Effect of an Educational Program on Nurses’ Practice Regarding Care of Patients with Cerebral Stroke

Background : The terms "stroke" and "nontraumatic cerebral hemorrhage" are used interchangeably. The ratio of infarct to bleeding varies by demographic (race, age, comorbidities), but it is roughly 4 to 1. A variety of disease mechanisms can cause a cerebral infarction, but they all result in obstruction of cerebral arteries or veins. Aim of the study : Explore effect of an educational program on nurses’ practice regarding care of patients with cerebral stroke. Subjects and method: Design : A quasi-experimental design was utilized to conduct the study in the intensive care unit at Port Said general hospitals. Setting : The study was conducted in the intensive care unit at Port Said General Hospital. Subjects: convenient sample (50) nurse. Tools : Nurses' observational checklist. The Results : (20%)of studied nurses had satisfactory total practice preprogram compared to (96%) immediately after post-program implementation and (92%) of them followed up 3months after program implementation. Conclusion : Statistically significant differences in nurse practice before, immediately, and after program implementation. Recommendations : Provides a continuous training program for nurses in the care of stroke patients, as well as hands-on training in low-practice areas to provide the highest level of care for nurses.


INTRODUCTION
Cerebral Circulation: The brain does not store nutrients, has high metabolic demands, and necessitates a large amount of blood flow.Approximately 15% of the cardiac output, or 750 ml per minute, is delivered to the cerebral circulation.The blood routes in the brain are distinctive in various respects.First, unlike other organs in the body, arterial and venous blood vessels do not run in parallel; this is partly due to the venous system's role in the absorption of cerebrospinal fluid.Second, the circle of Willis provides collateral circulation to the brain, allowing blood flow to be altered as necessary.Third, brain blood arteries contain two layers rather than three, making them more likely to rupture when weakened or pressured (Proulx, S.T. 2021).
When patients present within a specified time window of symptom onset, the concept of "time is brain" has become the major premise for guiding rapid clinical diagnosis and acute therapeutic selection.( Honan & Esposito, 2018) A stroke is a disease in which normal blood flow to a portion of the brain is interrupted, depriving it of nutrition and oxygen.As a result, the damaged area's brain cells die in a short amount of time ( Patnaik et al. 2019).
Stroke is one of the most frequent disorders, affecting one out of every four people at some point in their lives.The majority of strokes are caused by a reduction in or interruption of blood flow to the brain (ischemic stroke).A number of these could be caused by a moderate or severe case of cerebral vein thrombosis.Bleeding is responsible for 20-30% of strokes, which is caused by damage to small and medium blood vessels.A stroke is a life-threatening medical condition that causes a localized neurological impairment.Prompt examination, diagnosis, and therapy to restore blood flow can help to alleviate symptoms and prevent brain injury (H Barker,2021).
The study discovered that stroke rates and outcomes differed depending on gender, race, and geographic region.Women are more likely to develop AIS throughout their lives and have worse results.Stroke rates were higher in black men, and the disparity was even greater among younger patients (Samaniego & Hassan, 2019).(Hickman & Fitzpatrick, 2018) A stroke is a highly complex process that may be separated into two stages: a relatively simple early "plumbing" issue caused by a disturbance in blood flow and energy supply to the brain, and a more complex secondary cascade issue.On the one Port Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 280 hand, it is influenced by the interaction of metabolism and dysfunction, as well as the interaction of hemodynamic and molecular alterations.When a blood clot or embolus blocks blood flow to any portion of the brain, the brain tissue begins to lose oxygen and matrix (Brain & Hayes, 2019).
An ischemic stroke is caused by a clogged blood vessel.This is ischemia (92 percent), which is a blockage of the arteries delivering blood to the brain.Cerebral or carotid arteries, or cerebral veins, are the most possible ones (Csiba & Baracchini,2016).
Hemorrhagic strokes are caused by blood artery rupture and blood flow into the brain (about 10 percent ).Aneurysms and arteriovenous malformations are two types of compromised blood vessels that can cause a hemorrhagic stroke.Uncontrolled high blood pressure, on the other hand, is the most common cause of hemorrhagic stroke (sustained hypertension).When blood penetrates the brain tissue (parenchyma), the ventricles, or the subarachnoid space, it is called a hemorrhagic stroke.Normal brain metabolism is interrupted when blood forms a mass outside the vasculature that compresses nearby brain tissue, resulting in increased intracranial pressure (ICP), secondary bleeding, and additional ischemia ( Patnaik et al.,2019).
Symptoms of any sort of stroke include: The American Heart Association and the American Stroke Association have identified five signs or symptoms that demand immediate EMS response: Numbness or weakness of the face, arms, or legs, especially on one side of the body, disorientation, or difficulty speaking or understanding Difficulty One or both eyes experience a sudden vision change.Walking becomes very difficult suddenly.Dizziness, dizziness, dizziness, dizziness, dizziness, dizziness, sudden intense headache discomfort with no apparent cause (Denny et al., 2019).
Vital signs (lung function, heart rate, blood pressure), neurological symptoms, the severity of neurological deficit based on validated stroke scales, time to symptom onset, and potential applicability for specific treatments should all be considered during the initial clinical evaluation of patients with severe stroke (Mendelow et al., 2015;Urden et al., 2019).Assessment of mental status (orientation, mood, cognition, memory, attention, speech, and language), motor control, swallowing ability, hydration status, fluid output, skin integrity, and activity levels should all be part of a systematic strategy for analyzing and documenting findings.Ongoing nurse assessments continue to focus on changes in cognition and functional impairment, guiding nursing diagnoses as needed (Honan & Esposito, 2018).
Nurses play a crucial role in the care of patients who have had a cerebrovascular accident (CVA).When caring for stroke victims, nurses must possess certain competencies and practical skills.Nurses must collaborate well with members of diverse teams both within and outside of institutions (Buijck & Ribbers, 2018;Tulek, et al., 2018).Nurse supervision: One of the most difficult tasks for intensive care nurses in assessing and caring for patients with neurological disorders.Neurological assessments of the depth and complexity observed in other body systems may not be included in basic nursing education or critical care training ( book,2016) In the acute phase after a stroke, nursing interventions aim to prevent secondary brain injury (intracranial hypertension), protect the airway (due to pharyngeal muscle paralysis), provide systemic support (vital signs, fluid, and electrolyte balance), and avoid complications (atelectasis and pneumonia).A general assessment of the patient's condition should be performed upon admission to the emergency department (A&E), determining their baseline neurological status and appropriate positioning, while the level of consciousness should be determined quickly, as it is one of the most sensitive indicators of neurological status.Advanced care should involve the routine practice of a variety of particular nursing treatments, including continence management, stress zone care, swallowing management, and early mobilization, to aid patient recovery (Theofanidis & Gibbon, 2016).

Significance of the study
The burden of stroke and the high prevalence of its risk factors in Egypt are alarming, a lot of studies internationally showed that there are a lot of irreversible complications Port Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 282 occurred due to bad nursing intervention for critically ill patients with cerebral stroke, and the situation is made worse as the national data on stroke statistics are very limited.
Moreover in Egypt, found that most hospitalized patients with cerebral stroke have many complications due to a lack of nurses' practice (Asal 2014).

This Study aims to:
Evaluate effect of an educational program on nurses' practice regarding care of patients with cerebral stroke.This aim will be achieved through the following objective:
2. Develop an educational program regarding cerebral stroke.
3. Implement the educational program regarding cerebral stroke.
4. Evaluate the educational program immediately after implementation and a follow-up will be carried out after 3months.

Research Hypothesis:
To achieve the research objectives, the following research hypotheses were formulated: Enrollment in a stroke nursing training program will improve nurses' practice of caring for stroke patients

SUBJECT AND METHOD Research Design:-
The design of this study is a quasi-experimental design done to evaluate the impact of educational program on nurses' practice related to the care of patients with cerebral stroke.

Scoring system:
For nurse practice, give 1 for every correct answer and 0 for every wrong answer The total scores for responding nurses were added and converted to percentages.The total amount for the Nurse Internship is calculated as follows: -All values ≤ 75% are considered unsatisfactory -although values >75% are considered satisfactory.

Statistical analysis of data:
Collected data were organized, tabulated, and statistically analyzed using the Statistical Package for Social Sciences (SPSS) version 16 for Windows running on an IBMcompatible computer.Qualitative data (categorical data) were expressed as relative frequency (number) and percentage distribution, and chi-square (X2) or Mann-Whitney test (Z) was calculated for comparison between groups.Quantitative data were expressed as mean ± standard error, and Student's (t) test was calculated to compare the two means.For interpretation of results, p-values ≤ 0.001 were considered significant.

Operational design
The operational design includes the preparatory phase, content validity, pilot study, and fieldwork.-Reliability:

Port
It evaluates the tool's internal consistency using the Alpha Cronbach coefficient, which in practice is (0.834).

C-Pilot study
To verify the tool's clarity, objectivity, and feasibility, a pilot study will be done on a 10% sample.It is carried out before data collection to determine appropriateness.

D-Field work
the study was conducted through three phases: 1-Preparatory phase 2-Implementation phase

A-A training plan was established to analyze the outcomes of the Nurse Practice
Assessment concerning the care of stroke patients, as well as the requirements identified during the assessment phase, (Asal, 2014).To help with data collecting, the researchers generated the following documents at this point.

B-Program objectives:
-Improve nurses' practice related to the care of patients with cerebral stroke.

B-Planning of action:
-The researchers applied all the steps in front of the participants and discussed the rationale and caveats for each step.
Port Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 285 -At the end of the research, the nurse asks if the ambiguous steps need to be repeated or checked before demonstrating again.

C-Permission for conducting the study
The head nurse of the Medical Intensive Care Unit at Port Said General Hospital took over the study after describing the goal, date, and location (El-Zohor Hospital, Port Foaud General Hospital, and El-Salam Hospital).-Using various teaching approaches such as demonstrations and repetitions, provide procedures clearly and concisely.-Go over the reasons and considerations for each step with them.-Nurses were asked at the end of the session whether any points needed to be reiterated or explained before they could demonstrate again.

Phase III: Evaluation phase
-Each nurse was evaluated two times for practice using the observational checklist tool

Ethical consideration:
Permission to conduct the research was obtained from the competent authorities in the research environment after describing the aim.Explain the study's purpose to each participant so that they understand the significance of their involvement.Patients will be given a brief explanation of the study to ensure that the information received will be kept confidential and used solely for research reasons.The data collection technique does not detract from the work's overall harmony.Nurses will be notified of their ability to withdraw from the study at any time, and all data obtained from study subjects will be treated with the highest secrecy.unit.Their experience ranged between 1 and 25 years, the median experience was 6 years and regarding courses, 84% of them had CPR courses.

Table (2)
Nurses' practice before, after, and 3 months after the program regarding the care of patients with cerebral stroke by observational checklist.Regarding nurses' practice regarding the care of stroke before and after the program, it was significantly different after the program when compared to corresponding values before the program regarding the care of stroke.The difference 3 months after the program, is still statistically significant.However, the difference at 3 months when compared to values after the program showed a non-significant difference indicating that, the program is still effective after 3 months Table (3): Total score of nurse's practice regarding care of patients with cerebral stroke throughout all phases of the program indicates that the 80.0% of the total nurses' practice was unsatisfactory before the program, while 96.0% of the total nurses' practice was satisfactory immediately after the program as well as, 92.0% of them shows a satisfactory practice in follow up 3 months after the program.

Table (4):
Differences in the total score of nurses' practice in the care of patients with cerebral stroke.
Shows there was a significant difference in the total score of nurses' practice regarding cerebral stroke throughout the program intervention between post-test and preprogram (P<0.001),follow up after 3months, and pre-program (P<0.001).While there was no statistically significant difference between immediately post and follow up were (P= 0.32).

The
National Institutes of Health (NIHSS) Stroke Scale has become a widely used measure for determining the severity of a stroke and analyzing patient outcomes after therapy.The NIHSS is a 42-point rating scale, with 0 indicating no neurological impairment and 42 signifying the worst possible result.It examines six primary areas of neurological function: (1) locomotor control, (2) visual function, (3) motor function, (4) Port Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 281 sensory and neglect (ignoring impulses on one side of the body), (5) cerebellum function, and (6) language and.The National Institute of Health Stroke Scale (NIHSS) was developed by stroke teams and is now used by caregivers to track neurological deficits in stroke patients and to record stroke severity.(Urden et al. 2019, Urden et al., Urden et al., Urden Maintain a care plan to keep care of a thorough neurological examination. :-The research was carried out in the Intensive Care Unit of Port Said General Hospital (El Zohor Hospital): the medical unit on the third floor has two rooms (8 beds for men and 6 beds for women), and the ICU on the first floor has two rooms with four beds each, Port Foaud General Hospital: Medical Units (male and female rooms on the scored floor and ICU on the sconed floor, and Port Said General Hospital: ICU and medical units on the sconed floor Port Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 283 Subjects:-A convenient sample was used with available nurses in mentioned units (50 nurses).Tools of data collection: Tool I: Nurses' practice observational checklist.It has been adapted (Asal, 2014) for nurses' practice in the care of stroke patients.It contains a set of items (17 statements or questions) related to maintaining the patient's airway, correct positioning, assessing the state of consciousness, checking vital signs, and documenting admission and delivery.Part (1): It includes information about the nurses studied, such as their name, age, and gender, as well as information about their jobs, such as years of experience and involvement in training programs.Part (2): It includes 17 statements or questions about managing the patient's airway, proper placement, assessing the patient's level of awareness, checking vital signs, and documenting admission and delivery.
Said Scientific Journal of Nursing Vol.10, No. 1, March 2023 284 A-Preparatory phase It includes a review of nursing textbooks, as well as research on individual aspects of the subject using books, papers, the Internet, and journals and periodicals (e.g.pub med, Cochrane databases, MEDLINE) B-Content validityThe tools were evaluated for clarity, relevance, completeness, understandability, and applicability by 11 expert reports from academic medical and surgical nurses and medical paramedics who directly treat stroke patients.

-
At the beginning studied nurses were divided into 5 groups (10 nurses ) -During this meeting the researcher: a-Explain the purpose of the study b-Give each nurse handout including procedure steps to facilitate remembering practical steps about the care of patients with cerebral stroke.
Relation between total nurses' practice & Demographic characteristics of study nurses during care of patients with cerebral stroke.It illustrates that there was a significant relation between demographic characteristics of the studied nurses and their practice related to gob and educational level pre, post immediately, and 3 months after educational program implementation.

Table ( 1
): Demographic characteristics of the studied nurses (n=50): shows that, most of the studied nurses were in the age group from 20 to less than 30 years with a mean age Regarding their educational level, 52.0% of studied nurses have Technical Secondary school of nursing, and 96.0% of them work in the intensive care

Table ( 2
): Nurses' practice before, after, and 3monthes after the program regarding the care of patients with cerebral stroke by observational checklist Relation between total nurses' practice & Demographic characteristics of study nurses during care of patients with cerebral stroke.
P2: Comparison between before program and three months after program: P3: comparison between direct after program and three months after program, * indicate significanceTable ( 5):