State-of-the-Science Nursing Review Nursing Best Practices to Prevent Stroke in Women Elaine T. Miller, PhD, RN, CRRN
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troke remains the third leading cause of death in women affecting 3.8 million women compared with 3 million men.1,2 Almost half of the women surviving stroke are anticipated to have residual deficits, including cognitive dysfunction and weakness 6 months later.3 With the aging population and increased longevity of women in our society, there is an urgent need to concentrate on stroke prevention for women, identify those most at risk, and then take immediate action. Nurses practice in a variety of clinical settings (eg, hospitals, clinics, schools, community outreach programs, etc), thereby having numerous opportunities to empower others to reduce the likelihood of stroke through education and management of personal risk behaviors. The purpose of this article is to summarize best evidence underpinning essential nursing activities targeting stroke prevention in women.
Identification of Key Stroke Risk Factors for Women A variety of risk factors trigger nurses and other healthcare providers (HCPs) to immediately act. The most prominent stroke risk factors for women are the following:
• Hypertension: Stage I hypertension with systolic blood
pressure (SBP) 140 to 159 or diastolic blood pressure (DBP) of 80 to 90; stage 2 SBP ≥160 or DBP ≥100.4 • Preeclampsia and eclampsia and pregnancy-induced hypertension. High blood pressure during pregnancy is defined as mild (SBP 140–149 mm Hg or DBP 90-99) and moderate (SBP 150–159 mm Hg or DBP 100–109 mm Hg) or severe SBP ≥160 mm Hg or DBP ≥110 mm Hg).5 • Obesity: defined as a body mass index of ≥30 kg/m2 is associated with increased risk of stroke even after adjustment for other factors, such as age, physical activity, smoking, alcohol consumption, and conditions, such as hypertension and diabetes mellitus.1,5 • Atrial fibrillation (AF): note if present recognizing that elderly women (ie, ≥75 years)are at higher risk for stroke if AF is present.5 • Oral contraception: may be harmful to women with additional stroke risk factors, such as cigarette smoking, prior thromboembolic events.5 • Hormone replacement therapy: concerns seem similar to cardiovascular disease and should not be used as primary or secondary prevention of stroke in postmenopausal women.5 • Migraine with aura: increased stroke risk occurs in women who also smoke and have the aura.5
Most research studies indicate no sex differences in treatment seeking time when a stroke is suspected, a few others suggest some women, especially from minority groups, tend to wait longer than men.6,7 When assessing women, HCPs should always emphasize the importance of seeking immediate treatment (125 mg/dL or receiving treatment Stroke or TIA • History of cerebral ischemia Vascular disease • Prior myocardial infarction, peripheral artery disease or aortic plague
•Females at higher risk BP indicates blood pressure; and TIA, transient ischemic attack.
(not even aspirin) with a score of 0, and optional aspirin with a score of 1.11 For patients with a prior stroke, transient ischemic attack, or CHA2DS2-VASc score of ≥2, oral anticoagulants are recommended with options being warfarin, diabigatran, rivaroxaban, or apixaban.11 “In patients with AF, antithrombotic therapy should be individualized based on shared decision-making after discussion of the absolute and relative risks of stroke and bleeding, and the patient’s values and preferences” (January 24).11
Essential Considerations in Designing and Implementing Nursing Interventions Advance practice nurses recognize that long-term care management is characterized by a multifaceted and dynamic interaction of factors affecting knowledge, as well as attitudinal and behavioral outcomes. Essential considerations include sex, age, culture and race/ethnicity, learning styles, emotional status, readiness to learn, readiness to change, developmental stage, literacy, and self-efficacy.12–17 Kulturel-Konak and colleagues14 found that women prefer hands-on learning experiences, make intuitive or feeling-based judgments, are more people-oriented, and more comfortable with ambiguity. Educational interventions are also more effective when the teaching is learner-centered and individualized.13,16 Fundamental nursing care aspects producing successful behavioral change outcomes include consistent patient monitoring, scheduling regular follow-up and healthcare support (eg, education, counseling), control of substance abuse, such as alcohol and smoking, individualized dietary regimen, including fat, salt, fruit, and vegetable intake along with medication regimen monitoring and adjustment to manage BP.9–15 Results from Chiu and Wong’s randomized control trial further revealed that nurse-run clinics have positive effects on BP control, and adherence to health lifestyle and follow-up telephone call reinforce the coaching efforts of nurse clinical
consultations.15 Another 2014 nursing study targeting adults with AF emphasized the importance of individualized patient education to achieve positive outcome for older adults who had cognitive, as well as functional, limitations.16 Providing quality evidence-based care requires that nurses and other HCPs receive consistent continuing education to maintain their stroke knowledge (eg, risk factors, treatment guidelines, etc) and how to translate this knowledge into practice.12,13,16–20 Sustainability of staff, patient, and family stroke knowledge and behavior change remains a persistent challenge requiring multiple teaching/learning events and reinforcement to achieve targeted outcomes.12,13,15–21 There is no simple formula pertaining to the timing, frequency, and length of each educational intervention.12,13,15,19 Assessing the immediate outcome of each encounter is essential along with structuring a plan of a focused individualized educational encounters with repetition of content through alternative learning modes (eg, patient teachback what is learned, handout listing key points, review questions with short quiz/assessment of learning, simulations, small group discussions) to reinforce learning retention.12,13,15–19 So how is the learning experience best packaged to maximize stroke prevention in women? For most Americans, the average reading level is at the 8th or 9th grade level with 1 out of 5 adults reading at or below the 5th grade level.11,19,20 Yet, the majority of patient educational materials (55% to 90%) are written at the 9th grade level or higher making reading and comprehension difficult for many citizens.21,22 Consistently, patients rate the provision of stroke education as a major care priority, but indicate providing a single brochure is not adequate.23–28 Patients want tailored educational strategies that extend over a period of time, perhaps as often as 6 to 8 times, with a consistent educator coordinating the experience (often identified as the nurse).12–17,23–29 Effective approaches include problem solving, goal setting with specific and tailored action plans, measurable outcomes, use of educational experiences incorporating not just printed materials, but video, internet resources, simulation, gaming, discussion groups, access to experts (eg, nurses, physicians, psychologists, case managers), stress management activities, and hands-on-training pertaining to medication management, diet choices, and feasible exercise.12–17,23–29
Conclusions HCPs and nurses in particular must take advantage of every opportunity to educate and reinforce stroke prevention in women (ie, stroke signs/symptoms, risk factors, strategies to reduce individual risk factors and importance of seeking treatment immediately) when a stroke or transient ischemic attack is suspected. Women of all ages should be targeted who are at risk and not just women ≥50 years. Numerous areas of investigation are still needed and should concentrate on the most salient risk factors and aspects affecting outcomes (eg, timing and intensity of nursing efforts, preferred combinations of teaching and care management approaches, cost effectiveness) for different age, race, education, socioeconomic, and cultural groups of women. Great strides have occurred, but more research and its translation into nursing practice must occur. For, nurses will continue to play a pivotal role in the prevention of stroke in women whether in a clinical or social setting.
Downloaded from http://stroke.ahajournals.org/ at CONS CALIFORNIA DIG LIB on November 14, 2015
Miller Nursing Best Practices to Prevent Stroke in Women e77
Take-Home Points
• Interventions to prevent stroke in women should be individualized (patient-centered) with coordinated opportunities that incorporate multiple tailored strategies to achieve targeted outcomes. • HCPs should routinely assess if intended outcomes are achieved and revise their plan as needed. • Management of stroke risk factors for women is a life-long process. • Stroke prevention should focus on women of all ages, with an emphasis on those most at risk.
None.
Disclosures References
1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292. doi: 10.1161/01.cir.0000441139.02102.80. 2. National Center for Health Statistics. Health, United States, 2011. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2012. http://www.cdc.gov/nchs/hus/contents2011.htm#031. Accessed September 25, 2014. 3. Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119– 126. doi: 10.1016/S1052-3057(03)00042-9. 4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. doi: 10.1001/jama.289.19.2560. 5. Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council for High Blood Pressure Research. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1545–1588. doi: 10.1161/01.str.0000442009.06663.48. 6. Barr J, McKinley S, O’Brien E, Herkes G. Patient recognition of and response to symptoms of TIA or stroke. Neuroepidemiology. 2006;26:168–175. doi: 10.1159/000091659. 7. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. 2006;37:1248–1253. doi: 10.1161/01.STR.0000217200.61167.39. 8. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507– 520. doi: 10.1001/jama.2013.284427. 9. Hong WH. Evidence-based nursing practice for health promotion in adults with hypertension: a literature review. Asian Nurs Res (Korean Soc Nurs Sci). 2010;4:227–245. doi: 10.1016/S1976-1317(11)60007-8. 10. Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41:2731–2738. doi: 10.1161/STROKEAHA.110.590257.
11. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–e76. doi: 10.1016/j.jacc.2014.03.022. 12. Miller EL, Murray L, Richards L, Zorowitz RD, Bakas T, Clark P, et al; American Heart Association Council on Cardiovascular Nursing and the Stroke Council. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41:2402–2448. doi: 10.1161/STR.0b013e3181e7512b. 13. Kitchie S. Determinants of learning. In: Bastable SB, ed. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 4th ed. Burlington, MA: Jones and Bartlett Learning; 2014:114–163. 14. Kulturel-Konak S, D’Allegro ML, Dickinson A. Review of gender differences in learning styles: suggestions for STEM education. Contemp Issues Educ Res. 2011;4:9–16. 15. Chiu CW, Wong FK. Effects of 8 weeks sustained follow-up after a nurse consultation on hypertension: a randomised trial. Int J Nurs Stud. 2010;47:1374–1382. doi: 10.1016/j.ijnurstu.2010.03.018. 16. Ferguson C, Inglis SC, Newton PJ, Middleton S, Macdonald PS, Davidson PM. Atrial fibrillation: stroke prevention in focus. Aust Crit Care. 2014;27:92–98. doi: 10.1016/j.aucc.2013.08.002. 17. Struwe JH, Baernholdt M, Noerholm V, Lind J. How is nursing care for stroke patients organised? Nurses’ views on best practices. J Nurs Manag. 2013;21:141–151. doi: 10.1111/jonm.12016. 18. Lawrence M., Kerr S, Watson HE, Jackson J, Brownice MG. A survey of stroke nurses’ knowledge of secondary prevention lifestyle issues. Br J Neurosci Nurs. 2009;5:518–523. 19. Oikarinen A, Kääriäinen M, Kyngäs H. A framework of counseling for patients with stroke in nursing: a narrative literature review. J Neurosci Nurs. 2014;46:E3–E14. doi: 10.1097/JNN.0000000000000079. 20. Sarna LP, Bialous SA, Kraliková E, Kmetova A, Felbrová V, Kulovaná S, et al. Impact of a smoking cessation educational program on nurses’ interventions. J Nurs Scholarsh. 2014;46:314–321. doi: 10.1111/ jnu.12086. 21. Hoffmann T, McKenna K. Analysis of stroke patients’ and carers’ reading ability and the content and design of written materials: recommendations for improving written stroke information. Patient Educ Couns. 2006;60:286–293. doi: 10.1016/j.pec.2005.06.020. 22. Shieh C, Hosei B. Printed health information materials: evaluation of readability and suitability. J Community Health Nurs. 2008;25:73–90. doi: 10.1080/07370010802017083. 23. Sit JW, Yip VY, Ko SK, Gun AP, Lee JS. A quasi-experimental study on a community-based stroke prevention programme for clients with minor stroke. J Clin Nurs. 2007;16:272–281. doi: 10.1111/j.1365-2702.2005.01522.x. 24. Cameron V. Best practices for stroke patient and family education in the acute care setting: a literature review. Medsurg Nurs. 2013;22:51–55, 64. 25. Sullivan KA, Katajamaki A. Stroke education: retention effects in those at low- and high-risk of stroke. Patient Educ Couns. 2009;74:205–212. doi: 10.1016/j.pec.2008.08.024. 26. Bakas T, Clark PC, Kelly-Hayes M, King RB, Lutz BJ, Miller EL; American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. Evidence for stroke family caregiver and dyad interventions: a statement for healthcare professionals from the American Heart Association and American Stroke Association. Stroke. 2014;45:2836–2852. doi: 10.1161/STR.0000000000000033. 27. Sullivan KA, White KM, Young RM, Scott C, Mulgrew K. Developing a stroke intervention program: what do people at risk of stroke want? Patient Educ Couns. 2008;70:126–134. doi: 10.1016/j.pec.2007.09.006. 28. See L, Peng PI, Lin N, Lai H, Chang K, Jean W, et al. Acceptability of an education computer multimedia on safe use of medication and patients and family members. Int J Risk Safety Med. 2010;22:137–148. 29. Stone K. Enhancing preparedness and satisfaction of caregivers of patients discharged from an inpatient rehabilitation facility using an interactive website. Rehabil Nurs. 2014;39:76–85. doi: 10.1002/rnj.123. Key Words: nursing ◼ nursing management ◼ prevention ◼ primary care ◼ stroke
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Nursing Best Practices to Prevent Stroke in Women Elaine T. Miller Stroke. 2015;46:e75-e77; originally published online March 10, 2015; doi: 10.1161/STROKEAHA.114.006320 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
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troke remains the third leading cause of death in women affecting 3.8 million women compared with 3 million men.1,2 Almost half of the women surviving stroke are anticipated to have residual deficits, including cognitive dysfunction and weakness 6 months later.3 With the aging population and increased longevity of women in our society, there is an urgent need to concentrate on stroke prevention for women, identify those most at risk, and then take immediate action. Nurses practice in a variety of clinical settings (eg, hospitals, clinics, schools, community outreach programs, etc), thereby having numerous opportunities to empower others to reduce the likelihood of stroke through education and management of personal risk behaviors. The purpose of this article is to summarize best evidence underpinning essential nursing activities targeting stroke prevention in women.
Identification of Key Stroke Risk Factors for Women A variety of risk factors trigger nurses and other healthcare providers (HCPs) to immediately act. The most prominent stroke risk factors for women are the following:
• Hypertension: Stage I hypertension with systolic blood
pressure (SBP) 140 to 159 or diastolic blood pressure (DBP) of 80 to 90; stage 2 SBP ≥160 or DBP ≥100.4 • Preeclampsia and eclampsia and pregnancy-induced hypertension. High blood pressure during pregnancy is defined as mild (SBP 140–149 mm Hg or DBP 90-99) and moderate (SBP 150–159 mm Hg or DBP 100–109 mm Hg) or severe SBP ≥160 mm Hg or DBP ≥110 mm Hg).5 • Obesity: defined as a body mass index of ≥30 kg/m2 is associated with increased risk of stroke even after adjustment for other factors, such as age, physical activity, smoking, alcohol consumption, and conditions, such as hypertension and diabetes mellitus.1,5 • Atrial fibrillation (AF): note if present recognizing that elderly women (ie, ≥75 years)are at higher risk for stroke if AF is present.5 • Oral contraception: may be harmful to women with additional stroke risk factors, such as cigarette smoking, prior thromboembolic events.5 • Hormone replacement therapy: concerns seem similar to cardiovascular disease and should not be used as primary or secondary prevention of stroke in postmenopausal women.5 • Migraine with aura: increased stroke risk occurs in women who also smoke and have the aura.5
Most research studies indicate no sex differences in treatment seeking time when a stroke is suspected, a few others suggest some women, especially from minority groups, tend to wait longer than men.6,7 When assessing women, HCPs should always emphasize the importance of seeking immediate treatment (125 mg/dL or receiving treatment Stroke or TIA • History of cerebral ischemia Vascular disease • Prior myocardial infarction, peripheral artery disease or aortic plague
•Females at higher risk BP indicates blood pressure; and TIA, transient ischemic attack.
(not even aspirin) with a score of 0, and optional aspirin with a score of 1.11 For patients with a prior stroke, transient ischemic attack, or CHA2DS2-VASc score of ≥2, oral anticoagulants are recommended with options being warfarin, diabigatran, rivaroxaban, or apixaban.11 “In patients with AF, antithrombotic therapy should be individualized based on shared decision-making after discussion of the absolute and relative risks of stroke and bleeding, and the patient’s values and preferences” (January 24).11
Essential Considerations in Designing and Implementing Nursing Interventions Advance practice nurses recognize that long-term care management is characterized by a multifaceted and dynamic interaction of factors affecting knowledge, as well as attitudinal and behavioral outcomes. Essential considerations include sex, age, culture and race/ethnicity, learning styles, emotional status, readiness to learn, readiness to change, developmental stage, literacy, and self-efficacy.12–17 Kulturel-Konak and colleagues14 found that women prefer hands-on learning experiences, make intuitive or feeling-based judgments, are more people-oriented, and more comfortable with ambiguity. Educational interventions are also more effective when the teaching is learner-centered and individualized.13,16 Fundamental nursing care aspects producing successful behavioral change outcomes include consistent patient monitoring, scheduling regular follow-up and healthcare support (eg, education, counseling), control of substance abuse, such as alcohol and smoking, individualized dietary regimen, including fat, salt, fruit, and vegetable intake along with medication regimen monitoring and adjustment to manage BP.9–15 Results from Chiu and Wong’s randomized control trial further revealed that nurse-run clinics have positive effects on BP control, and adherence to health lifestyle and follow-up telephone call reinforce the coaching efforts of nurse clinical
consultations.15 Another 2014 nursing study targeting adults with AF emphasized the importance of individualized patient education to achieve positive outcome for older adults who had cognitive, as well as functional, limitations.16 Providing quality evidence-based care requires that nurses and other HCPs receive consistent continuing education to maintain their stroke knowledge (eg, risk factors, treatment guidelines, etc) and how to translate this knowledge into practice.12,13,16–20 Sustainability of staff, patient, and family stroke knowledge and behavior change remains a persistent challenge requiring multiple teaching/learning events and reinforcement to achieve targeted outcomes.12,13,15–21 There is no simple formula pertaining to the timing, frequency, and length of each educational intervention.12,13,15,19 Assessing the immediate outcome of each encounter is essential along with structuring a plan of a focused individualized educational encounters with repetition of content through alternative learning modes (eg, patient teachback what is learned, handout listing key points, review questions with short quiz/assessment of learning, simulations, small group discussions) to reinforce learning retention.12,13,15–19 So how is the learning experience best packaged to maximize stroke prevention in women? For most Americans, the average reading level is at the 8th or 9th grade level with 1 out of 5 adults reading at or below the 5th grade level.11,19,20 Yet, the majority of patient educational materials (55% to 90%) are written at the 9th grade level or higher making reading and comprehension difficult for many citizens.21,22 Consistently, patients rate the provision of stroke education as a major care priority, but indicate providing a single brochure is not adequate.23–28 Patients want tailored educational strategies that extend over a period of time, perhaps as often as 6 to 8 times, with a consistent educator coordinating the experience (often identified as the nurse).12–17,23–29 Effective approaches include problem solving, goal setting with specific and tailored action plans, measurable outcomes, use of educational experiences incorporating not just printed materials, but video, internet resources, simulation, gaming, discussion groups, access to experts (eg, nurses, physicians, psychologists, case managers), stress management activities, and hands-on-training pertaining to medication management, diet choices, and feasible exercise.12–17,23–29
Conclusions HCPs and nurses in particular must take advantage of every opportunity to educate and reinforce stroke prevention in women (ie, stroke signs/symptoms, risk factors, strategies to reduce individual risk factors and importance of seeking treatment immediately) when a stroke or transient ischemic attack is suspected. Women of all ages should be targeted who are at risk and not just women ≥50 years. Numerous areas of investigation are still needed and should concentrate on the most salient risk factors and aspects affecting outcomes (eg, timing and intensity of nursing efforts, preferred combinations of teaching and care management approaches, cost effectiveness) for different age, race, education, socioeconomic, and cultural groups of women. Great strides have occurred, but more research and its translation into nursing practice must occur. For, nurses will continue to play a pivotal role in the prevention of stroke in women whether in a clinical or social setting.
Downloaded from http://stroke.ahajournals.org/ at CONS CALIFORNIA DIG LIB on November 14, 2015
Miller Nursing Best Practices to Prevent Stroke in Women e77
Take-Home Points
• Interventions to prevent stroke in women should be individualized (patient-centered) with coordinated opportunities that incorporate multiple tailored strategies to achieve targeted outcomes. • HCPs should routinely assess if intended outcomes are achieved and revise their plan as needed. • Management of stroke risk factors for women is a life-long process. • Stroke prevention should focus on women of all ages, with an emphasis on those most at risk.
None.
Disclosures References
1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–e292. doi: 10.1161/01.cir.0000441139.02102.80. 2. National Center for Health Statistics. Health, United States, 2011. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2012. http://www.cdc.gov/nchs/hus/contents2011.htm#031. Accessed September 25, 2014. 3. Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119– 126. doi: 10.1016/S1052-3057(03)00042-9. 4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. doi: 10.1001/jama.289.19.2560. 5. Bushnell C, McCullough LD, Awad IA, Chireau MV, Fedder WN, Furie KL, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council for High Blood Pressure Research. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1545–1588. doi: 10.1161/01.str.0000442009.06663.48. 6. Barr J, McKinley S, O’Brien E, Herkes G. Patient recognition of and response to symptoms of TIA or stroke. Neuroepidemiology. 2006;26:168–175. doi: 10.1159/000091659. 7. Mandelzweig L, Goldbourt U, Boyko V, Tanne D. Perceptual, social, and behavioral factors associated with delays in seeking medical care in patients with symptoms of acute stroke. Stroke. 2006;37:1248–1253. doi: 10.1161/01.STR.0000217200.61167.39. 8. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507– 520. doi: 10.1001/jama.2013.284427. 9. Hong WH. Evidence-based nursing practice for health promotion in adults with hypertension: a literature review. Asian Nurs Res (Korean Soc Nurs Sci). 2010;4:227–245. doi: 10.1016/S1976-1317(11)60007-8. 10. Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41:2731–2738. doi: 10.1161/STROKEAHA.110.590257.
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Nursing Best Practices to Prevent Stroke in Women Elaine T. Miller Stroke. 2015;46:e75-e77; originally published online March 10, 2015; doi: 10.1161/STROKEAHA.114.006320 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
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