069.

2. Control your blood pressureHigh blood pressure is one of the most important and easily controlled stroke risk factors. Knowyour blood pressure and control it. Because there are no symptoms, many people do not knowthat they have high blood pressure.

Blood pressure is given two numbers, for example 120/80.The top number, the systolic blood pressure, is a measurement of the forces your blood puts onblood vessel walls as your heart pumps. The bottom number, diastolic blood pressure is ameasurement of the force your blood puts on the blood vessel walls when your heart is at rest.

• For people over age 18, normal blood pressure is lower than 120/80. A blood pressurereading consistently 120/80-139/89 is pre-hypertension. If yours is in this range, you aremore likely to develop high blood pressure. Also called hypertension, high bloodpressure is a reading of 140/90 or higher.

• Have your blood pressure checked at least once each year—more often if you have high blood pressure, have had a heart attack, stroke, are diabetic, have kidney disease,have high cholesterol or are overweight. For blood pressure readings check thepharmacy/drug/grocery store or fire station.

• If you are at risk for high blood pressure, ask your doctor how to manage it moreaggressively.

Many times blood pressure can be controlled through diet and exercise. Even light exercise—afast walk, bicycle ride, swim or yard work—can make a difference. Adults should do some form

of moderate physical activity for at least 30 minutes five or moredays per week, according to the Centers for Disease Control andPrevention. Regular exercise may reduce your risk of stroke.Before you start an exercise program, check with your doctor. For some people who have high blood pressure, losing weight,reducing sodium or other lifestyle changes will not lower highblood pressure as much as needed. These people will probablyneed to take medication.

3. Maintain a healthy weightIf you are overweight, especially if you carry a lot of weight aroundyour waist, you are at higher risk for health problems such as highblood pressure, high blood cholesterol, diabetes, heart disease, and

22

Stroke Guidebook

Stroke Guidebook

stroke. If you are overweight, start eating a healthy diet and exercise regularly. Quick-weight lossdiets do not work. Body Mass Index (BMI) looks at height-to-weight ratio. It can tell if you areobese. Discuss it with your doctor. For more information and to calculate your BMI online visitthe American Heart Association’s website www.americanheart.org and search BMI.

4. Eat foods low in sodium (salt).Too much sodium (salt) in the diet can cause high blood pressure, which can lead to stroke.Foods high in saturated fat and cholesterol can cause fatty deposits on the walls of your arteries(blood vessels). This causes atherosclerosis (hardening of the arteries). Atherosclerosis can causepoor blood flow in certain areas of your body, and put you at higher risk for health problemssuch as stroke and heart disease. For more information on eating right and for some tastyhealthy recipes visit the American Heart Association’s Web site www.deliciousdecisions.org.

5. Avoid excessive alcohol. One or two drinks a day may help increase HDL (“good”) cholesterol, but more than that cancontribute to high blood pressure, heart disease, and stroke. Alcohol can also increase dehydration.

6. Exercise often. Be physically active. Exercise can help with blood pressure control, reduce cholesterol levels, reduce risk of developing diabetes,and aid in weight control.

7. Stay hydrated.It is very important to keep blood liquid and flowing. A general rule of thumb is to drink enough to keep from getting thirsty. This isespecially important when exercising and during the summer or earlywinter when dehydration is the most likely.

8. Manage your cholesterol levels.High amounts of dietary cholesterol may increase blood cholesterol in some people. Eat lessthan 300 milligrams (mg) of cholesterol per day. The body needs some cholesterol to stayhealthy. The body needs cholesterol to build cell walls and make hormones. However, toomuch cholesterol in your body may be bad for your health.

Elevated cholesterol (particularly “bad” cholesterol, or LDL) is a risk factor for heart diseaseand stroke.

23

Cholesterol readings are divided into two types.Low-density lipoprotein (LDL) cholesterol is commonly called the “bad” cholesterol, and is atype of fat in the blood that contains the most cholesterol. It can contribute to the formationof plaque (or fatty deposits) buildup in the arteries, known as atherosclerosis.

You want your LDL to be low, generally less than 130 milligrams/per deciliter (mg/dL), but ifyou have had a stroke/TIA or heart attack your goal is less than 100 and if you have diabetesyou want your LDL to be less than 70.

High-density lipoprotein (HDL) is known as the “good” cholesterol, and is a type of fat in theblood that helps to remove cholesterol from the blood, preventing the fatty buildup andformation of plaque.

You want your HDL to be as high as possible, generally higher than 40 mg/dL for men andabove 50 for women.

Some ways to raise HDL and lower LDL are:• Decreasing body weight.• Avoiding foods high in saturated fat, dietary cholesterol, and excess calories.• Exercising for at least 20 minutes three times a week.• Stop smoking.• Taking appropriate medications.

9. Manage your diabetesSome people are more likely to develop diabetes.Diabetes increases the risk of heart disease andstroke. During regular check ups your doctorshould screen for diabetes. If you have diabetes,you can manage it by carefully following yourdoctor’s recommendations. A blood test calledHemoglobin A1c should be done every threemonths and should be below 7mg/dL. HemoglobinA1c is used to determine your average blood sugarlevels over the last three months.

24

Stroke Guidebook

10. Controlling atrial fibrillationMany forms of heart disease can increase your stroke risk. Atrial fibrillation (Afib) is anirregular heartbeat. Afib is when the top chambers of the heart fibrillate (quiver) and do notempty effectively. This fibrillation can cause blood clots to form. The clot can travel from theheart to the brain and cause a stroke. Warfarin (Coumadin) and aspirin are often prescribed totreat atrial fibrillation. You and your doctor should monitor taking warfarin carefully. Workwith your doctor to manage atrial fibrillation.

Following up after dischargeBe sure to follow your personal dischargeinstructions. Make sure you understand andagree with them. Know your personalmodifiable risk factors from the list above. Itis very important to have regular checkupsand work with your doctor to reduce orcontrol your personal modifiable risk factors.Your doctor can monitor your risk factorsand suggest treatments.

Stroke Guidebook

25

Stroke Guidebook

26

National

American Stroke Association, a division of the American Heart Association888.478.7653 www.strokeassociation.orgAsk for the Stroke Family Warmline to talkwith a stroke survivor or caregiver, get a list ofstroke support groups in your area or ask forStroke Connection magazine

National Stroke Association1-800-STROKES 1-800-787-6537www.stroke.orgInformation on stroke, including prevention,treatment, rehabilitation, and support forstroke survivors and their families or subscribeto Stroke Smart magazine.

National Institute of NeurologicalDisorders and Stroke800.352.9424www.ninds.govGovernment information available on avariety of stroke-related topics.

Local

First Call, a division of the United Way904.632.0600 or 211Can refer you to community resources.

Independent Living ResourceCenter of Northeast Florida904.399.8484www.cilj.comAdvice, information, and referrals for disabledindividuals.

Jewish Family and Community Services904.448.1933Multiple services, including counseling

Baptist Behavior Health 904.376.3800Psychological and psychiatric counseling services

Resources for stroke survivors and their families*

*This information is provided by Baptist Health as a resource and should not be consideredan endorsement.

Compiled by Michelle Silver, MSN, ARNP, FNP-BC

Clinical Outcome Specialist StrokeNursing Clinical Practice Division

Baptist Health

Summer 2008

Stroke Guidebook

27

Contributions

The Stroke Center TeamThe Neuroscience NursesThe Clinical Practice Division

Note: This guide was compiled from medical information that is available to the general public.It should not be considered recommended treatment for any particular individual. Strokesurvivors should check with their doctors about any personal medical concerns.

The information in this patient guide was gathered from the following resources:American Heart Association National Stroke Association

American Stroke Association The Centers for Disease Control

community.e-baptisthealth.com Thompson MICROMEDEX

National Institute of Neurological Disorders

Stroke Guidebook

Notes

28

Stroke Guidebook

Notes

29

BAPTIST HEALTH

800 Prudential DriveJacksonville, Florida 32207904.202.CARE (2273)

e-baptisthealth.com

BAPTIST MEDICAL CENTER DOWNTOWN

800 Prudential DriveJacksonville, Florida 32207904.202.2000

BAPTIST MEDICAL CENTER BEACHES

1350 13th Avenue SouthJacksonville Beach, Florida 32250904.627.2900

BAPTIST MEDICAL CENTER NASSAU

1250 South 18th StreetFernandina Beach, Florida 32034904.321.3500

BAPTIST MEDICAL CENTER SOUTH

14550 Old St. Augustine RoadJacksonville, Florida 32258904.821.6000

WOLFSON CHILDREN’S HOSPITAL

800 Prudential DriveJacksonville, Florida 32207904.202.8000