Stroke 2012

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Objectives

• Identify 2 modifiable risk factors for stroke

• Identify commonly seen warning signs of stroke

• Identify 2 inclusion and 2 exclusion criteria of TPA

• Identifies appropriate nursing care measures post TPA

• Explain the importance of continuing stroke education

Stroke Facts

• Leading cause of adult disability

6.4 million American survivors

• 3rd leading cause of death in U. S.

• 795,000 cases annually & rising

A stroke occurs every 45 seconds

• >50% of patients are still disabled at six years

$73.7 billion per year

• Medical emergency

What is a stroke?

• Insufficient blood flow to a portion of the brain that results in sudden and severe neurological symptoms

Can occur in any vessel in the brain

Two types

• Hemorrhagic: 20% of population; the young

– Ruptured blood vessel

– Prognosis is usually poor

• Ischemic: 80% of population

– Embolic- Clot either in vessel or dislodged from another part of the body (heart)

– Thrombotic- plaque blockage

– Hypotension

UPMC St. Margaret is a Joint Commission Certified Primary Stroke Center

• We follow and meet the standards set by the Joint

Commission to provide quality stroke care.

• We have access to a neurologist 24h, 7 days a week

through telemedicine with the UPMC Stroke Institute.

• We have the ability to administer IV Alteplase (TPA) for

ischemic stroke patients

Stroke/TIA Signs and Symptoms

• Signs and Symptoms to watch out for:

• Facial droop

• Vision changes

• Difficulty speaking or understanding others

• Loss of balance or coordination

• Weakness/numbness on one side of the body

Time is brain

• 3h window for TPA treatment

• Pt’s who are treated within 3h have higher survival

rates and have less disability

• Major hurdle is public unaware of stroke warning signs

Initial Nursing Management-ED

• Emergency Room

• A “Brain Attack” is called

• Neurological assessment, including an initial NIHSS is

completed

• The patient is seen by the ED physician

• STAT head CT

• Check Blood Sugar, and take full set of labs

• Manage BP if hypertensive- SBP >185 or DBP >110

• Encourage use of stroke order set

The Golden Hour

• Door to MD < 10 minutes

• Door to neurologist (telemed) <15 minutes

• Door to STAT Head CT < 30 minutes

• Door to CT/Labs interpreted < 45 minutes

• Door to drug <60 minutes

Telemedicine

• There are two telemed machines here at St. Margaret.

• One is located in CT holding and one in the ED.

• We use telemed in order to provide our patients with 24/7

neurology access.

• There are telemed jacks in every ICU and ED patient room

as well as one in the CT holding area.

Initial Nursing Management-Direct Admit

• Direct Admission

• Neurological assessment, including an initial NIHSS is

completed

• STAT head CT

• Encourage use of stroke order set

National Institute Health Stroke Scale

• An initial NIHSS must be done on all stroke/TIA patients or

any patient with new onset signs and symptoms.

• NIHSS must be done Q 8 HRS for non ICU admissions.

• NIHSS must be done Q 4 HRS for ICU admissions.

Alteplase t-PA

• Only FDA approved treatment for ischemic stroke

• Must be given within 3h of onset of symptoms

• Administered only in ED and ICU

Contraindications to giving t-PA

• Evidence of intracranial hemorrhage on pretreatment

evaluation.

• Suspicion of subarachnoid hemorrhage on pretreatment

evaluation.

• Recent (within 3 months) intracranial or intraspinal

surgery, serious head trauma or previous stroke.

• History of intracranial hemorrhage.

• Uncontrolled hypertension at time of treatment (BP>185

mm Hg systolic or >110 mm Hg diastolic.

• Seizure at onset of stroke.

• Known bleeding.

Alteplase Administration (ED & ICU Only)

• If possible, an accurate weight must be obtained

• Dose is 90mg/kg, bolus is 10% of original dose

• Two nurses must verify the dosages and patient

information.

• t-PA is kept in the accudose in the ED as well as in the

pharmacy for availability to ICU.

Administering t-PA continued • During administration watch for any signs of bleeding and

continue to monitor vitals.

NIHSS must be completed every 15 minutes during

administration, then q30min x4h

BP must be taken q15min x2h, q30min x6h, q1h x16h

• The patient must stay in the ICU for 24h for frequent

monitoring; if no ICU beds, the patient must be transferred to

another UPMC facility

• Any change in LOC necessitates a stat CT scan to check for

hemorrhagic conversion

• Once administered the patient should not receive

anticoagulants or anti-platelet therapy for 24 hours

• Follow CT needs completed at 24h

Consulting Neurology

• During the patient’s stay here in

the hospital, neurologists should

be consulted for patient care.

Calling a Condition C

• Any stroke patient that has a change in level of

consciousness

• Any inpatient that presents with stroke signs/symptoms

Bedside Dysphagia Screening

• Bedside dysphagia screening must be done on all patients

who present or have a new onset of Stroke/TIA s/s

• Pass-the patient can have PO meds only until seen by

speech

• Fail-the patient can have nothing by mouth and must

be seen by speech

Stroke Education

• Education begins when the patient enters the hospital

• Education is individualized to the patient’s needs

• Education that needs to be completed:

• Stroke/TIA warning signs

• Stroke/TIA risk factors

• Need for follow-up care

• Medications related to risk factors/stroke

• Activation of 911

• Tests and procedures, including results

Risk Factors for Stroke

• High blood pressure

• Diabetes

• Atrial Fibrillation

• Use of tobacco

• Alcohol and drug abuse

• Physical inactivity/obesity

• Family history of Stroke

• Previous Stroke/TIA

• High Cholesterol

• Carotid or other artery

disease

• Sickle cell disease

• Patent foramen ovale

Documentation

• All Stroke education should be documented under Iview-

SKAT education

• IF YOUR PATIENT HAS NO FAMILY OR IS UNABLE TO

UNDERSTAND YOUR EDUCATION, DOCUMENT THIS

ALSO

• You may use the stroke education booklet to assist in

educating your patient

• Complete the stroke screening form to have information

populated into the discharge note

• REMEMBER, IF YOU DON’T CHART IT, YOU DIDN’T

DO IT!

VTE/DVT Prophylaxis

• This should be initiated by hospital day two

• Included therapy:

• SCD’s

– Must document when on and when removed

• Anticoagulants

– Heparin

– Coumadin

» Must document date of next PT/INR on discharge instructions

– Pradaxa

• Antiplatelets

– Aspirin, Plavix. Aggrenox, Ticlid

Medications at Discharge

• All stroke/TIA patients should also be discharged on

antiplatelet or anticoagulation therapy in order to prevent

a recurrent stroke/TIA

• If contraindicated, the physician must document the

reason

Labs

• All stroke/TIA patients should have a lipid panel and

hemoglobin A1C done.

• If the LDL is greater than 100 mg/dl the patient should be

discharged on a lipid lowering med.

• If the med is contraindicated, the physician must

document the reason .

STROKE DISCHARGE

• Planning starts on admission

• Patients must be evaluated by physical, occupational, &

speech therapy

• Consult home care if applicable

• Consult social services for supportive needs

• Assess patient’s emotional well being

Depression is common

Rehabilitation

All stroke patients should be assessed for suitability for

rehab as early as hospital day one.

The earlier the rehabilitation process is initiated, the

better the patient outcome.

During PT/OT and speech therapy, the therapists work

with the patient to improve their deficits and help

them to regain normal functioning.

PT/OT also prepares the patient for a safe discharge

to home

Stroke Resources

• National Stroke Association

www.stroke.org

• American Stroke Association www.strokeassociation.org

• National Institute of Neurological Disorders and Stroke

http://www.ninds.nih.gov/disorders/stroke/stroke.htm

• Activase

www.activase.com