Case Studies
The following two case studies illustrate the use of the guidelines to meet individual stroke survivor and family needs.
A.R. was a 59-year-old Mexican-American woman who lived with her husband, two daughters, a son-in-law, and three grandchildren in a small converted mobile home. Before her stroke, she had been a school-bus driver; more recently, she had cared for her grandchildren, cooked for her extended family, and managed the home. Her husband was a retired unskilled worker and their family income from his Social Security was $1,100/month; they had no health or medication insurance.
A.R. experienced a thrombus affecting the left hemisphere of her brain while driving her car. She was able to drive home, but unable to get out of the car due to paralysis on the right side of her body; her speech was dysarthric. She was admitted to a local hospital and discharged after 23 days. She received no inpatient rehabilitation and only received in-home physical therapy for 3 weeks, which was discontinued due to lack of ability to pay.
A.R.'s problem list and the educational guidelines that were used in her household are detailed in Figure 3. She was able to use a walker to ambulate within the house without assistance, but to accommodate her weakness and instability, she used a donated wheelchair when going out of the house. With the team's assistance, she initiated exercises on her right hand and learned to balance herself at the sink and use her right hand to anchor dishes in warm water while she washed them with her left hand. Returning to this familiar role increased her self-esteem and helped reclaim her role within the family. She used a hand mirror to do facial exercises and family members were taught to instill liquid tears into her right eye to prevent dryness. Being with her three young grandchildren encouraged her to practice her speech and use her right hand to balance the children on her lap.
Problems Identified and Guidelines Used with A.R. and Family
A.R. was denied Social Security disability benefits because her work history was insufficient and the family income was too high for county medical assistance. Her medication bottles were empty. Her blood pressure was 170/94 mm Hg, and her blood glucose was 180 mg/dl. The team helped her apply for free medications from pharmaceutical companies. With the correct medications and lifestyle changes, she learned to successfully manage her diabetes and hypertension. She was unable to leave her home because it had steep concrete-block steps without hand railings. After a referral from the program team, the local area agency on aging replaced the unsafe concrete-block steps at the door with a ramp so she could safely exit the house in her walker or wheelchair. Arguments between A.R. and her husband, stress related to lack of finances, and the presence of three families within one small house resulted in frequent family conflicts. These conflicts escalated until her husband moved out of the house for a time. He returned to help care for her when the daughters and their families moved into their own apartments. Although A.R. remained primarily housebound, she enjoyed reading magazines, watching television, helping to care for her grandchildren, and occasionally going to school events with the family.
R.J. was a 50-year-old African-American man who lived with his wife and an adult son. He sustained a right-brain thrombotic stroke; this was his second stroke in 2 years. He made a strong recovery after his first stroke and was able to return to work as a car salesperson. He had a preferred provider organization (PPO)-type insurance with no medication coverage. R.J. was hospitalized for 14 days in acute care and 60 days in inpatient rehabilitation before discharge. His PPO was slow to approve his claims for outpatient therapy. As a result, his therapy was episodic, with breaks of 2–3 weeks between each approved set of sessions. R.J.'s wife worked full time as a customer service representative for a local discount store and she expressed frustration at trying to handle the demands of caregiving and a full-time job. An adult son provided care during the day on a temporary basis until his mother could make other arrangements.
R.J.'s problem list and the guidelines used with his family are detailed in Figure 4. He applied for and received Social Security disability benefits and also obtained medical insurance through the county system so he could continue consistent outpatient therapy. He improved his mobility so he could transfer with assistance using a walker, and he also could bear some weight on his left leg. He received botulinum toxin Type A (Botox) injections for his muscle spasticity. The team helped him apply for free medications through programs managed by pharmaceutical companies. He was able to control his hypertension and seizures with medications. His wife was referred to the state provider assistance program, through which she could quit her job and became R.J.'s primary paid caregiver. This allowed her to be compensated for staying home and caring for her husband, relieving much of her stress and frustration over finances and her husband's quality of care.
Problems Identified and Guidelines Used with R.J. and Family
J Neurosci Nurs. 2008;40(3):173-179,191. © 2008 American Association of Neuroscience Nurses
Cite this: Evidence-Based Educational Guidelines for Stroke Survivors After Discharge Home - Medscape - Jun 01, 2008.
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