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