Creating a patient educational pamphlet tor brain attack /by Jud i th A. Urey. Thesis Nurs. 2000 U73c c .2 CREATING A PATIENT EDUCATIONAL PAMPHLET FOR BRAIN ATTACK By Judith A. Urey, BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: Date Judith Schilling, CRNP, PhD Committee Chairperson ________ Thomas White, MSN, CRNP, CEN Date X. i Table of Contents Contents Page Abstract... iii Chapter 1. Introduction.... 1 Background of the Problem 1 Statement of the Problem 6 Statement of the Purpose 6 Assumptions 6 Limitations 7 Definitions of Terms 7 Theoretical Framework 8 Summary 9 Chapter 2. Review of Literature Written Education Materials Brain Attack History... Brain Anatomy and Physiology Types of Brain Attack .. Risk Factors for Brain Attack .... Prevention of Brain Attack Summary.. Chapter 3. Methodology •• ii Model for Evaluating PEM’s Pre-design phase Design phase .. 17 17 18 Pilot test phase 18 Implementation/distribution phase 19 Evaluation phase 19 SMOG Readability Test 19 Summary 20 Chapter 4. Results 21 Description of the Pamphlet 21 Summary 22 References 23 Appendixes A. McLaughlin SMOG Formula. B. Pamphlet.. 26 iii Creating a Patient Educational Pamphlet For Brain Attack Abstract Many different types of educational materials are used by health care providers to enhance the teaching process in our current health care arena. Persons require simplified information about risk factors and prevention of risks to decrease the incidence and severity of brain attack or stroke. The signs and symptoms of brain attack also need to be emphasized in order that persons will seek emergency help as soon as possible should these symptoms occur. A patient education pamphlet was created for use in a northwestern Pennsylvania medical center. The pamphlet was designed to teach persons about risk factors for brain attack and that brain attack is a medical emergency. The pamphlet included what occurs in the brain during a brain attack, the risk factors for brain attack, a brain attack prevention plan, how to reduce the risk for brain attack, and the signs and symptoms of brain attack. The McLaughlin (1969) SMOG readability formula was used to write the pamphlet at the eighth grade reading level. The Evaluating Printed Education Materials Model (Bernier & Yasko, 1991) was used to develop the pamphlet. Dorothea Orem’s (1995) Self-care Deficit Theory served as the theoretical framework for this scholarly project. 1 Chapter 1 Introduction This chapter presents the project purpose and an overview of the need for an educational brochure concerning risk factors and prevention of brain attack. Dorothea Orem’s (1995) self-care deficit theory is used as a theoretical framework for the scholarly project. The background of the problem, problem statement, purpose of the study, assumptions, limitations, and definition of terms are provided. Background of the Problem Hippocrates, 2400 years ago, recognized and defined stroke as the sudden onset of paralysis, calling it apoplexy (National Institute of Neurological Disorders and Stroke [NINDS], 1999). The first person known to have investigated the pathologic signs of apoplexy was Johann Jacob Wepfer who was bom in Switzerland in 1620. He described the postmortem bleeding in the brains of patients who died of apoplexy and, from his studies, gained knowledge of the carotid and vertebral arteries that supply blood to the brain tissue. Wepfer was the first person to suggest that apoplexy could also be caused by blockage of one of the main arteries. Stroke then become known as cerebral vascular disease (NINDS, 1999). Very little specific treatment was available until recently. In the last two decades basic science and clinical investigators have learned a great deal about stroke. Stroke is a brain attack and is an emergency. Every minute that the brain cells are deprived of oxygen because of a clogged artery from plaque, a blood clot, or ruptured vessel, brain cells die and cannot recover. 2 During an acute stroke, otherwise called brain attack, additional close brain cells are at risk for secondary injury. A chain reaction of electrical and ischemic events ensues in response to the cell death, which can produce larger areas of impaired brain function. Rapid treatment of acute brain attack is imperative to improve chances of survival and minimize the size of brain tissue damage (National Stroke Association [NSA], 1999a). A transcient ischemic attack (TIA) is a hallmark warning of stroke and one- third of all persons who have a TIA progress to a stroke (NS A, 1994a). TIAs are temporary focal brain deficits that reflect known vascular territories. Symptoms clear completely in less that 24 hours (Hickey, 1997). Risk factors for stroke are divided into those that are modifiable and unmodifiable (NSA, 1994b). Medically modifiable risk factors include previous stroke, high blood pressure, carotid artery disease, heart disease, and atrial fibrillation. Additional modifiable risk factors include cigarette smoking, elevated blood cholesterol, excessive alcohol use, obesity, and sedentary life style. Non-modifiable risk factors are age, gender, race, and family history of stroke. The non-modifiable risk factor of age is an important one. After age greater than 55 years, the risk of stroke doubles each decade with two-thirds of all strokes occurring after age 65 (NINOS, 1999). Men are at a greater risk for stroke but 25% more women die from stroke than men (NINOS, 1999). Men normally live shorter lives ttan women do so they are younger when they have a stroke giving them a higher sun™! rate than women. 3 Familial predisposition for hypertension, diabetes mellitus, and the influence of common life styles may also contribute to familial stroke (NINDS, 1999). Racial disparities are seen with African Americans having double the stroke risk of European Americans. African Americans have higher incidences of the genetic diseases diabetes mellitus, hypertension, and sickle cell anemia. African Americans ages 45 to 55 years have four to five times the number of strokes of whites but after age 55 the incidence rate is equal. Incidence and mortality from strokes among Asian, Hispanic, and Native Americans are similar to European Americans. Researchers have found a “stroke belt” (NINDS, 1999) in the southeastern U.S. Persons living there have the highest stroke mortality rates in the country. Three states within the stroke belt - North Carolina, South Carolina and Georgia - have extremely high stroke mortality rates. Their mortality rate is more than twice the mortality rate for the rest of the U.S., as well as being higher than the mortality rate for the rest of the stroke belt states. It is believed that the increased rates are due to lower socioeconomic status and regional life style factors that may include greater preference for salty, high fat foods and increased cigarette smoking. Multiple risks compound the destructive effects and create an overall cumulative efiect. Hypertension is the most powerful risk factor for stroke. Stroke risk increases four to six limes when persistent Hood pressure is greater than 140/90 (NINDS, 1999). Treatment with antihypertensive medication decreases inciderce of stroke by 38% and stroke finality by 40%. Heart disease is the second most powerhd risk footer 4 with atrial fibrillation bringing a four to six-ftld increased risk. Among those older than SO years with atrial fibrillation, one in four persons will have a stroke. Mitral valve stenosis can double the stroke risk; cardiac surgery holds a 1% stroke risk. Diabetes increases stroke risk three times with its highest potential in the 5th to 6th decades of life. Elevated serum cholesterol confers a slightly increased risk due to its propensity to increase athlerosclerosis and arterial plaque formation. Although there are genetic links to hypertension, heart disease, and diabetes, a family history of cerebral vascular malformation is the strongest predictor of stroke. Cerebral autosomal dominant arteriopathy with subcorticol infarcts and leukoencephalopathy is a genetic vascular disease (NINDS, 1999). A rare genetic vascular malformation of abnormally formed blood vessels, it causes strokes, subcortical dementia, migraine-like headaches, and psychiatric disturbances. Symptoms of this disorder begin near age 45 years and most patients do not live to age 65 years. Its incidence in the U.S. is unknown. The most powerful modifiable risk factor for stroke is cigarette smoking. It carries a double risk for ischemic stroke and a 3.5 times increase for subarachnoid hemorrhage. Smoking increases risk by promoting athlerosclerosis but after smoking cessation risk drops to that of someone who has never smoked after 2 to 4 years (NINDS, 1999). Other less notable risk factors include high alcohol consumption and illicit dreg use (NINDS, 1999). Most illicit drugs and alcohol produce this effect by increasing blood pressure Interferon, alcohol, and cocaine also interfere with blood 5 clotting factors and alter blood viscosity thereby increasing the risk of stroke. Neck injuries hold a low modifiable risk for stroke. There are special risks for stroke for women and children (NINDS, 1999). Pregnancy increases risk three to thirteen times and, although rare, subarachnoid hemorrhage is the leading cause of maternal deaths in the U.S. Postpartum women are at a nine times higher risk of ischemic stroke and 28 times higher risk of hemorrhagic stroke from unknown reasons. Menopausal women share an increase risk of stroke if they are not receiving estrogen replacement. Children under age 15 have more hemorrhagic strokes than ischemic strokes. Medical complications that can lead to stroke in children include infection, injury, vascular malformation, sickle cell anemia, and Marfans Syndrome. As summarized by the American Heart Association (1999) the most common signs and symptoms of acute stroke include: 1. Numbness, weakness or paralysis of face, arm, or leg especially if only one side of the body is effected. 2. Sudden blurred or loss of vision in one or both eyes. 3. Difficulty speaking or understanding simple statements. 4. Dizziness, loss of balance, or another symptom. loss of coordination, especially combined with 6 Statement of the Problem During clinical practice this writer recognized a need for an increased awareness of stroke risk factors. Persons could benefit from early detection and treatment of risk factors for acute stroke. Stroke is a brain attack and a medical emergency. In 1999 the number of people within the U.S. who suffered a stroke was over 700,000 (NSA, 1999b). Stroke remains the third leading cause of death in the U.S. and the primary cause of disability with direct and indirect health care costs in excess of $43 billion each year (NSA, 1999b). Preventative care can decrease the occurrence of strokes with their associated death, disability, loss of productivity, and medical costs. Statement of the Purpose The purpose of this scholarly project was to design an educational pamphlet for the general public about brain attack to increase awareness that brain attack is an emergency. Persons experiencing signs and symptoms of brain attack should call 911 and seek emergency treatment immediately. Risk factors and prevention by controlling risk factors were also emphasized. Assumptions The assumptions underlying this scholarly project were as follows: 1. Persons will be able to understand the concept of brain attack and its priority as an emergency. 2. There is a need for a brain attack education pamphlet for persons with risk 7 factors. 3. Persons are motivated to learn. 4. Persons want to have improved health and avoid a brain attack. 5. Information provided by a brain attack pamphlet would lead to improved patient outcomes and decrease disabilities. 6. Persons are able to read at the eighth grade level. Limitations The limitations of this scholarly project included: 1. The pamphlet is limited to persons who are able to read English at least at the eighth grade level, understand the concept of brain attack, and who are interested in a pamphlet on brain attack. 2. The pamphlet was developed by this project director. Definition of Terms The following terms are defined as they were used in this project. 1. Brain attack is an acute ischemic stroke (NINDS, 1996). 2. Atrial fibrillation is rapid and irregular contraction of the atria of the heart. This can lead to formation of blood clots in the heart, which may dislodge and travel to the brain causing an acute ischemic stroke (Bronstein, Popovich, & Stewart- Amidei, 1991). 3. Carotid artery stenosis is a 70% or greater narrowing of the lumen of the carotid artery (Massaro, 1998). 4. Hypercholesterolemia is total blood cholesterol greater than 240 mg/dl (American Heart Association [AHA], 1999). 5. Diabetes mellites is a disease characterized by insufficient secretion and/or 8 utilization of insulin with multiple long-term complications including atherosclerosis and carotid artery stenosis (Dennison, 1996). 6. Obesity is measured by body mass index (BMI) which is a relationship of a person s body weight to their height. A person with a BMI of 25.0 to 29.9 carries a moderate risk for stroke and a person is at higher risk with a BMI over 30.0 (AHA, 1999). 7. Inactive or sedentary life style is a life style consistent with less than 30 minutes of aerobic exercise three times a week (NS A, 1994b). Theoretical Framework The theoretical framework of this scholarly project was Dorothea Orem’s Self- Care Deficit Theory of Nursing. Orem’s 1995 theory is based on the belief that an individual has the ability to initiate and perform their own activities to meet health care needs (self-care) and the needs of their dependents (dependent care) for growth, functioning and development. Orem described self-care agency as the ability to engage in self-care and dependent care agency as the ability to engage in dependent care activities. Self-care agency is vital for performance of self-care. Orem (1995) described therapeutic self-care demand as the regulation of growth and functioning and asserts that it is a role of nurses to assist persons in meeting their own therapeutic self-care demands. The concern arises for the nurse practitioner when there is a deficit between the self-care agency or a dependent care agency and the therapeutic self-care demand. When a self-care deficit occurs the nurse practitioner may assist the person in the care of the disabling stroke or in the prevention of the disabling disease. Assistance is given in maintaining nonnal growth and development, prevention, and the promotion 9 of the person’s well being. Assistance is give„ by the nurse practitioner to help individuals to meet their self-care requisites by means of: (a) acting or doing for another, (b) guiding or directing, (c) providing physical or psychological support, (d) providing and maintaining an environment that supports development, and (e) teaching (Orem, 1995). The nurse practitioner provides assistance by patient teaching. The patient may use a pamphlet for disease prevention and health promotion. Primary prevention is addressed by the nurse practitioner with utilization of the pamphlet and reinforced as the patient rereads it at home. Effective patient education occurs when the nurse practitioner guides patients to learn healthy behavior and assists them to incorporate these behaviors into everyday life. The goal is for the person to achieve their own selfcare and independence (Orem, 1995). Orem described three types of nursing systems as wholly compensatory, partially compensatory, and supportive-educative. The nurse practitioner can assist the selfcare agent in the supportive-educative role by providing written information in the form a pamphlet. The pamphlet then supports the person’s goal of reaching self-care demand and fulfilling self-care deficit. Summary Stroke or brain attack is an emergency and should be treated as a priority (NSA, 1999b). The purpose of this scholarly project was to design an educational pamphlet to increase awareness that brain attack is an emergency. The goal of the writer was to initiate primary prevention to increase the person’s likelihood of obtaining preventative care, and rapid treatment if brain attack symptoms should occur. Dorothea Orem’s self-care deficit theory provided the theoretical framework for 10 this scholarly project. The supportive educative role of the nurse practitioner was emphasized in the improvement of self-care deficit. Assumptions, limitations, and definitions of terms appropriate to this project have been provided. Today’s emphasis on education in the health care environment reinforces the nurse practitioner’s role in the development of education materials for patients and the general public. 11 Chapter 2 Review of Literature The purpose of this scholarly project was to develop an educational pamphlet for brain attack in order to increase awareness that brain attack is an emergency and to help persons control then- risks for stroke. The educational pamphlet will be utilized in a northwestern Pennsylvania medical center. The pamphlet was written to the eighth grade readability level as determined by McLaughlin’s (1969) SMOG formula (Appendix A). This chapter reviews the literature pertaining to the definition, pathophysiology, signs and symptoms, and preventative measures for brain attack. The educative process of pamphlet development also is reviewed. The Evaluating Printed Education Materials (EPEM) model was developed by Bernier and Yasko in 1991. The model describes five phases in the preparation of printed educational material. The five phases are pre-design, design, pilot test, implementation/distribution, and the evaluation phase (Bernier & Yasko, 1991). Written Education Materials Primary healthcare providers play a definitive role in the educational process (Whitman, Graham, Gleit, & Boyd, 1992). Mathis (1989) wrote that educational material should be written simply, precisely, and organized carefully. Lange (1989) suggested using of figures, diagrams, repetition of key points, bold letters, underline, and bright colors for patient and reader interest. It was suggested by Doak, Doak and Root (1985), that 68% of educational materials available are written at the ninth grade level but that the majority of persons in the United States have a reading level at the eighth grade or lower. 12 Brain Attack History Brain attack is the third leading eause of death the „ s md of disability at a cost of oyer $43 billion dollars per year in direct and indirect healthcare costs (AHA, 1999). Health care expenditures include medication, equipment, and loss of productivity. Approximately 500,000 Americans per year suffer from acute ischemic stroke also known as brain attack. Two-thirds of all brain attack victims sustain some form of permanent disability. There are an estimated 3,890,000 brain attack survivors in the United States (Schretzman, 1999). The AHA has heightened the sense of urgency by renaming stroke to that of brain attack, in the hope that persons will realize it is an emergency and requires emergency intervention. Education about the risk factors and prevention guidelines may decrease cost and disability due to brain attack. Brain Anatomy and Physiology The brain houses more than 10 billion cells that transmit messages to and from all the parts of the body. As headquarters for the central nervous system the brain controls every thought and most movement. The central core of the brain is called the brain stem and it performs vital functions such as respiratory drive. The lowest part of the brain stem, the medulla oblongata, connects the brain and spinal cord. Its responsibility is for control of breathing, heartbeat, and body temperature regulation. The pons, located at the front of the brain stem just above the medulla oblongata, serves as a bridge between the right and led hemispheres of the cerebellum. Another purpose is to facilitate communication between the cerebrum, cerebella, and medulla oblongata. Behind the brain stem is a twin-lobe structure the cerebellum that is responsible for coordinating movement, balance, and equilibrium. A small but 13 important organ is a nerve eluster at the base of the brain called the hypothalmus responsible for things such as sleep and wakefulness, thirst and hunger, and sexual urges. The hypothalmus also controls endocrine activity by regulating the work of the pituitary gland and has an important role in the control of emotions of pain and pleasure. The pituitary gland attached to the hypothalmus secretes hormones that regulate growth, reproduction, and other metabolic processes. The cerebrum is the largest part of the brain and is the seat of creativity. It is divided into four lobes or sections defined as the frontal lobe, the occipital lobe, the parietal lobe, and the temporal lobe. The occipital lobe is located in the back of the brain and its centers are responsible for sight. The parietal lobe is located in the upper middle part of the brain and carries functions for touch sensations and spatial orientation. The temporal lobe located near the temples of the skull contains centers for hearing, smell, and memory. The frontal lobe located behind the forehead controls voluntary motor coordination, and higher thought processing centers of memory and reasoning (Dennison, 1996). Blood is supplied to the brain by two main pairs of arteries called the internal carotid arteries and the vertebral arteries. The anterior circulation to the brain is supplied by the common carotids and their distal branches, which include the internal carotid arteries, the middle cerebral arteries, and the anterior cerebral arteries. The posterior circulation is made up of the vertebral arteries, the basilar artery, and posterior arteries (Hickey, 1997). The wide range of signs and symptoms of acute stroke or brain attack are based on the underlying pathology within the cerebral artery affected. The Hood supply can be interrupted by occlusion of the Hood vessel or rupture of the blood vessel. Occlusion of the blood vessel accounts for S5% of all strokes tmd is called ischemic 14 stroke. Rupture of a blood vessel in the brain causes hemorrhagic stroke and is either from an aneurysm or hypertension (Hickey, 1997) A complex cascade of events occurs at the site of the infarcted cerebral tissue. In the penumbra, the area around the necrotic core, cells remain viable for several hours after the ischemic event. This makes it a good target site for pharmacological intervention in the hope of protecting these tissues from further damage. Clinical trials are on-going for neuroprotective agents to protect the cells from secondary injury associated with the ischemic cascade (Hickey, 1997). Types of Brain Attack The pathophysiology of a stroke is divided into two distinct categories: hemorrhage and ischemia. Hemorrhage results when there is bleeding into the brain from either an intracerebral or subarachnoid vessel (Bronstein, Popovich, & Stewart- Amidei, 1991). Intracerebral bleeding is associated with hypertension and subarachnoid bleeding is caused most frequently by a ruptured aneurysm (Hickey, 1997) . Ischemia occurs when the blood supply to the brain tissue is interrupted by a thrombus or embolus (Bronstein et al., 1991). Hemorrhagic strokes account for 17% of the total strokes in the U.S. and ischemic strokes account for 83% (Roberts, 1997). Hemorrhagic strokes can be further categorized into intracerebral hemorrhages (10%) and subarachnoid hemorrhages (7%). Ischemic strokes are further categorized into large or small vessel thrombotic strokes (31%) or embolic strokes (32%) (Massaro, 1998) . Risk Factors for Brain Attack Risk actors are divided into those that are modifiable and nonmodifiable (NSA, 1994a). Age doubles risk for each decade over 55 years. African American race 15 doubles the risk for brain attaek and being male increases risk moderately. Having had a previous stroke or transient ischemia attack (TIA) increases brain attack risk ten times. High blood pressure increases risk four to six times, as does heart disease, especially atnal fibrillation and left ventricular hypertrophy. Diabetes holds increased risk of two to four times and excessive alcohol intake, obesity, and lack of exercise are all associated with increased risk. Smoking increases risk two times and high cholesterol and carotid artery disease each increase risk three times. Persons can reduce their risk of brain attack by becoming aware of their risk factors and taking control by making changes in their life style (NSA, 1994a). Prevention of Brain Attack The National Stroke Association (NSA, 1999b) guidelines for stroke prevention include control of modifiable risk factors and awareness of the uncontrollable risk factors. Controllable risk factors are divided into two basic types including treatable medical disorders and life style factors. Treatable medical disorder risk factors include hypertension, hypercholesterolemia, heart disease, atrial fibrillation, and a history of previous stroke or TIA. Lifestyle risk factors include smoking, excessive alcohol intake, and being overweight. Risk reduction plans should include blood pressure control, a low salt diet, and medication regime compliance (NSA, 1999b). Diet, weight loss, smoking cessation, minimizing alcohol consumption and regular exercise should be life style modifications for those at risk for acute stroke. Persons with atrial fibrillation may need to be treated with anticoagulation therapy or aspirin to decrease the risk of blood clot formation within the heart. Heart disease medication needs to be taken as directed and compliance with the risk reduction p!an is imperative. Chofoterol may need to fie 16 controlled with medication but certainly a low fat, low cholesterol diet is indicated. Stopping smoking will significantly decrease stroke risk within 2 years; within 2 to 4 years of quitting one’s risk will be the same as someone who never smoked (NINDS,1999). Carotid artery surgery may be indicated for carotid artery blockages in the goal of preventing acute stroke (NSA, 1999b). Smith (2000) reported results from the United States Preventative Services Task Force stressing that it is important for clinicians to assist patients in assuming responsibility for their own health. Primary prevention is most often defined as prevention of disease among patients who have not yet developed the disease. Secondary prevention describes the prevention of the sequence of events which leads to further progression of the disease among those who have early, preclinical disease. As a nurse practitioner and a primary care provider, primary prevention can be practiced with emphasis on preventative therapies. Summary The literature review has included Bernier and Yasko s EPEM model for construction of patient educational materials. Written education materials and their role in the education process were described. Brain attack history, risk factors, types of brain attack, and brain anatomy and physiology were included. Prevention of brain attack education was also presented. 17 Chapter 3 Methodology The purpose of this scholarly project was to develop a patient education pamphlet for brain attack risk factors, prevention, and to increase awareness that brain attack is an emergency. Dorothea Orem’s (1995) Self-Care Deficit Theory of Nursing provided the theoretical framework for this project. The Evaluating Printed Educational Materials Model (Bernier & Yasko, 1991) was used to develop the pamphlet. McLaughlin’s (1969) SMOG readability formula was used for 8th grade reading level calculation. Emphasis on education in today’s health care market mandates instructional materials to supplement the educative process. The most common forms of educative materials are printed education materials (Bernier & Yasko, 1991). Model for Evaluating Printed Education Materials The Evaluating Printed Education Materials (EPEM) Model was developed by Bernier and Yasko in 1991. The model describes five phases in the preparation of printed educational material. The five phases are pre-design, design, pilot test, implementation/distribution, and the evaluation phase (Bernier & Yasko, 1991). Pre-design phase. The pre-design phase included establishment of the purpose, intended audience, and objectives for the pamphlet. This pre-design phase included identification of the educational need and clear identification of the intended target population. A review of literature identified deficits in existing educational pamphlets. Input was received from health professionals involved in the care of acute stroke patients including a request for this type of pamphlet by the cardiac care manager in a 18 medical center in northwestern Petmsyjvania. The cost cf.be priming of the pamphlet will be covered by the medical ceMer. Persons delivering the educational pamphlet are knowledgeable about the content and have access to the project director for any questions. Design phase. In the design phase guidelines were written for developing content that emphasized organization, motivational features, linguistics, and graphics. Essential information was covered in three or four main points. This included anatomy and physiology of the brain, risk factors for brain attack, preventions, and signs and symptoms of acute stroke or brain attack. The National Institute of Neurological Disorders and Stroke (1999), the National Stroke Association (1994a, 1994b, 1999a, 1999b), and the American Heart Association (1999) were valuable sources of the information used in the construction of the pamphlet. Pictures were used to improve understanding and each conveyed a single idea or concept. Short simple sentences were used to convey one idea at a time: the pamphlet is written in the second person. Color was used for highlighting material, which promotes learning, and both upper and lower case letters are used for ease of reading. Pilot test phase. Pilot study of the brain attack pamphlet was conducted in December of 2000. In the pilot phase both professionals and lay persons reviewed the materials to provide positive or negative feedback. A pilot test was performed using health professionals and lay persons over age 60. Six intensive care registered nurses and six adult persons over age 60 were asked to review the pamphlet. These persons ages ranged from 39 to 74, 10 were Caucasian and 2 were African American. Request for feedback for ways to revise or improve the content or design of the pamphlet was made. Pilot study revisions included changes in text for simplification of 19 terminology, request for eolor detail, and graphic additions. A single request was made for use of highlighted colors in red. In the interviews, three persons asked for the use of bold type in the description of risk factors. The revisions were made accordingly. The pamphlet overall was thought to be an effective teaching tool and all of the persons who participated in the pilot study expressed interest in the pamphlet. Implementation/distribution phase. Learning potential is maximized by providing the material at a time when it is needed thus fulfilling the implementation and distribution phase of the model. The pamphlet will be made available to persons at screening events sponsored by the medical center. Instruction was provided to the staff for distribution of the pamphlet. Evaluation phase. The evaluation phase is fulfilled on a formal or informal basis using a small, representative sample of patients. The procedure for the evaluation will include feedback from five persons who have experienced a stroke or brain attack. Any new ideas that emerge from the evaluation phase will be shared with the writer and other persons qualified or interested in the project. SMOG Readability Test The SMOG Readability Test (Appendix A) was used to measure the readability of this pamphlet. Ten sentences from the beginning of the pamphlet, ten from the middle, and ten from the end of the pamphlet were used to calculate the formula. There were 33 three syllable words counted which was rounded to 30 as the nearest perfect square. The number achieved was 5 and the number 3 was added to this nearest perfect square a number of S. This number was the SMOG grade which represented the reading grade a person must have reached to My understand the text of the pamphlet (McLaughlin, 1969). This pamphlet was written at the Sth grade readability level. 20 Summary This chapter has described the five phase EPEM model (Bernier & Yasko, 1991) was used as the basis for development of this patient education pamphlet. The SMOG formula developed by McLaughlin (1969) was utilized for the readability of the pamphlet. Pilot study results and revisions are included. 21 Chapter 4 Results This chapter provides the results of the scholarly project to develop an educational pamphlet for brain attack, risk factors, signs and symptoms, and prevention (Appendix B). It was designed for distribution in a northwestern Pennsylvanian medical center. The pamphlet contents are outlined and described. The educational pamphlet was designed to provide information about brain attack or acute stroke, risk factors, signs and symptoms of stroke, and preventative care. Dorothea Orem’s concept of self-care was the theoretical basis of the scholarly project. Bernier and Yasko’s EPEM model for development of educational pamphlet was utilized and the SMOG formula for readability was calculated. The goal of the pamphlet was to increase awareness of persons in a northwest Pennsylvania community about brain attack and its prevention. Description of the Pamphlet The pamphlet described in detail the pathophysiology of brain attack. Risk factors were divided into modifiable and non-modifiable. A brain attack prevention plan was described, highlighting all elements of risk reduction. Brain attack signs and symptoms were presented and discussed with emphasis on the fact that brain attack is an emergency. The pamphlet was 6 pages in length. The Broderbund Print Shop Deluxe version 6.0 computer program was utilized for addition of graphics and border details. Headings were done in bright red for attention purposes and bold lettering was used for added detail to listed items in the pamphlet. The graphic pictures correlated to the text at their origin of insertion and size was acco p manipulation of the program features. 22 Summary This chapter includes the result of a scholarly project for development of an educational pamphlet for brain attack. The description of the pamphlet is provided. 23 References American Heart Association (1999). Controlling your risk factors [Brochure], Dallas, TX: Author. Bernier, M., & Yasko, J. (1991). Designing and evaluation printed education materials. Model and instrumentation development. Patient Education and Counseling, 18, 253-262. Bronstein, K., Popovich, J., & Stewart-Amidei, C. (1991). Promoting stroke recovery. St. Louis: Mosby Year Book. Dennison, R. (1996). Pass CCRN. St. Louis: Mosby Year Book. Doak, C., Doak, L.,& Root, J. (1985). Teaching patients with low literacy skills. Philadelphia: Lippincott. Hickey, J. (1997). Neurological and neurosurgical nursing (4th ed.). New York: Lippincott. Lange, J. (1989). Developing printed materials for patient education. Dimensions of critical care nursing,8, 250-259. Massaro, L., Brain attack overview & treatment, Northwest PA Nurse Practitioner Conference, October 9, 1998, Riverside Inn, Cambridge Springs, PA. Mathis, D. (1989). Writing patient education materials. Orthopaedic Nursing,8(5), 39-42. McLaughlin, H. (1969). SMOG grading-A new readability formula. Journal of 24 Reading., 12, 639-645. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1996). A systems approach to immediate evaluation and management of hyperacute stroke. Stroke, 28(8), 15-23. National Institute of Neurological Disorders and Stroke (May, 1999). Stroke hope through research. Bethesda, MD: Author. National Stroke Association (1994a). Stroke prevention: Reducing risk & recognizing symptoms [Brochure]. Englewood, CO: Author. National Stroke Association (1994b). Your NS A stroke risk appraisal and prevention plan [Brochure]. Englewood, CO: Author. National Stroke Association (1999a). Stroke is a brain attack [Brochure]. Englewood, CO: Author. National Stroke Association (1999b). The brain at risk - Understanding.and preventing stroke [Brochure]. Englewood, CO: Author. Orem, D. E. (1995). Nursing: concepts of practice (5th ed.). St. Louis: Mosby Year Book. Roberts, C. (1997). Focus on thrombolytic therapy for acute ischemic stroke. Heartbeat^), 1-11. Schretzman, D. (1999). Aca.e ischemic s.reke. TteNurse Practi.ioner, 24(2), 71- 72, 75, 80, 82, 87-88. 25 Smith, S. C. (2000). Putting prevention into daily practice. In K. Robinson (Ed.) The Medical Clinics of North America, 84, pp. 267-278. Philadelphia, PA: Saunders. Whitman, N., Graham, B., Gleit, C., & Boyd, M. (1992). Teaching in nursing practice (2nd ed.). Norwalk, CT: Appleton & Lange. 26 Appendix A McLaughlin SMOG Formula The SMOG formula was originally developed by G. Harry Me Laughlin in 1969. It will predict the grade-level difficulty of written material within 1.5 grades in 68% of the written passages tested. It is simple to use and faster than most other measures. The procedure is presented below: Instructions 1. You will need 30 sentences. Count out 10 consecutive sentences near the beginning, 10 consecutive from the middle, and 10 from the end. For this purpose, a sentence is any string of words punctuated by a period (.), and exclamation point (!), or a question mark (?). 2. From the entire 30 sentences, count the words containing three or more syllables, including repetitions. 3. Obtain the grade level from Table on the next page, or calculate the grade level as follows: Determine the nearest perfect square rooi>t of the total number of words of constant of 3 to the square root to obtain the grade three or more syllables and then add a c< level. Example. Total number of multi-syllabic (3) or more syllables w 67 64 Nearest perfect square.. 27 Square root Add constant 3 Grade 11 is the grade level for this example. ..8 11 28 Smog Conversion Table Word Count Grade Level 0-2 4 3-6 5 7-12 6 13-20 7 21-30 8 31-42 9 43-56 10 57-72 11 73-90 12 91-110 13 111-132 14 133-156 15 157-182 16 183-210 17 211-240 18 McLaughlin, C. H. (1969). SMOG-grading: A new Journal of Reading, 12, 639-645. readability formula. ■ Appendix B i ♦ I I Bl Ik: I1 B & STROKE IS A “BRAIN ATTACK” S' I CALL 911 An educational pamphlet for brain attack a D Stroke or “Brain Attack”: What Happens To Your Brain Blood vessels that supply oxygen to the vital tissues in the brain can get blocked or break open. This causes a brain attack or stroke. If a stroke happens because a blood vessel gets blocked, it is called an ischemic stroke. If the blood vessel breaks, it is called a hemorrhagic stroke. Ischemic strokes are the most common and are usually painless. Hemorrhagic strokes are usually associated with severe painful headache, upset stomach. ft II I II - and vomiting. Stroke is the third leading cause of death in the United States. It is the main cause of disability. Several things increase a person’s risk ot having a stroke. Everyone can benefit from decreasing their risks for acute stroke. Preventative care can decrease strokes and their associated disabilities, death, loss of productivity, and medical costs. S i M What Are The Risk Factors For Brain Attack? AGE: Over 55 years, a person’s risk doubles every 10 years i RACE: African Americans have twice the risk as White Americans ♦ GENDER: Males have slightly more risk than females HIGH BLOOD PRESSURE: High blood pressure increases risk four to six times DIABETES: Diabetes increases risk two to four times HEART DISEASE: Especially an irregular heart beat, called Atrial Fibrillation, increases risk four to six times HIGH CHOLESTEROL: High cholesterol increases risk three times ♦ SMOKING: Smoking cigarettes increases risk two times * CAROTID ARTERY DISEASE: The carotid artery in the neck supplies blood to the t brain. If it is partially blocked, risk of stroke increases three times PREVIOUS MINI-STROKE (TIA) OR STROKE: Increases risk of another TIA or I 5< stroke ten times EXCESSIVE ALCOHOL INTAKE: Drinking too much alcohol causes a moderate increased risk OBESITY: Being very overweight increases risk moderately EXERCISE: Lack of regular exercise causes a moderate increased risk I WHAT SHOULD YOU DO? Brain Attack Prevention Plan ♦> Prevention includes controlling whatever risk factors you can, and being aware of those risk factors that can’t be controlled. Risk factors that can’t be controlled are I I divided into treatable medical disorders and lifestyle factors. Treatable medical disorders include: high blood pressure, high blood cholesterol, diabetes, carotid artery disease (clogged neck arteries), heart disease, atrial fibrillation (irregular heart beat), and a [4 history or previous stroke or mini stroke (TIA). Lifestyle risk factors include smoking, » excessive alcohol intake, high salt diet, and being overweight. 4’ S’ ♦> p; HOW CAN YOU REDUCE YOUR RISK FOR BRAIN ATTACK? HIGH BLOOD PRESSURE: Keep your blood pressure below 135/85 HIGH BS ,OOD C HOLESTEROL: Keep your blood cholesterol less than 200 mg/dl DIABETES: Have regular medical checkups and control your blood sugar levels CAROTID ARTERY DISEASE: Some people may need surgery to remove the buildup I of plaque in the arteries in their neck HEART DISEASE: Follow your doctor’s instructions for medication, diet, and exercise s I programs ♦ ATRIAL FIBRILLATION: People with atrial fibrillation take blood thinning medications to prevent clots from forming in the heart SMOKING: Stop smoking immediately EXCESSIVE ALCOHOL INTAKE: Limit alcohol intake to 4 ounces of wine, 12 ounces of beer, or I ounce of whiskey each day OBESITY: Participate in a weight reduction plan REGULAR EXERCISE: Get 30 minutes of exercise 3 times weekly HIGH SALT DIET: Limit your salt intake and don’t use added salt. Eat fewer salty foods and don’t add salt to your food at the table MEDICATIONS: Always follow your doctor’s directions when taking medications JI I I M BRAIN ATTACK: KNOW THE SYMPTOMS Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden trouble seeing with one or both eyes ♦ Sudden confusion, trouble speaking, or trouble understanding what others are saying Sudden trouble walking, dizziness, loss of balance, or loss of coordination Sudden severe headache I BRAIN ATTACK OR STROKE IS AN EMERGENCY - CALL 911! If you are having a stroke or brain attack emergency, treatment may save your life and increase your chances for recovery. Meadville Medical Center oilers complete stroke care and advanced forms of treatment. I I■ I I I