With the establishment of the Patients' Bill of Rights in 1972 came the mandate for nursing and medicine to establish standards of care.1 Since that time, the consumer of health care has become more knowledgeable of the health care system. Consumers participate in health systems agencies as do health care providers. Together they make decisions that will affect the local as well as national health scene. The cost of medical care has served as an impetus for consumer involvement. To this end, two areas have received attention: the length of hospital stay and the quality of care received.
The second area is the focus of this article. Quality patient care, although theoretically practiced, requires validation. Hence, the nursing audit has evolved. Patient care standards are geared principally toward care of the acute client in a general hospital.
THE STROKE PATIENT
A need exists for standards of care for patients embarking on the next stage in the wellness-illness continuum, namely extended care. One large population that fits this category is composed of patients who have had strokes. More than 500,000 persons experience completed strokes annually in the United States. Approximately one-third of these persons require admission to extended-care facilities (ECFs).2 At the time of transfer to the ECF, most of these patients have completed their initial programs of care, for example, acute care, active rehabilitation, and medical and nursing evaluation. Now they require nursing care and supportive therapies aimed at maintaining an optimal level of wellness.
NURSING PROCESS APPLIED TO THREE STROKE PATIENTS
IDENTIFICATION OF GUIDELINES
National committees, organized to investigate stroke care and facilities have completed extensive studies and have reported both statistics and guidelines for care in acute care hospitals.3
The Cerebrovascular Committee of the Chicago Heart Association identified the need to extend this scope to include guidelines for care of stroke patients in extended-care facilities. An ad hoc committee spearheaded by the author, a nursing educator, was composed of two other nurses - an inservice nursing director and a nurse clinical specialist in a rehabilitation institute. All three nurses have worked with stroke patients and had exposure to extended-care facilities. Collectively these nurses identified guidelines, validated them with nursing directors and staff nurses in ECFs, and made revisions accordingly. A draft was presented to the Cerebrovascular Committee, which was composed of a physiatrist-chairperson, a neurologist, internist, doctor of osteopathic medicine, cardiologist, occupational therapist, social worker, public health nurse, and nutritionist, in addition to the ad hoc committee members. Revisions contained in the document were accepted within one year.
The guidelines identified were formulated into statements of the nursing care to be performed by nursing staff members in ECFs. The acronym "A PERSON" is used to assist the nurse in remembering the various aspects of care. Examples of assessments and interventions within each category are as follows:
Assessment is the systematic collection of data on the health of the resident on admission. This assessment is to be continued throughout the resident's stay and to be communicated to the appropriate staff in addition to being recorded.
Psychosocial includes the identification of the resident as an individual having social, sexual, and emotional needs. Care plans should reflect individualized consideration of each resident and his/her program.
Elimination includes methods of management of bowel and bladder elimination that support the resident's self esteem, promote optimal function, and are physiologically safe.
Rest and Activity provides assurance that adequate comfort, mobility, ADL (activities of daily living), recreation, and sleep are provided.
Safety is to be maintained at an optimal level both within the environment and within the care that is provided.
Oxygenation is aimed at the maintenance of adequate circulation and ventilation.
Nutrition is focused on the maintenance or restoration of adequate fluid and electrolyte balance, ingestion, digestion, absorption, and metabolism, including appropriate use of devices for nutritional intake.
These guidelines can be used by different nursing populations for different purposes.
A standardized nursing care plan can be developed using these guidelines since they are comprehensive in scope and specific to a patient who has suffered a cerebrovascular accident (see Figure). Second, the guidelines can be used in the establishment of audit criteria for the evaluation of current nursing practice since the guidelines are written in behaviorally measurable terms. Third, these guidelines can serve as an outline for nursing faculty in defining specific content to be taught to the population. Fourth, the material contained in this article can be included in orientation programs for new nursing personnel who are going to work with patients who have had strokes.
To date, these guidelines have been circulated to the extended-care facilities in the Chicago area. However, a follow-up study of their utilization has not been conducted. The author would appreciate communicating with readers who have ideas on implementation of these guidelines.
Guidelines are needed for the nursing care of a stroke patient beyond the acute hospital setting. This patient, while in an acute hospital, receives a high level of nursing care and is shown interest by the staff. However, once the acute aspect of care is completed and extended care is instituted, a different approach frequently is observed. The guidelines presented here pinpoint the aspects of care that continue to be important to the maintenance of the stroke patient at a high level of wellness.
- 1. Tucker S: Patient Care Standards. St. 2. Sahs AL, Hartman EC, Aronson SM (eds): Guidelines for Stroke Care. Maryland, DHEW, 1976. p 244.
- 3. Ramey I: Guidelines (or nursing care of stroke patients. Stroke 1972; : 633-681.
- Callan CA: A patient after cerebrovascular accident. Nurs Times 1980; 76:1961-19.
- Labi MLC: Psychosocial disability in physically restored long-term stroke survivors. Arch Phys Med Rehabil 1980; 61:561-565.
- Stewart C: Principles of patient education for the patient with an altered neurological status. Neurosurg Nurs 1980; : 1979-1983.
- Wolamin HT: The long road back from stroke. Geriatric Nursing 1980; :34-36.
- A special thanks to R. King and E. Moser, who co-authored the guidelines, to J. GoIdschmidt, MD, and to Chicago Heart Association, who supported the endeavor.
NURSING PROCESS APPLIED TO THREE STROKE PATIENTS