Persons with stroke and their nursing care in nursing homes

Abstract

The overall aim of this thesis was to describe and explore the health status and health care needs of persons with stroke in relation to care planning following acute hospital care, as well as health status in persons living in nursing homes (NHs), focusing on those with stroke, their nursing care needs and nursing care.

The RAI, a multidimentional instrument, was used to assess the health status of the persons. Patients (n= 114) from two acute stroke wards were assessed at time for discharge decision. Reason for discharge placement and further care planning were collected from the patients' case records. 519 persons from thirteen NHs, of whom 100 suffered from a stroke were assessed according to RAI, as well as 40 persons with a stroke living in 5 NHs. Registered nurses (RNs) (n=30) were interviewed about the persons with stroke (n=40) and the nursing care provided as well as about their knowledge in stroke care. In addition these person's nursing records were reviewed. Statistical analyses were used to test differences in health status among the patients in relation to discharge placement, and in relation to diagnose groups among the 519 persons in NHs.

Results showed that discharge decision from acute care was uncertain for some of the most severely impaired patients often discharged to a nursing home, due to a very short time before the decision (mean 5.6 days). Bowel and bladder incontinence and eating and feeding problems were seldom recorded in the discharge summary and for some patients discharged to a NH further care planning were insufficient.

There were significant differences between the diagnose groups in many functions, and frequency of very/severely impaired cognition were 30% in persons with stroke, more than half in persons with dementia and 15% in the rest. Persons with stroke were most in need of extensive or total assistance in many of the activities of daily life (AM).

Qualitative content analyses was used to analyse the interviews and nursing records. Cognition, mood, eating, feeding, nutrition, pain, urinary elimination and transfer were areas that became the focus for the analyse.

The RNs descriptions of such care in nursing homes elucidated the complexity arising from these disorders in the individual's daily life. The RNs' descriptions of the persons' disabilities and disorders often lacked a diagnostic reasoning and like there interventions, were expressed in everyday language. Uncertainty was expressed about the persons' disorders and disabilities, their causes and treatment. This was probably aggravated by communication difficulties with many of the patients, lack of knowledge of stroke care, lack of time to observe and interact with these persons, not using any instrument to help achieve a better description and differentiation of the disorders, poor access to or collaboration with multiprofessional staff. There was also a contrasting picture, mostly from the RNs with special training in stroke care and collaboration with paramedical staff.

Thus several of the nursing homes appeared not to provide adequate care for stroke patients. There is a risk that some old, severely impaired stroke patients, discharged to a nursing home shortly after the onset and with a vague care plan, do not get the care needed and fail to rehabilitate to maximum potential or to preserve function.