cerebrovascular accident (cva) - wakemed · a second major cause of stroke is bleeding in the...

C e r e b r o v a s c u l a rA c c i d e n t ( C VA ) [ P A T I E N T / F A M I L Y E D U C A T I O N ]

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If you have received this notebook insert youprobably have a family member or loved onewho has suffered from a stroke, also called acerebrovascular accident or CVA and who isreceiving rehabilitation services throughWakeMed. The following information isbeing provided to help you understand thecomplex nature of strokes and the process ofrehabilitation and recovery from the stroke.

The National Stroke Association defines astroke as a brain attack that occurs when ablood clot blocks an artery (a vessel thatcarries blood to the body from the heart) ora blood vessel (a tube through which theblood moves through the body) breakscausing decreased oxygen to that part of thebrain. Brain cells then die and brain damageoccurs. When this happens the abilitiescontrolled by that area of the brain arepartially or completely lost. Things likespeech, memory, and movement are affected.A stroke can be caused by an embolus,thrombus or a hemorrhage. Strokes are the3rd leading cause of death in America andthe number one cause of adult disability.

WakeMed Health & Hospitals is the onlyJoint Commission-certified Primary StrokeCenter in Wake County. The WakeMedStroke Team is made up of specially trainedphysicians, nurses and therapists, who arededicated to the care of stroke patients. The stroke program at WakeMed begins in the emergency room with specialists whotreat strokes emergently and provides acontinuum of services from inpatientrehabilitation services to outpatient/daytreatment rehabilitation. The WakeMedStroke continuum is designed to provideappropriate services for the patient’s specificimpairments and level of functioning.

[ I N T R O D U C T I O N ]

P A T I E N T / F A M I L Y E D U C A T I O N N O T E B O O K | 3

The human brain consists of millions ofnerve cells (neurons). It weighs about 3pounds and is jello-like in consistency. It floats in fluid (cerebral spinal fluid), is covered by protective membranes(meninges), and is enclosed in the bony skull(cranial vault). It communicates with the restof the body through nerves running throughthe spinal cord and the peripheral nervoussystem. The brain is a large consumer ofoxygen, which is supplied by a complexsystem of blood vessels.

The brain is sometimes referred to as “theorgan of behavior” as it controls almosteverything we do. It controls thoughts,memory, speech, emotions, sensoryinformation, body movement, and thefunction of many other organs in the body.It is also responsible for the patterns ofbehavior we refer to as personality. The brainhas four main sections, which include: thebrainstem, cerebellum, the limbic system,and the cerebral cortex.

• Brainstem: The brainstem is the lowestpart of the brain and connects the brain tothe spinal cord. It is involved in regulatingour level of alertness, and also controlsbasic bodily functions such as heart rate,breathing, body temperature, anddigestion.

• Cerebellum: The cerebellum is located atthe back of the brain. It is involved withmovement, coordination, and balance.

• Limbic System: The limbic system islocated above the brain stem deep insidethe brain. It is involved in our emotionalfunctioning and also plays a role in theability to remember new information.

• Cerebral cortex: The cerebral cortex is theouter layer of the brain and is divided intoleft and right hemispheres, or halves. Eachhemisphere controls movement and feelingin the opposite side of the body. Theoutermost inch of the cerebral cortex iscomposed of neuron cell bodies and isreferred to as “grey matter”, because of itsgrey color. Below the grey matter is the“white matter”, which consists of incomingand outgoing axons that can be thought ofas the arms of the neurons. These axons, orarms, start out at the neuron’s cell body,and reach out to connect with otherneurons in different areas of the brain sothat these different areas of the brain cancommunicate with one another. Thecerebral cortex controls the highest levelsof thinking and behavior. Each hemisphereis further divided into four lobes.

• Frontal lobes: The frontal lobes areinvolved in complex cognitive functionssuch as planning, organizing, initiating,monitoring and controlling behaviors oremotions. These are often referred to as“Executive Functions”. The center forspeech is also located in the frontal lobe.In most people this is in the left frontallobe.

[ T H E B R A I N ]


• Temporal lobes: The temporal lobescontrol hearing and the left temporal lobeis involved in understanding language.Both temporal lobes are also involved withmemory – the left temporal lobe for verbalmemory and the right temporal lobe forvisual memory.

• Parietal lobes: The parietal lobes processincoming bodily sensory information fromthe opposite side of the body. They are alsoinvolved in visual spatial informationprocessing, and the left parietal lobe isinvolved in reading.

• Occipital lobes: The occipital lobes processvisual information. They allow us torecognize and understand what the eyesare “seeing”.


Unfortunately, strokes (sometimes called"brain attacks" can attack any of thepreviously mentioned areas of the brain.When this happens partial or completelosses of function may occur.

Approximately every 40 seconds, someone inthe United States has a stroke. A stroke canhappen when the following occurs:

• A blood vessel that supplies blood to thebrain is blocked by a blood clot. This iscalled an ischemic stroke.

• A blood vessel breaks open, causing bloodto leak into the brain. This is called ahemorrhagic stroke.

If blood flow is stopped for longer than afew seconds, the brain cannot get blood andoxygen. Brain cells can die, causingpermanent damage.

I S C H E M I C S T R O K E

Ischemic stroke is the most common type ofstroke. Usually this type of stroke resultsfrom clogged arteries, a condition calledatherosclerosis. Fat, cholesterol, and othersubstances collect on the wall of the arteries,forming a sticky substance called plaque.Over time, the plaque builds up. This oftenmakes it hard for blood to flow properly,which can cause the blood to clot. There aretwo types of clots: A clot that stays in placein the brain is called a cerebral thrombus. Aclot that breaks loose and moves through theblood to the brain is called a cerebralembolism.

Other causes of ischemic stroke include:

• Abnormal heart valve

• Inflammation of the inside lining of theheart chambers and heart valves(endocarditis)

• Mechanical heart valve

A clot can form on a heart valve, break off,and travel to the brain. For this reason, thosewith mechanical or abnormal heart valvesoften must take blood thinners.

H E M O R R H A G I C S T R O K E

A second major cause of stroke is bleedingin the brain. This is called a hemorrhagicstroke. It can occur when small blood vesselsin the brain become weak and burst. Somepeople have defects in the blood vessels ofthe brain that make this more likely. Theflow of blood that occurs after the bloodvessel ruptures damages brain cells.

[ S T R O K E O R C E R E B R O V A S C U L A R A C C I D E N T S ( C V A S ) ]


High blood pressure is the number one riskfactor for strokes. The following alsoincrease your risk for stroke:

• Diabetes

• Family history of stroke

• Heart disease

• High cholesterol

• Increasing age

Certain medications make blood clots morelikely, and therefore your chances for astroke. Birth control pills can increase thechances of blood clots, especially in womanwho smoke and who are older than 35.

Men have more strokes than women. But,women have a risk of stroke duringpregnancy and the weeks immediately afterpregnancy. The following can increase therisk of bleeding into the brain, which makesyou more likely to have a stroke:

• Alcohol use

• Bleeding disorders

• Cocaine use

• Head injury

To help prevent a stroke:

• Avoid fatty foods. Follow a healthy, low-fatdiet.

• Do not drink more than 1 to 2 alcoholicdrinks a day.

• Exercise regularly: 30 minutes a day if youare not overweight; 60 - 90 minutes a dayif you are overweight.

• Get your blood pressure checked every 1 -2 years, especially if high blood pressureruns in your family.

• Have your cholesterol checked. If you areat high risk for stroke, your LDL "bad"cholesterol should be lower than 100mg/dL. Your doctor may recommend thatyou try to reduce your LDL cholesterol to70 mg/dL.

• Follow your doctor's treatmentrecommendations if you have high bloodpressure, diabetes, high cholesterol, andheart disease.

• Quit smoking.

S Y M P T O M S

The symptoms of stroke depend on whatpart of the brain is damaged. In some cases,a person may not even be aware that he orshe has had a stroke. Symptoms usuallydevelop suddenly and without warning.They may be episodic (occurring and thenstopping) or they may slowly get worse overtime. Symptoms may include:

• Change in alertness (consciousness)

• Coma

• Lethargy

• Sleepiness

• Stupor

[ S T R O K E R I S K S ]


• Unconsciousness

• Withdrawn

• Difficulty speaking or understandingothers

• Difficulty swallowing

• Difficulty writing or reading

• Headache

+ Occurs when lying flat

+ Wakes you up from sleep

+ Gets worse when you change positionsor when you bend, strain, or cough

+ Starts suddenly

• Loss of coordination or balance

• Movement changes, usually on only oneside of the body

• Difficulty moving any body part

• Loss of fine motor skills

• Nausea or vomiting

• Seizure

• Sensation changes, usually on only one sideof the body

• Decreased sensation

• Numbness or tingling, usually on only oneside of body

• Sudden confusion

• Weakness of any body part but usually onone side of body

• Vision changes

• Decreased vision

• Loss of all or part of vision

T R E A T M E N T

A stroke is a medical emergency. Immediatetreatment can save lives and reducedisability. It is important to get the personto the emergency room immediately todetermine if the stroke is due to bleeding ora blood clot so appropriate treatment can bestarted within 3 hours of when the strokebegan.

Our goal throughout the continuum andduring your stay here at WakeMedRehabilitation is to provide you with bestrehabilitation that is available. The overallgoal of long-term treatment is to help yourecover as much function as possible andprevent future strokes.

To accomplish this WakeMed Rehabprovides a comprehensive treatment teamcomprised of specialized rehabilitationdoctors (physiatrists), nurses, physicaltherapists and assistants, occupationaltherapists and assistants, speech-languagepathologists, therapeutic recreationspecialists, case managers, neuro-psychologists, dieticians, and rehabilitationaides. You will participate in a variety ofgroup and individual therapies tailored tomeet your needs throughout your stay.

[ I S C H E M I C S T R O K E ]


A stroke has the potential to affect manyareas of a person’s functioning. In order toensure rehabilitation is comprehensive, therehabilitation treatment team addresses allthe major functional areas. These includemedical management, cognition,communication, behavior, mobility, self-careand the psychosocial aspects of care.WakeMed’s Stroke treatment protocols andthe patient’s Plan of Care are organized inthis manner. These functional areas, andhow a stroke can impact them, are describedbelow.

M E D I C A L

Depending on the nature and severity of thestroke, there may be other medical issuesresulting from the stroke that can impactrecovery and the course of a patient’srehabilitation. Some individuals may havedifficulty breathing initially, so atracheotomy tube may need to be placed inthe neck to help them breathe. Even whenthey recover the ability to breathe on theirown, the tube may remain in place for awhile longer to help clear secretions fromthe trachea. The ability to produce anaudible voice is temporarily affected by thepresence of this tube. During the course ofrehab, a patient may have an objective studyperformed to ensure least restrictive diet andprevent pneumonia. A Modified BariumSwallow Study (MBS) is performed inRadiology using fluoroscopy to observe thepath of food and liquids as they enter the

body. A Fiberoptic Endoscopic Evaluationof Swallowing (FEES) is more commonlyperformed on the Rehab unit where a tinycamera is inserted in the nose to observe thefood or liquids as well. Results of thesestudies will help the MD and SLP decidewhat diet is safest. Food may be chopped orpureed and liquids may be thin or thickenedto different consistencies.

Many individuals with strokes have troubleswallowing safely (dysphagia). In some casesa feeding tube must be inserted through thenose to give liquid nutrition. When theswallowing problems are severe and likely tolast a long time, a gastrostomy feeding tube(PEG) can be surgically placed in thestomach. This allows liquid nutrition to begiven in large amounts several times a dayinstead of continuously dripped in, and isoften more comfortable for the patient.Generally, this tube can be removed onceswallowing improves.

When a brain is injured from any kind ofneurological insult including strokes, itbecomes more sensitive to developingseizures. Seizures are caused by abnormalelectrical discharges in the brain. Symptomsmay vary depending on the part of the brainthat is affected, but seizures often causeunusual sensations, uncontrollable musclespasms, and even loss of consciousness.Medications can be used to stop seizuresand to prevent them from occurring.

Another problem commonly seen inindividuals with strokes is spasticity.

[ I M P A C T O N F U N C T I O N A L A R E A S ]


Spasticity is a condition in which musclesare continuously contracted. This abnormalincrease in muscle tone results from a faultysignal from the brain to the muscles. Thestiffness and tightness of the muscles mayinterfere with movement, speech, and thequality of walking. The degree of spasticitycan vary from mild muscle stiffness tosevere, painful, and uncontrollable musclespasms. Treatment for this will depend onthe particular individual’s circumstances, butcould include such things as medications,and stretching exercises.

C O G N I T I O N

Cognition is another word for thinking skillsand includes such things as attention,memory, language, visual-spatial abilities,and executive skills. Cognition is frequentlyadversely affected by strokes. Cognitivechanges with strokes are more likely seenwith someone who has had a CVA on theright side of the brain.

Cognitive deficits can vary from mild tosevere or profound, depending on theseverity of the stroke and the stage ofrecovery a person is in. Cognition oftenshows improvement as recovery progresses.Also, some areas of cognition may be moreimpaired than others.

For example a person may have severememory problems, but relatively intact visualperceptual skills. Individuals in the earlystages of recovery from a stroke may have

difficulty staying awake and alert.Sometimes, individuals with a stroke areawake and alert, but are very confused andrestless and have a limited ability tounderstand the world around them. If thepatient is functioning at this level ofcognitive impairment, he or she may haveproblems with irritability, restlessness, poorattention, poor memory, difficulty solvingeveryday problems, and insight (difficultyunderstanding what changes have happenedsince the stroke).

Because of confusion and memorydifficulties, the patient may “confabulate” ortalk about things he or she thinks happenedbut which did not. As they improve andbegin to understand what has happenedpatients often begin to participate moremeaningfully in therapies and otheractivities. For example, the patient may beable to start to participate in dressing,feeding and bathing him or herself again,with assistance and guidance.

Some individuals with strokes will have lesssevere cognitive impairments, or will havemore severe impairments in some areas ofcognition, and mild or no impairment inothers. Many patients who start with moresevere cognitive deficits may showsignificant improvement, and eventuallyhave less severe impairment in some or allareas of cognition. The patient mayremember some things from day to day, andmay be fully oriented (meaning they knowwho they are, where they are, and what dateand time it is). The patient may be able to


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dress independently, and eat independently.However, some amount of supervision andassistance might be needed due to thingslike poor short-term memory, poorperceptual skills, or other cognitive deficits.The patient may not be able to see thesecognitive problems and may try to do thingsthe same way he or she did before thestroke.

In strokes of the least severity, or in patientswith the highest recovery, cognitive deficitsare subtle, and would not be noticed bypeople who did not know the person beforethe stroke. They may still include mildmemory deficits, but also difficulties inplanning and organizing their day-to-dayfunctioning, particularly in complexactivities like working or going to school.Rehabilitation efforts at this level arefocused on teaching the patient strategies tohelp them in these areas.

C O M M U N I C A T I O N

Speaking, listening, reading, writing andgesturing are all ways we communicate.Having difficulty speaking and /orunderstanding words is called "aphasia" andthis is usually associated with strokes on theleft side of the brain. Patients with aphasiamay have problems doing some or all ofthese things. Problems communicating canrange from mild to profound depending onthe nature and severity of the stroke.Individuals with the most severe strokes areunable to communicate at first. They may

sometimes have their eyes open, and appearto be awake, but may not be able to speak orrespond to you.

Some individuals can follow simpledirections and may be able to talk usingsimple words or gestures (for example, thepatient may point to a cup to tell you he orshe wants something to drink), but mayhave difficulty finding the right words to say.Words said may not always make sense.

Patients may also experience "dysarthria"where weakness of the face, lips, tongue andlarynx (Voice box) may cause speech to be"slurred" and unintelligible.

Apraxia can also be the result of a stroke.This is a motor planning disorder that cancause the patient to know what word theywant to say but have difficulty planning thespeech sounds. They may appear to be"searching" for a word with long delays ininitiating speech.

Your speech pathologist will evaluate andrecommend treatment for thesecommunication and swallowing problems inRehab. Generally as the patient improves,communication skills become more andmore accurate.

M O B I L I T Y

Mobility is about movement, whether it isgoing from laying down to sitting up,walking to the bathroom, or wheeling awheelchair down the hall. In order to move

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the body, the brain must coordinate balance,strength and motor control.

Areas of function that can affect mobility ina person with a stroke are:

• Balance – allows upright posture withoutfalling over.

• Strength– the amount of power that yourmuscles have.

• Coordination– the smooth movement ofmultiple body parts in harmony.

• Sensation – the body has several types ofsensation, all of which are interpreted bythe brain:

+ Hot/cold and sharp/dull

+ Deep pressure

• Proprioception – tells the body where it isin space

• Tone – an increased resistance tomovement, a common problem in strokepatients, particularly troublesome if itoverpowers available active movement.Tone can increase with laughing,coughing, sneezing, infection, fever orimpaction. Tone is easily mistaken foractive movement, but it is not under thepatient’s control.

• Range of Motion – Orthopaedic injuries,increased muscle tone, or changes in motorcontrol can reduce the patient’s ability tomaintain joint flexibility.

• Posture – An individual’s ability to sit upor stand including head position iscontrolled by the brain. The stroke mayalso affect vision, perception, and motorcontrol, all of which play a part in posture.

• Motor Control – a combination ofstrength, balance, coordination andsensation to produce purposeful, controlledmovement.

• Motor planning – the selection of thecorrect motor plan, including starting,continuing, and stopping a desiredmovement appropriately.

Mobility deficits in stroke patients are mostcommonly addressed by the physicaltherapist in Rehab. Here at WakeMed weuse a variety of approaches to facilitatemobility, and we encourage the patient touse the affected side of the body as much aspossible to retrain those muscles andpathways in the brain.


A D L ’ S

Activities of Daily Living (ADL’s) are all theactivities people engage in on a daily basisincluding work, school, leisure, and self-careactivities. Self-care activities include:grooming, bathing, dressing, toileting, andperforming toilet and shower transfers.Initially, it’s obvious a patient can’t work or goback to more complex activities, but he or shealso may not be capable of basic self-care dueto a combination of cognitive and physicalfactors. Patients may be totally dependentupon others to care for them. In less severestrokes, or as patients with more severe strokesbegin to recover, they are often able to resumeaspects of self-care starting with the simplest(such as assisting a therapist with wiping one’sface) and moving to the more complex (suchas dressing one’s self with little or noassistance).

Performing activities of daily living andregaining your independence in these areas isa focus of our occupational therapydepartment.

L E I S U R E S K I L L S

Having physical and cognitive changes oftenleads to a decrease in one's ability toparticipate in leisure activities in and outsideof their home. Our therapeutic recreationspecialists can help you find new ways to enjoyyour favorite hobbies and activities.

P S Y C H O S O C I A L

A stroke patient’s psychological functioningand psychosocial situation may be severelydisrupted by the stroke. The degree ofdisturbance is usually determined by theseverity of the stroke and degree of cognitivedeficits. Early in their recovery patients oftencannot understand what has happened tothem and are highly confused. They may bevery fearful or angry and have no control overtheir emotions leading to inappropriatebehavior. To families, they may not seem as ifthey are the same person. Because of theircontinued cognitive problems, explanations oreven attempts to “counsel” them areineffective. They do, however, sometimesrespond well to family support. As patientsrecover they may begin to be able tounderstand their situation and what’shappened to them. At this point they are atrisk for depression or other adjustmentdifficulties and need to be closely monitored.

Every family is different but for most the ideaof long-term recovery from a stroke can beoverwhelming. However, the injured brain canoften heal and the changes can be inspiring.Along with the hope that recovery brings isthe balance of acceptance of more permanentchanges. This sets the foundation for effectivecoping and can often be the most challengingaspect of rehabilitation for patients andfamilies.

[ A C T I V I T I E S O F D A I L Y L I V I N G ]


Patients are affected by their stroke in manyways, beyond their cognitive and physicalfunctioning. Family members and caregiversare also affected by the patient’s stroke.Patients and families may experience a rangeof emotions that will change from time totime. Some examples of these emotionsinclude: • Disbelief • Anger • Guilt • Depression • Isolation • Panic • Hope

It is important to recognize that theseemotions are normal, and an expected partof the process of trying to understand andcope with a patient’s stroke. A stroke affectsnot only the patient, but everyone else whoknows and cares about that person. It is alsoimportant to recognize that the youngchildren or grandchildren of patients can bevery distressed and upset by the stroke. Itcan be a very confusing time for children,and their daily routine is often verydisrupted. We recommend that families tryto “normalize” children’s routines. If possible,children of patients with strokes shouldreturn to their normal school and activityroutine as soon as possible. If you are notsure how to explain the patient’s stroke to achild, or if you have questions about how to prepare the child to visit the patient forthe first time, a consultation with one ofWakeMed’s Child Life Specialists can be arranged.

Similarly, spouses and other family membersmay want to consider trying to return to asnormal of a routine as possible. You shouldtry to get adequate rest and good nutrition,and not feel guilty that you are not at thehospital continuously, particularly after thepatient transfers to the Rehab Hospital orNeuro Care Unit. The patient will be busyduring the day with therapies and otheractivities, and will need rest breaks betweentherapies.

R E C O V E R Y

One of the first questions families ask whentold a family member has had a stroke is“how long will it take my family member toget better?” Unfortunately, we usually don’tknow the exact answer to that question. Onething we do know is that recovery from astroke is a gradual process that may continuefor months and even years.

It is everyone’s goal to maximize thepatient’s recovery and ability to liveindependently or with very little help. Someindividuals will eventually reach the goal ofbeing able to live independently, and returnto activities such as work and driving;however, others may continue to need morehelp from family and friends. There is nopromise how much or how quickly eachperson may recover. Each person recovers athis or her own pace.

[ A C T I V I T I E S O F D A I L Y L I V I N G ]


Stroke rehabilitation occurs in many settingsthroughout the WakeMed system. Thepatient may pass through several differentrehabilitation settings as he or she recoversfrom the stroke, and different people spenddifferent amounts of time in each setting.When a person progresses from one settingto the next, therapists communicate withone another to maintain a good continuityof care.

A C U T E H O S P I T A L

If a patient suffers a stroke and is admittedto WakeMed for emergency medicalmanagement of his or her stroke, he or shewill typically begin to receive rehabilitationservices as soon as medical stabilizationoccurs, often within the first 24 hoursfollowing a stroke.

N E U R O C A R E U N I T

This acute hospital unit at WakeMed isspecially designed for individuals with moresevere injuries and strokes, who aremedically stable, and can benefit fromcoordinated rehabilitative services, but mayneed more time to recover before beingready to move to the next step.

While on the Neuro Care Unit, eachpatient’s schedule will be individualized toaccommodate the patient’s current level offunctioning. Therapies available includeoccupational therapy, physical therapy, and

speech therapy. In addition, patientstypically receive neuropsychological services,and therapeutic recreational services areavailable on an as-needed basis. Therapiesare available Monday through Friday, with atypical schedule being occupational,physical, and speech therapy one to twotimes per day. However, this may varydepending on the individual needs of thepatient. Patients may be scheduled fortherapies any time between 9 am and 4 pm,usually with a break over lunch from Noonto 1 pm. Visiting hours are from 4 pm to 8pm Monday through Friday, and 10 am to 8pm Saturday and Sunday, or after scheduledtherapies.

W A K E M E D R E H A B I L I T A T I O N

H O S P I T A L

If your family member needs intense,inpatient rehabilitation, he or she may beadmitted to WakeMed RehabilitationHospital, where a coordinated,comprehensive rehabilitation program willbe developed. While in the Rehab Hospital,each patient will get a minimum of threehours of therapy per day, five days per week.Therapy on weekends will be on an asneeded basis. Available therapies includeoccupational therapy, physical therapy, andspeech therapy. In addition, patients willreceive neuropsychological services, andrecreational therapy on an as needed basis.Pet therapy dogs visit on occasion as well.Typically, between 7 am and 8:30 am, the

[ R E H A B I L I T A T I O N S E T T I N G S ]


occupational therapist will be assistingpatients with ADL’s (grooming, bathing,dressing, toileting, feeding). Patients may bescheduled for therapies any time between8:30 am and 5 pm, with a break over lunchfrom Noon to 1 pm. The therapists assignedto the patient will set up the patient’sMonday through Friday therapy schedule onthe day of admission. A schedule card isplaced in a plastic sleeve on the patient’swheelchair, with a copy posted in thepatient’s room. Saturday and Sunday therapyschedules will be posted in the same placeeach Friday evening.

D A Y T R E A T M E N T P R O G R A M S

WakeMed Outpatient Rehab offers “daytreatment” services. Individuals live at home,but come in several days a week forcontinued coordinated, multi-disciplinarycare with oversight by a case manager.When attending day treatment program,each patient’s schedule is individualized. Thenumber of hours per day, and days per weekof therapy to be given will be determined bythe treatment team upon admission to theprogram, after the initial evaluation iscompleted. Therapies offered includeoccupational therapy, physical therapy, andspeech therapy. In addition, neuro-psychological services, nursing services, andcase management services are available.

O U T P A T I E N T T H E R A P Y

S E R V I C E S

If less intensive services are needed, or if justa single service is needed, an individual mayreceive outpatient treatment at one ofWakeMed’s many outpatient rehabilitationsites. WakeMed currently offers outpatientrehabilitative services at several sites inRaleigh, as well as in Cary, Apex, Fuquay-Varina, Zebulon, and Clayton. Whenreceiving outpatient therapy services, eachpatient’s schedule is individualized. Thenumber of hours per day, and days per weekof therapy to be given will be determined byeach individual therapist upon admission tothe program, after the initial evaluation iscompleted. Therapies offered includeoccupational therapy, physical therapy, andspeech therapy.

H O M E H E A L T H T H E R A P Y

S E R V I C E S

If after discharge from the hospital thepatient is home-bound, and meets certaincriteria, WakeMed may send rehabilitationtherapists to your home to providerehabilitative services. The number of hoursper day, and days per week of therapy to begiven will be determined by each individualtherapist after the initial evaluation iscompleted. Therapies offered includeoccupational therapy, physical therapy, andspeech therapy. In certain cases, a nurse mayalso visit the home.

[ R E H A B I L I T A T I O N S E T T I N G S ]


[ F A M I L Y I N V O L V E M E N T ]

Family involvement in a patient’s care isboth encouraged and appreciated. Familymembers are considered important membersof the treatment team, and good familysupport and involvement can be veryimportant to a patient’s overall recovery.There are a number of ways in which weinvolve families.

C A S E M A N A G E M E N T

The clinical case manager serves as the teamleader and as a point of contact for patientsand their families with the medical/therapystaff. The case manager can help the patientand his or her family with personal,financial, emotional, and social issues thatmay arise during the hospital stay. The casemanager will meet with the patient and/orfamily upon admission to rehab to providean overview of the rehab process. At thismeeting, the case manager will gatherinformation about the patient in order toassess needs and allow the team to know thepatient better. The case manager can alsoarrange individual and group counseling tohelp patients and families learn to cope withproblems resulting from the stroke. The casemanager also provides information toinsurance companies for their review of thepatient’s hospital stay.

The case manager can assist patients andfamilies in coping with the emotions thatoccur throughout the recovery process.Depending on comfort level, patients andfamilies can participate in individual

counseling or participate in a support groupmeeting. The case manager can also referpatients and families to ongoing counselingin the community. There are also a numberof legal and financial issues that may need tobe addressed, if the patient is going to behospitalized and/or incapacitated for aperiod of time. Examples of these issues can be: • Guardianship • Advanced Directives • Short Term/Long Term Disability • Supplemental Security Income (SSI) • Social Security Disability Income (SSDI)• Power of Attorney• FMLA paperwork

The case manager will also be the patientand family’s point-person for dischargeplanning. Throughout a patient’s hospitalstay, the case manager will be discussingoptions that are available for discharge, andwill work with the patient and family to planfor a safe discharge. Patients are typicallydischarged from the inpatient rehab programwhen they have achieved their dischargegoals or progressed to a level that allowsthem to receive rehab services in a homecare setting, outpatient center, or alternativecare setting. Occasionally, patients aredischarged if they fail to demonstratesignificant progress in therapies over aperiod of time, or cannot tolerate the level oftherapy required by the program. Preparingfor discharge from the rehab unit can bevery overwhelming for many patients andfamilies. The case manager will be availablethroughout a patient’s stay to discuss


discharge needs and options, and to ensure asafe, smooth discharge from the rehab unit.

Whether a patient is going back home or toanother location, the case manager will workwith the patient and family to determine thebest way to make this transition. If goinghome at discharge is not an option, the casemanger will help to find a nursing home orassisted living facility that can continue tomeet the patient’s needs. If the patient is toreturn home at discharge, and will continueto need therapy, outpatient rehab, daytreatment, or home health services can bearranged. The case manager will arrangefollow up therapy and order any equipmentneeded before the patient leaves the hospital.The case manager can make referrals tocommunity resources that can continue tohelp the patient and family after discharge.

M E D I C A L R O U N D S

During the stay in the Neuro Care Unit orRehab Hospital, the Physiatrist (a physicianwho specializes in physical rehabilitation)and a Physician Assistant (PA) will visitwith patients every morning. They willaddress any active medical issues and makeany necessary changes in care. This mayinclude changing medication, ordering teststo diagnose new problems or monitorexisting ones, and referring to other healthcare specialists to address specific issues. Thedoctor and the PA will work closely with thenursing staff, case manager, and the therapy

staff, and will meet with them formallyevery week to coordinate care. If necessary,they will also bring in other physicianspecialists to assist with a patient’s care.

If there are medical questions or concerns,please bring them to the attention of thenurse or case manager.

N U R S I N G C A R E

Upon admission to the Neuro Care Unit orRehab Hospital, the admitting nurse will doa complete physical assessment includingheart and lung sounds and examination ofskin for wounds, rashes or reddened areas.The patient and family will be given a copyof My Important Papers which will havehelpful information including patients’rights, advance directives, pain management,and unit-specific information. The patientand family will be asked to answer questionsas part of a nursing admission assessment.They will also be asked to sign a consentform granting permission for use of the“whiteboard” in the patient’s room. Thewhite board is used to record importantinformation needed to coordinate thephysical care of the patient. For example, itwill indicate how much, and what type ofassistance a patient needs with transfers toand from the wheelchair. Caregivers canlook at this board and have a snapshot ofwhat is needed to care for the patient.

We always encourage family participation ina patient’s day-to-day care. We will try to

[ F A M I L Y I N V O L V E M E N T ]


include families during personal care, if family ispresent and willing to participate. We ask thatfamilies do not try to transfer patients to orfrom the bed, wheel chair, or commode, orprovide personal care, until they have hadtraining by the nursing or therapy staff (formalfamily education sessions will be set up by thecase manager). Nursing staff will provideeducation to patients and families regardingcare, medications, and medical conditions. Ourgoal is to enable the families to care for patientsin the safest possible way as they reach theirfullest potential.

Upon admission to one of our day treatmentprograms, the patient and family will meet witha Rehabilitation Nurse who will do a completephysical assessment. During the initial sessionwith the nurse the patient and family will beasked to provide information regarding anycurrent medical issues, a list of currentmedications, and a list of follow up physician’sappointments. The nurse will provide writtenand verbal education to patients and familiesregarding stroke and recovery and will continueto be available as needed throughout the daytreatment stay.

F A M I L Y T R A I N I N G S E S S I O N S

At some point in a patient’s rehabilitation, oftenshortly before discharge from the hospital, orprior to a planned day pass, family memberswho will be responsible for caring for thepatient will be invited to accompany the patientto his or her therapies, so that instruction can beprovided on such things as assisting withwalking, assisting with bathing and dressing,assisting with transferring the patient to andfrom the wheelchair, bed, commode, car, etc.Teaching on special dietary or swallowingprecautions, or administration of medicationsmight be provided as well. This training isdesigned to prepare families to be able to carefor the patient when he or she is dischargedfrom the hospital. Depending on the needs ofeach individual patient, sometimes families willonly need to attend one session. Other times,multiple sessions will be needed. The casemanager will be responsible for arranging thesesessions at a time that is as convenient aspossible for the patient’s family.


Patients who are receiving inpatientrehabilitation on the Neuro Care Unit, or inthe Rehab Hospital will typically be dressedin street clothes each morning, so they willneed several changes of clothing. Loosefitting clothing like T-shirts and elastic waistpants are the best choice. The patient willalso need a good pair of shoes such assneakers. Dirty linen will be gathered in abag in the patient’s bathroom, to belaundered by the family. Families are askedto bring in personal toiletries, such asdeodorant, shampoo, body wash that thepatient prefers to use. Electric razors mayalso be brought in. Other personal itemssuch as radios or CD players can be broughtin, but the hospital cannot be responsible forlost or stolen items. If you have familypictures or albums labeled with names anddates, we would love to incorporate this intheir therapy.

Lists of favorite TV shows, hobbies, music,and other preferences are helpful also.

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W H I L E I N T H E H O S P I T A L ]


This notebook insert was meant to provideyou with introductory information aboutstroke and the rehabilitation process. As youbecome more familiar with strokes, you willprobably have many more questions.WakeMed’s staff has a great deal of expertiseand experience in this area and will provideyou further information or answer yourquestions throughout the rehabilitationprocess. In addition, you may find theresources listed below helpful:

National Stroke Association:http://www.stroke.org

American Stroke Association:http://www.strokeassociation.org

Resources from the Mayo Clinic:http://www.mayo.edu

A guide from American Medical Association:http://www.ama-assn.org

CVA Stroke Support Group: Raleigh Area Stroke Support Groups: Second Tuesday of each month Noon - 1 pm WakeMed Raleigh Campus RehabilitationHospital, Health Park For more information, call 350-4163

Clayton Area Stroke Support Group: Third Wednesday of each month Noon - 1 pm WakeMed Clayton Medical ParkFor more information, call 350-4174

Cary Area Stroke Support Group: First Monday of each month 6:30 - 8 pm WakeMed Cary Hospital Conference Room AFor more information, call 460-9094

WakeMed Stroke Network: See your Case Manager for details abouthaving a former patient who has had a strokecome and talk to you.

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I N P A T I E N T

L O C A T I O N

WakeMed Rehabilitation Hospital3000 New Bern AvenueRaleigh, NC 27610Admissions: 919-350-7876

O U T P A T I E N T

L O C A T I O N S

WakeMed Raleigh Campus(includes Cardiac Rehab)3000 New Bern AvenueRaleigh, NC 27610

WakeMed Raleigh Medical Park23 Sunnybrook Road, Suite 300Raleigh, NC 27610

WakeMed Clayton Medical Park555 Medical Park PlaceClayton, NC 27520

Wake Forest Road3701 Wake Forest RoadRaleigh, NC 27609

WakeMed North Hospital10000 Falls of Neuse RoadRaleigh, NC 27614

WPP-Physical Therapy at North(located in the Physicians Office Pavilion)

10010 Falls of Neuse Road, Suite 015Raleigh, NC 27614

WPP-Physical Therapy atCambridge Village of Apex10000 Cambridge Village LoopApex, NC 27502

WakeMed Cary Hospital(exclusively for pelvic health & lymphedema)

1900 Kildaire Farm RoadCary, NC 27518

Cary(includes Cardiac Rehab)300 Ashville Avenue, Suite 220Cary, NC 27518

W O U N D C A R E

WakeMed Wound CareWakeMed Raleigh Campus3000 New Bern AvenueRaleigh, NC 27610

H O M E H E A L T H

WakeMed Home Health Services2920 Highwoods BoulevardRaleigh, NC 27604

S P E C I A L T Y

O U T P A T I E N T

F I T N E S S P R O G R A M S

& G E N E R A L F I T N E S S

WakeMed Healthworks3000 New Bern AvenueRaleigh, NC 27610

Referrals & QuestionsInpatient: 919-350-7876Outpatient: 919-350-7000WPP-PT practices: 919-350-1508Wound Care: 919-350-4515Home Health: 919-350-7990

WakeMed Rehab locations at Raleigh Campus, Raleigh Medical Park, Clayton Medical Park Wake Forest Road and North Hospital operateunder the license of the WakeMed Raleigh Campus. WakeMed Rehab locations at Cary Hospital and on Ashville Avenue operate under thelicense of WakeMed Cary Hospital. WPP-PT locations operate as independent practices.

R e h a b i l i t a t i o n F a c i l i t i e s [ W A K E M E D R E H A B I L I T A T I O N L O C A T I O N S ]

cerebrovascular accident (cva) - wakemed · a second major cause of stroke is bleeding in the...

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