nursing care across the acute stroke
DESCRIPTION
Nursing care across the acute strokeTRANSCRIPT
1
Acute Inpatient Stroke Care
Best Practice Best Practice Nursing Care Nursing Care Across the Across the Acute Stroke Acute Stroke ContinuumContinuum
N S
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
This session includes presentations and This session includes presentations and activities to enhance your learningactivities to enhance your learning
The focus is on working with colleagues to The focus is on working with colleagues to discover best ways of using the tools in your discover best ways of using the tools in your clinical settingsclinical settings
So, sit back (or stand up) and have fun!!! So, sit back (or stand up) and have fun!!!
Welcome!
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So, what do you want to get out of this module?
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Expectations?
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Identify the goal of acute inpatient stroke care within the stroke care continuum
Review the components and Best Practice Recommendations related to acute inpatient stroke care
Identify how you can help to implement these recommendations at your institution
Identify the benefits of early assessment and stroke rehabilitation
Identify your role in patient and caregiver education Create a stroke care action plan for acute inpatient stroke care
Objectives
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Introduction 15 min Stroke 101(optional) 15 min Acute Inpatient Stroke Care BPRs 45 min Break 15 min Components of Acute Inpatient Care BPRs 60 min Early Assessment & Stroke Rehab 15 min Patient and Family Education 15 min Putting It All Together 30 min
Agenda
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Prevention of strokePublic awareness & patient education
Prevention of strokePublic awareness & patient education
Hyperacute stroke management
Hyperacute stroke management
Acute inpatient stroke careAcute inpatient stroke care
Stroke rehabilitation & community reintegration
Stroke rehabilitation & community reintegration
Continuum of Stroke Care
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Synthesis of best practice recommendationsfor stroke care across the continuum
Address critical topic areas Commitment to keep current and update
every two years First edition released in 2006 Current update released in 2008
With four new recommendations Elaboration of existing ones www.cmaj.ca December 2, 2008
Canadian Best Practice Recommendations for Stroke Care
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Intended only for audiences
with no previous knowledge of
stroke.
Intended only for audiences
with no previous knowledge of
stroke.
Stroke 101Stroke 101Acute Inpatient Stroke Care
Best Practice RecommendationsBest Practice Recommendations
04/11/23 9
Acute Inpatient Stroke Care
45 min
4.1: Stroke unit care
Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit Core interdisciplinary team should consist of people with appropriate
levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech– language pathology, social work and clinical nutrition
Interdisciplinary team should assess patients within 48 hours of admission and formulate a management plan
Clinicians should use standardized, valid assessment tools to evaluate the patient's stroke-related impairments and functional status
Best Practices Recommendations
OVERVIEWOVERVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
04/11/23 11TABLE DISCUSSIONTABLE DISCUSSION
1. At your tables, discuss: What are the benefits of a dedicated stroke unit vs. a
medical floor? What are some challenges you experience in getting
patients out of the ER? Identify what’s happening in your institution now and
brainstorm strategies to explore
1.1. Compared with alternative care, Compared with alternative care, stroke unit care showed a reduction stroke unit care showed a reduction in the odds of:in the odds of:
Death at final follow up Death at final follow up
Death or institutionalized care Death or institutionalized care
Death or dependency Death or dependency
Benefits of Stroke Care Unit
Data demonstrated improved patient outcomes when
treated in an organized stroke
unit with dedicated stroke
staff!
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Stroke unit care can reduce Stroke unit care can reduce the likelihood of death and the likelihood of death and disability by as much as 30%disability by as much as 30%
Evidence suggests patients Evidence suggests patients treated in stroke units have treated in stroke units have fewer complications, earlier fewer complications, earlier recognition of pneumonia and recognition of pneumonia and earlier mobilizationearlier mobilization
Why Is This Important?
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Characterized by a coordinated
interdisciplinary team approach for preventing
stroke complications
and recurrence, and accelerating mobilization and
early rehab.
Let’s take a break…Let’s take a break…15 min
Components of Acute Inpatient Care Components of Acute Inpatient Care Best Practice RecommendationsBest Practice Recommendations
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Acute Inpatient Stroke Care
60 min
1. Referring to the case study in your PW, each table will prepare a set of Case Notes to bring to an interdisciplinary meeting to begin establishing rehabilitation goals
2. Base your notes on Best Practice Recommendation 4.2 Components of acute inpatient care
3. Venous thromboembolism, temperature, mobilization, continence, nutrition and oral care
4. When done, we’ll conduct our meeting with each table getting a turn to present
Interdisciplinary Meeting
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
TABLE ACTIVITYTABLE ACTIVITY
Mrs. C is a 76 year old right handed woman who was admitted to the Stroke Unit post thrombolysis. She lives with her 80 year old husband who requires some assistance with ADL’s due to his Parkinsons’ disease.
They live in a 2 bedroom condominium and have the support of 2 adult children nearby.
On admission Mrs. C is found to have expressive aphasia, right sided weakness (arm weaker than leg) and right visual neglect.
Past medical history: hypertension, hypercholesteremia, osteoporosis, gastroesophageal reflux
No known allergies and does not drink or smoke
Case Study
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Mrs. C’s vital signs are: BP 158/70 P-100 and irregular R-22 Temperature: 37.4’C
Mrs. C appears anxious and frustrated, especially when trying to communicate. She is restless and makes attempts to get out of bed
Case Study
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2: Components of acute inpatient care
Risk for venous thromboembolism, temperature, mobilization, continence, nutrition and oral care should be addressed in all hospitalized stroke patients Appropriate management strategies should be implemented for
areas of concern identified during screening Discharge planning should be included as part of the initial
assessment and ongoing care of acute stroke patients
Best Practices Recommendations
REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2a Venous Thromboembolism Prophylaxis4.2a Venous Thromboembolism Prophylaxis
4.2a Venous thromboembolism prophylaxis
All stroke patients should be assessed for their risk of developing venous thromboembolism High risk patients include patients with inability to move one or both
lower limbs and those patients unable to mobilize independently
Patients who are identified as high risk for venous thromboembolism should be considered for prophylaxis provided there are no contraindications Early mobilization and adequate hydration should be encouraged
with all acute stroke patients to help prevent venous thromboembolism
Best Practices Recommendations
REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2a Venous thromboembolism prophylaxis
In addition to secondary stroke prevention, antiplatelet therapy should be used for people with ischemic stroke to prevent VTE;
The following interventions may be used with caution for selected people with acute ischemic stroke at high risk of VTE: Heparin in prophylactic doses (5000 units BID) or low molecular
weight heparin (with appropriate prophylactic doses per agent) External compression stockings
Best Practices Recommendations
REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Hot Off the Press!Hot Off the Press!Lancet May 27, 2009Lancet May 27, 2009
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Clots in Legs Or sTockings after StrokeClots in Legs Or sTockings after Stroke
Trial 1: Trial 1: Do graduated compression Do graduated compression stockings reduce the risk of stockings reduce the risk of DVT in stroke patients?DVT in stroke patients?
Trial 2: Trial 2: Are full length graduated Are full length graduated compression stockings compression stockings more effective than below more effective than below knee stockings in reducing knee stockings in reducing the risk of DVT? (QEII ) the risk of DVT? (QEII )
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ConclusionsConclusions
DVT occurred equally in patients with and DVT occurred equally in patients with and without stockings.without stockings.
Alteration in skin integrity was seen more often Alteration in skin integrity was seen more often in the stocking group.in the stocking group.
Data does not support use of (thigh length) Data does not support use of (thigh length) stockings in patients admitted to hospital with stockings in patients admitted to hospital with acute stroke.acute stroke.
Guidelines will be revised!Guidelines will be revised!
04/11/23
4.2b Temperature Management
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2b Temperature Management
Should be monitored as part of routine vital sign assessments (every 4 hours for first 48 hours and then as per ward routine or based on clinical judgment) For temperature more than 37.5°C, increase frequency of
monitoring and initiate temperature reducing measures For temperature more than 38°C, iidentify and treat source (site and
etiology) of fever in order to start tailored antibiotic treatment and antipyretics
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
Let’s take a break…Let’s take a break…15 min
4.2c Mobilization
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2c: Mobilization
Acute stroke patients should be mobilized as early and as frequently as possible preferably within 24 hours of stroke symptom onset, unless contraindicated Assessment of patients’ ability in activities of daily
living should be completed and reassessed regularly Within the first 3 days after stroke, blood pressure,
oxygen saturation and heart rate should be monitored before each mobilization
Acute stroke patients should be assessed by rehabilitation professionals as soon as possible after admission preferably within the first 24 to 48 hours
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
Mobilization is defined as
the act of getting a patient to
move in the bed, sit up, stand, and eventually
walk.
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AVERT Trial AVERT Trial
Within the first 3 days after stroke, blood pressure, oxygen saturation, Within the first 3 days after stroke, blood pressure, oxygen saturation, and heart rate should be monitored before each mobilizationand heart rate should be monitored before each mobilization
If during mobilization, there is a drop in blood pressure of greater than If during mobilization, there is a drop in blood pressure of greater than 30 mmHg this mobilization attempt should cease. If a drop of greater 30 mmHg this mobilization attempt should cease. If a drop of greater than 30 mmHg occurs on 3 consecutive attempts, further medical than 30 mmHg occurs on 3 consecutive attempts, further medical assessment is required. assessment is required.
Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). A Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). A Very Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before Very Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363
Mobilization: Physiological Monitoring
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
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Deterioration in the person’s condition in the first Deterioration in the person’s condition in the first hour of admission that: hour of admission that: resulting in direct admission to ICU, resulting in direct admission to ICU, a documented clinical decision for palliative a documented clinical decision for palliative
treatment (e.g. those with devastating stroke)treatment (e.g. those with devastating stroke) immediate surgery. immediate surgery.
Unstable coronary or other medical condition.Unstable coronary or other medical condition. A suspected or confirmed lower limb fracture at A suspected or confirmed lower limb fracture at
the time of stroke preventing mobilizationthe time of stroke preventing mobilization Systolic blood pressure less than 110, or greater Systolic blood pressure less than 110, or greater
than 220mmHg. than 220mmHg.
*Contraindications to Mobilization
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
*AVERT Trial recommendations
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Oxygen saturation of less than 92% with Oxygen saturation of less than 92% with supplementation. supplementation.
Resting heart rate of less than 40 or greater than Resting heart rate of less than 40 or greater than 110 beats per minute. 110 beats per minute.
Temperature of greater than 38.5°C. Temperature of greater than 38.5°C.
Persons who have received rt-PA can be Persons who have received rt-PA can be mobilized if the attending physician permits.mobilized if the attending physician permits.
*Contraindications to Mobilization
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
*AVERT Trial recommendations
4.2d Continence
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2d Continence
All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence and constipation Stroke patients with urinary incontinence should be assessed by
trained personnel using a structured functional assessment A bladder training program should be implemented in patients who
are incontinent of urine A bowel management program should be implemented in stroke
patients with persistent constipation or bowel incontinence
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
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Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
40-60% of stroke patients have urinary incontinence
25% of incontinent patients will have urinary incontinence at discharge
15% will have incontinence at 1 year post stroke
Urinary incontinence within 24 hours of a stroke is a predictor of functional disability
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Bladder Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
All stroke patients should be screened for urinary incontinence and retention (with or without overflow)
Urinary incontinence should be assessed by trained personnel using a structured functional assessment
The use of indwelling catheters should be avoided. If used, indwelling catheters should be assessed daily and removed as soon as possible
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Bladder Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
The use of a portable ultrasound (bladder scanner) is recommended as the preferred non-invasive painless method for assessing post void residual and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
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Assessment of Incontinence
Post residual volume
Urine culture
Vaginal examination
Rectal examination
Incontinence history
Fluid intake
Medical history
Medications
Functional ability
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Strategies for Urinary Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Ensure adequate fluid intake (1500-2000 mls)
Assess post void residuals (normal is 50-100 mls)
Review medications (?diuretics)
Introduce a regular toileting routine
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Strategies for Urinary Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Encourage bladder retraining (urge incontinence)
Pelvic muscle exercises – Kegal’s
Double voiding, Crede maneuver and intermittent catheterization (overflow incontinence)
Limit use of dietary bladder irritants ( caffeine, etoh, spicy foods)
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Bowel Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Bowel incontinence occurs in 30% of stroke patients and 97% regain control within one year.
Incontinence may result due to the following: Altered consciousness Cognitive deficits Impaired communication Neurogenic bowel without sensation
or control
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Bowel Incontinence
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Bowel function risk factor assessment should include: mobility, inactivity, adequate fluid and food intake, polypharmacy,
etc.
All stroke patients should be screened for fecal incontinence
A bowel management program should be implemented in stroke patients with persistent constipation or bowel incontinence
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Establishing a Bowel Program
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Encourage appropriate fluids, diet, and activity.
Choose an appropriate rectal stimulant.
Provide rectal stimulation initially to trigger defecation daily.
Select optimal scheduling and positioning.
Select appropriate assistive techniques.
Evaluate medications that promote or inhibit bowel function
Source: www.guideline.gov/
4.2e Nutrition
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2e Nutrition
The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool Results from the screening process should guide appropriate
referral to a dietitian for further assessment and the need for ongoing management of nutritional and hydration status
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
47
Nursing Interventions for Dysphagia/Nutrition
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Maintain all patients with stroke NPO (including oral medications) until a swallowing screen has been administered and interpreted, within 24 hours of patient being awake and alert
Screening results should guide appropriate referral to a Dietician for further assessment and the need for ongoing management of nutritional and hydration status
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Dysphagia/Nutrition
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Consideration of enteral nutrition support within 7 days of admission for patients who are unable to meet their nutrient and fluid requirements orally
This decision should be made collaboratively with the multidisciplinary team, patient and their caregivers/family
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Nursing Interventions for Dysphagia
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Assess for signs & symptoms of dysphagia Choking on food Stifled, suppressed or overt coughing during meals Nasal regurgitation Moist, wet voice Complaints of food sticking in the throat Drooling or loss of food &/or fluid from the mouth Pocketing of food in cheeks Slow, effortful eating Delay in initiating swallow (i.e. > 5 seconds)
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Dysphagia – Points to Remember
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
All stroke patients should have a nutritional screen within 48 hours of admission
Many dysphagic patients aspirate without any external sign that food or liquid is entering the airway – instead ‘silent aspiration’
Although many stroke patients will recover from dysphagia spontaneously, all stroke patients should have a SLP/RD assessment
The presence of a gag reflex does not exclude The presence of a gag reflex does not exclude the possibility of dysphagiathe possibility of dysphagia
4.2f Oral Care
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
4.2f Oral care
All stroke patients should have an oral/dental assessment, which includes screening for obvious signs of dental disease, level of oral care and appliances, upon or soon after admission For patients wearing a full or partial denture it must be determined if
they have the neuromotor skills to safely wear and use the appliance(s)
An oral care protocol should be established and include: Frequency Types of oral care products Strategies for patients with dysphagia Consultation with dentistry
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
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Oral Care
04/11/23REVIEWREVIEW
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Consider consulting dentistry, occupational therapy, speech language pathologists, and/or a dental hygienist to develop an oral care protocol
A referral to dentistry for consultation and management of oral health and/or appliances should be made as soon as possible
4.2g Discharge planning
Discharge planning should be initiated as soon as possible after patient admission to hospital (emergency department or inpatient care) A process should be established to ensure involvement of patients
and caregivers in the development of the care plan, management and discharge planning
Discharge planning discussions should be ongoing throughout hospitalization to support a smooth transition from acute care
Information about discharge issues and possible needs of patients following discharge should be provided to patients and caregivers soon after admission
Best Practices Recommendations
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
Check Up QuizCheck Up Quiz
QUIZQUIZ
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
In one clinical study, stroke unit care reduced the odds of what
three outcomes?
1. Death at final follow up 2. Death or institutionalized care 3. Death or dependency
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Name two common complications related to stroke.
Aspiration Pneumonia 40%Urinary tract infection 40%
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
In what type of unit should In what type of unit should patients admitted to hospital patients admitted to hospital with acute stroke or TIA be with acute stroke or TIA be
treated? treated?
In an interdisciplinary stroke unitIn an interdisciplinary stroke unit
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What type of planning should be included as part of the initial
assessment and ongoing care of acute stroke patients?
Discharge planningDischarge planning
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What type of treatment should patients who are identified as high
risk for venous thromboembolism be considered for?
Prophylaxis provided there are no contraindications
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
In addition to secondary stroke prevention, what type of therapy should be used for people with
ischemic stroke to prevent VTE?
Antiplatelet therapy
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What action should be taken if a patient’s temperature rises to more than 38°C?
Identify and treat source (site and Identify and treat source (site and etiology) of fever in order to start etiology) of fever in order to start tailored antibiotic treatment and tailored antibiotic treatment and
antipyreticsantipyretics
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
How often should the temperature of a stroke patient be monitored?
As part of routine vital sign assessments (every 4 hours for first
48 hours and then as per ward routine or based on clinical
judgment)
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
When should acute stroke patients be mobilized?
As early and as frequently as possible preferably within 24 hours of
stroke symptom onset, unless
contraindicated
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Mobilization of stroke patients is Mobilization of stroke patients is contraindicated when systolic blood contraindicated when systolic blood pressure is less than or greater than pressure is less than or greater than
what values?what values?
Systolic blood pressure less than Systolic blood pressure less than 110mm Hg or greater than 220mm 110mm Hg or greater than 220mm
Hg.Hg.
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What percentage of stroke patients What percentage of stroke patients have urinary incontinence?have urinary incontinence?
40-60% of stroke patients have 40-60% of stroke patients have urinary incontinenceurinary incontinence
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What does the use of a portable What does the use of a portable ultrasound (bladder scanner) to ultrasound (bladder scanner) to
access bladder function eliminate? access bladder function eliminate?
Risk of introducing urinary infection Risk of introducing urinary infection or causing urethral trauma by or causing urethral trauma by
catheterizationcatheterization
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What are three strategies for treating What are three strategies for treating overflow incontinence?overflow incontinence?
1.1. Double voiding Double voiding
2.2. Crede maneuver Crede maneuver
3.3. Intermittent catheterizationIntermittent catheterization
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Bowel incontinence occurs in what Bowel incontinence occurs in what percentage of stroke patients and percentage of stroke patients and
what percentage regain control within what percentage regain control within one year?one year?
Bowel incontinence occurs in 30% of Bowel incontinence occurs in 30% of stroke patients and 97% regain stroke patients and 97% regain
control within one yearcontrol within one year
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What should a bowel function risk What should a bowel function risk factor assessment include?factor assessment include?
Mobility, inactivity, adequate fluid and Mobility, inactivity, adequate fluid and food intake, polypharmacyfood intake, polypharmacy
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Identify four things you can do to Identify four things you can do to manage bowel incontinence.manage bowel incontinence.
1.1. Increase dietary fibre and fluidsIncrease dietary fibre and fluids2.2. Increase mobilityIncrease mobility3.3. Maintain a bowel recordMaintain a bowel record4.4. Establish a regular toileting Establish a regular toileting
routineroutine
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
The nutritional and hydration status of stroke patients should be screened
within what period of time after admission and using what tool?
Within Within the first 48 hours of admission using a valid screening tool
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Maintain all patients with stroke NPO Maintain all patients with stroke NPO (including oral medications) within 24 (including oral medications) within 24
hours of patient being awake and hours of patient being awake and alertalert
What should be done with all What should be done with all patients with stroke until a patients with stroke until a
swallowing screen has been swallowing screen has been administered and interpreted?administered and interpreted?
Check Up
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Acute Inpatient Stroke CareAcute Inpatient Stroke Care
The presence of a gag reflex does not exclude the possibility of dysphagia
The presence of a gag reflex does not exclude the possibility of
what?
Early Assessment &Early Assessment &Stroke RehabilitationStroke Rehabilitation15 min
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
When should stroke rehabilitation start?
When Should Stroke Rehabilitation Start
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Priorities are : Manage stroke sequelae to optimize recovery Prevent post-stroke complications that may interfere with recovery
process
Acute stroke accounts for the longest length of stay in Canadian hospitals and places a significant burden on inpatient resources, which increases further when complications are experienced.
When Should Stroke Rehabilitation Start
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Consider that rehabilitation is a process, not a place.
Rehabilitation and discharge planning begins at the time of admission to acute care
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What are the benefits of early assessment and rehabilitation?
Benefits of Early Assessment & Rehabilitation
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Assessment should start as early as possible in the ER and continue through the inpatient and community reintegration phases
Benefits of Early Assessment & Rehabilitation
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Early consultation with rehab professionals: Contributes to reductions in complications from immobility such as
joint contracture, falls, aspiration pneumonia and deep vein thrombosis
Contributes to early discharge planning for transition from acute care to specialized rehabilitation units or to the community
Should reduce the overall cost of care through improved outcomes and reduced time to discharge (BPG 5.1)
Examples of Assessment Tools
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Clinicians should use standardized, valid assessment tools to evaluate stroke-related impairments and functional status
Domain Selected Measure
Measures of stroke severity
Orpington Prognostic Scale (OPS) National Institute of Health Stroke Scale
Upper/lower extremity structure and function
Chedoke-McMaster Stroke Assessment (CMSA)
Language Screening in acute care and follow-up, with Frenchay Aphasia Screening Test (FAST)
Boston Diagnostic Aphasia Examination (BDAE) Cognition Montreal Cognitive Assessment (new addition
by Canadian Stroke Strategy cognitive working group, January 2008)
Self-care activities of daily living
Functional Independence Measure (FIM)
Your Role in Early Assessment &Stroke Rehabilitation
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
TABLE ACTIVITYTABLE ACTIVITY
When done, we'll review
some of your pearls of wisdom!
At your tables discuss What are the benefits of early assessment and
stroke rehabilitation at your institution? Where can you make a difference in realizing
these benefits? What is the role of the nurse in stroke
rehabilitation? What barriers and enablers do you see?
Family & Patient EducationFamily & Patient Education15 min
From the Patient and Family’s Perspective:From the Patient and Family’s Perspective:
Where You Can Make a Difference!
Did you know that skills training of
caregivers makes a huge difference
in patient outcomes in areas
of functionality and depression!
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
1. At your tables, discuss What would be your role in educating
and supporting patients and caregivers about acute inpatient stroke care?
2. When done, we'll debrief the whole group to identify some best practices
Patient and Family Education
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Content should be specific to; The phase of care Patient/caregiver readiness Patient/caregiver needs Education should be timely, interactive, up to date and provided in a
variety of formats, languages including aphasia friendly
Processes should be established by clinical teams for education including designating team members for provision and documentation of education
REVIEWREVIEW
Patient and Family Education
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
REVIEWREVIEW
Education content should include: The nature of the stroke and its manifestations Signs and symptoms of stroke Impairments and their impact on the person Caregiver training to manage Risk factors Post-stroke depression Cognitive impairment Discharge planning and decision making Community resources Home adaptations
Patient and Family Education
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
www.heartandstroke.ca
Putting It All TogetherPutting It All Together30 min
Case Study
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
1. Review the case study in your PW
2. With your team, answer the questions on the worksheet at the end of the study
3. We’ll review when done to share some best practices and get ready to create a Stroke Care Action Plan
TABLE ACTIVITYTABLE ACTIVITY
Case Study
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
Mrs. C is a 76 year old right handed woman who was admitted to the Stroke Unit post thrombolysis. She lives with her 80 year old husband who requires some assistance with ADL’s due to his Parkinsons’ disease.
They live in a 2 bedroom condominium and have the support of 2 adult children nearby.
On admission Mrs. C is found to have expressive aphasia, right sided weakness (arm weaker than leg) and right visual neglect.
Past medical history: hypertension, hypercholesteremia, osteoporosis, gastroesophageal reflux
No known allergies and does not drink or smoke
Case Study Questions
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
What would be the priority areas for Mrs. C’s care plan development?
What education would you provide for the family?
What complications would you be monitoring for with Mrs. C?
Case Study Questions
Acute Inpatient Stroke CareAcute Inpatient Stroke Care
1. With the case study we just reviewed in mind, create a stroke care action plan Identify 1-2 key learnings from today that you could take back to
help kick start your change initiatives
2. Use the Stroke Care Action Plan worksheet in your PW to record your plan
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