Evidence-Based Educational Guidelines for Stroke Survivors After Discharge Home

Sharon K. Ostwald, PhD RN FGSA; Sally Davis, MSN RN; Gayle Hersch, PhD OTR; Carolyn Kelley, DScPT PT NCS; Kyler M. Godwin, MPH


J Neurosci Nurs. 2008;40(3):173-179,191. 

In This Article


Because inpatient rehabilitation length of stay has become short, stroke survivors are increasingly being discharged home with many educational needs. The education that is provided in the hospital primarily focuses on physical rehabilitation. Once in the home environment, however, stroke survivors and families must adapt to physical and psychological changes in the stroke survivor, changes in family relationships, and environmental and financial challenges.

These guidelines represent an evidence-based interdisciplinary approach to comprehensive education for stroke survivors and their families. The content was individualized to survivors' and families' situations and their level of understanding. Information provided in the hospital setting was reviewed and reinforced with pictures, diagrams, and printed materials. Materials that have been developed by expert organizations such as the American Stroke Association (www.strokeassociation.org) and the National Stroke Association (www.stroke.org) were used liberally. These materials, which are available online or for a nominal fee, are written at various reading levels and tailored to different racial or ethnic groups; many also are available in Spanish.

A unique aspect of this educational program was the interdisciplinary team approach. The majority of visits were made by APNs, but families saw physical therapists for mobility and equipment issues and to address problems such as spasticity. Occupational therapists provided expertise on issues related to home safety, adaptive and leisure activities, and community reintegration. The team met weekly to discuss families and their needs, to identify the appropriate staff member to make the next visit, and to discuss referrals to community resources. All staff members were prepared to follow up on the guidelines because they had been involved in their initial development and families benefited from the high level of staff communication. The APNs benefited from weekly consultations with physical and occupational therapists on topics related to mobility, equipment, positioning, spasticity, home safety, and activities, while nurses provided expertise to therapists regarding specific medical and nursing problems, disease prevention, health promotion, and stress management.


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