AANN Comprehensive Review for Stroke Nursing, 2nd Edition, Ch. 7 Postacute Care: Digital Version-Stroke Chapter 7

Stroke Chapter 7

Pdf Summary

Postacute stroke care focuses on lifelong recovery, prevention of secondary complications, and helping survivors return to meaningful activities at home and in the community. Rehabilitation aims to restore, maintain, or compensate for lost function; restorative care emphasizes maintaining gains over time. Care should begin when medically appropriate and follow an individualized, patient- and family-centered plan.<br /><br />Postacute services span inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), long-term care hospitals, home health, outpatient therapy, day programs, and community or residential services. IRFs provide intensive, coordinated rehabilitation for eligible patients; other settings offer varying levels of medical and therapy support. Selection depends on clinical needs, function, resources, geography, and insurance. Nurses should explain options and advocate for an appropriate transition.<br /><br />An interprofessional team—including nurses, physicians, physical and occupational therapists, speech-language pathologists, social workers, and psychologists—sets shared SMART goals, assesses function, coordinates care, and supports community reintegration. Assessment covers mobility, self-care, communication, swallowing, cognition, mood, safety, continence, medication management, and participation. Discharge planning should start early and address prevention, follow-up, home modifications, equipment, exercise, and return to work or driving when appropriate.<br /><br />Family caregivers often take on substantial responsibilities with limited preparation and may experience stress, grief, exhaustion, or depression. Teams should assess caregiver willingness, capacity, health, resources, and readiness; provide practical training and stroke education; and connect caregivers with peer support and respite.<br /><br />Common rehabilitation challenges include mobility and transfer safety, cognitive and communication deficits, neglect, shoulder pain, depression, dysphagia, bowel and bladder problems, spasticity, and changes in sexuality or leisure. Interventions are individualized; options may include constraint-induced movement therapy, robotics, visual rehabilitation, and technology-assisted therapies.<br /><br />Stroke education should cover causes, risk factors, prevention, recognition, treatment adherence, rehabilitation, lifestyle, and community resources. Ongoing reassessment helps survivors and families adapt care as needs change and sustain health, independence, and quality of life.

Keywords

postacute stroke care

stroke rehabilitation

secondary complication prevention

inpatient rehabilitation facility

skilled nursing facility

interprofessional care team

caregiver support

discharge planning

functional recovery

community reintegration