Robin Jones MSN, RN, CNRN

Stroke Program Manager

Mission Health System

Asheville NC

Stroke: A Nursing Perspective

The Why

Stroke Nursing

“New approaches to the nursing care of

the stroke patient”

Clin Orthop Relat Res. 1978 Mar-Apr;(131):90-6.

Prevention and maintenance constitute a large part of the nurse's role

in caring for the stroke patient during the acute stage of his illness.

The nurse must have knowledge of both the subjective and objective effects

of a stroke to formulate an effective Nursing Care Plan.

Consistency is vital in providing an environment in which a stroke patient can

relearn fundamental activities. Confusion, and thus the diminished ability to learn, is often relieved by familiarity and predictability of surroundings, persons, and routines.

Nursing's participation in positioning, range of motion exercises, bowel and

bladder retraining and providing appropriate sensory input is essential.

The nurse must assume the role of coordinator and evaluator of the

patient's rehabilitation, using 24 hour-a-day observation coupled with educational background and experience, to determine

obstacles and assess the patient's ability to resume living in his previous environment.

Stroke Units

Approximately 25% of

patients with ischemic

stroke will deteriorate

clinically during the first

1-2 days (Jauch et al.,

2013)

9/20/2014 GHS Stroke Symposium

Patients who receive care in a specialized stroke unit, where the nurses and providers are educated and competent to provide unique care required by stroke patients, have better outcomes.

Lower morbidity and mortality in patients with ischemic stroke

There is a 17% to 28% reduction in deaths, a 7% increase in being able to live at home, and an 8% reduction in length of stay (Langhorne et al., 1997)

Centers that have higher volumes of stroke patients, esp. hemorrhagic generally have better outcomes (Connolly et al., 2012)

Stroke Units Interdisciplinary coordination of care and regular communication between team members is a hallmark of stroke units (Jauch et al., 2013)

Examples

Bedside report

RN/CNA delegation

SBAR hand-off

MDR daily

Shift huddles

Whiteboards

Surveillance as an Intervention in

Stroke Nursing Care

9/20/2014 GHS Stroke Symposium

Nurses’ role in early recognition of and actions to prevent or

minimize complications (Rhudy & Adnrowich, 2013)

A process in which nurses monitor, evaluate, and act upon

indicators of a change in a patient’s status (Kutney-Lee et al.,

2009)

Occurs over time and involves the ongoing collection and

interpretation or evaluation of information

Requires both cognitive and behavioral skills

Identification of factors influencing a situation to make a

decision

Nursing Interventions

Identify existing and potential diagnoses

Collaboratively establish plan of care

Focus on the whole person

Listen to the patient & caregivers

Provide interventions to prevent complications and to

promote rehabilitation

Provide support and encouragement

Surveillance

9/20/2014 GHS Stroke Symposium

Nursing

Diagnosis

Ineffective Cerebral

Tissue Perfusion

Impaired swallow Impaired physical

mobility

Impaired

communication

Rationale Interruption of blood

flow: occlusive disorder,

hemorrhage, cerebral

vasospasm, cerebral

edema

Dec LOC, dysphagia,

high risk for

aspiration

Airway obstruction

Neuromuscular;

weakness, parethesia,

flaccid/hyoptonic

Perceptual/cognitiv

Impaired cerebral

circulation,

neuromuscular

impairment, loss of

facial/oral tone

Surveillance Altered LOC

motor/sensory;

restlessness;

Language, cognitive,

emotional

Vital signs (HR, BP)

NIHSS; Neuro checks

Dysphagia

assessment

Oxygenation

Assess oral cavity

Auscultate BS

Assess skin color

Assess functional

ability/extent

Evaluate need for

positional aids

Observe color, edema

Inspect skin

Fall prevention

Risk VTE/PE

Assess type/degree

Listen

NIHSS

Anticipate and provide

for needs

Respect patient’s

preinjury capabilities

Actions Assess changes in LOC

and potential for inc ICP

Reperfusion treatment

Treat BP per parameters

Notify MD for acute

neurological changes

NPO until cleared

Consult SLP

IVFs/Enteral feed

Oral care

Positioning

Mobilize as soon as

stable

Anticoag or mech

prophylaxis w/in end

day 2

Consult with SLP

Speak in normal tones

avoid talking too fast

Education Initial & ongoing

Stroke Diagnosis

Diagnostic tests

Educate patient &

family regarding

swallow precautions

Educate patient &

family

Reinforce SLP

recommendations

Community resources

CMS /TJC STK 4 & 8 Dysphagia

screen

STK 1, 8, 10 STK 8/10

9/20/2014 GHS Stroke Symposium

Nursing

Diagnosis

Disturbed Sensory

Perception

Self-Care Deficit Risk for

recurrent

stroke

Impaired Glucose

Rationale Altered sensory reception,

transmission, integration

Psychological stress

Disorientation

Inability to tell position

Neuromuscular

impairment, dec strength

and endurance Depression

Perceptual/cognitive

Pain/discomfort

Determine

etiology if possible

to establish plan to

prevent recurrent

stroke

Brain cells require

glucose for

metabolism

Brain consumes 20-

25% of body’s glu

Surveillance Review pathology of

individual condition

Observe behavioral

responses

Evaluate visual deficits

Assess sensory awareness

Note inattention to body

parts

Assess abilities and level of

deficit for ADLs

Awareness of impulsivity

Allow sufficient time

Create plan for visual

deficits that are present

Assess patient’s ability to

communicate need to void

Identify bowel habits

Review pathology

of individual

condition

Identify risk

factors

Review all

diagnostic test

results

Monitor blood glucose

routinely upon

admission & freq.

thereafter

ICH monitor Q 4-8

hrs

Actions Eliminate extraneous

noise/stimuli

Speak in calm, quiet voice

Maintain eye contact

Approach from visually

intact side

Avoid doing things for

patient that patient can do

for self, but provide

assistance as necessary

Place food on tray related

to unaffected side

Anti-platelets by

end day 2

Anticoag for AF

Review POC daily

in preparation for

D/C

Treat glu to range of

140 – 180

Insulin IV or SQ

Oral

antihyperglycemic

meds

Education Encourage patient to

watch feet & consciously

position body parts

Educate patient and family

caregivers

Provide written

education

Teach Back

Educate patient and

family on rationale for

freq. glu checks

CMS /TJC STK 8 & 10 STK 8 & 10 STK 2, 3, 5, 6 STK 8

General Management of patients with

acute stroke Blood pressure

Oxygenation and ventilation

Neurological assessment

Temperature management

Blood glucose

VTE prophylaxis

Cardiac monitoring

Nutrition management

Mobilization

Safety Measures

Education of patient and/or caregivers Disease specific risk factors (HTN, Dyslipidemia, Smoking, Afib, DM, etc)

Signs & Symptoms

When to call 911

Medications (especially new Rx)

Follow up appointments

BP Management BP management is one of

the most important functions that a nurse caring for a stroke patient performs

If SBP rises too high, the blood-brain barrier may be disrupted, resulting in increasing cerebral edema, hemorrhagic transformation, or expansion of hemorrhagic stroke

If SBP is reduced dramatically, perfusion pressure may be inadequate for the penumbra, resulting in extension of the infarct, or loss of the penumbra

Nursing Considerations

Parameters will vary according to the patient’s history, and type and size of the stroke – generally permissive hypertensive in ischemic stroke (24 hours post thrombolytics)

Communication is key when delegating BP checks – who does the BP checks where you work?

Automatic BP cuff is utilized, high and low alarms should be set according to parameters ordered for that patient

BP parameters may be adjusted during recovery

Chronic HTN is # 1 risk factor for stroke

Discharge instructions may include new Rx and should include a goal BP range

Normal Blood Pressure

2 times more likely to have a stroke

4 times more likely to have a stroke

8 times more likely to have a stroke

STROKE

115/75

135/85

155/95

175/105

Neurological Assessment The ability to do a thorough

neuro assessment is a key skill of the stroke nurse

Correlation of findings on assessment with areas of the brain affected

Anticipate what changes to be vigilant for in the assessment over the next 24 to 48 hours

Consistency and standardization are critical in trending over time

NIHSS

Standardized language for describing stroke deficit

Predicts severity of injury and correlates with patient outcome

Nursing care protocols should not base notification on the provider on the 4-point change alone – A patient with loss of arm strength, with no other changes, will only have an increase of 3 points, but warrants action by the health care team

Review prior scores to compare change

Nursing Aims

9/20/2014 GHS Stroke Symposium

Determine cause of current stroke

Stabilize and recover

Avoid/Respond complications

Prevent secondary stroke

Prepare for discharge

Transition/follow up

Postdischarge nursing care

9/20/2014 GHS Stroke Symposium

Comprehensive care during the first 4 weeks after a stroke

improves overall morbidity and mortality

Throughout recovery, patient’s needs change, so the care plan

must be modified accordingly

Stressors such as illness and sleep deprivation can effect

stroke related deficits

Time frame for recovery and the amount of functional

recovery are hard to predict - no set time or level

Risk for post stroke depression

Stroke All or None and You

9/20/2014 GHS Stroke Symposium

Core Measures

Value Based Purchasing

Meaningful Use

Patient Satisfaction

LOS

30-day Readmission

30-day Mortality

At the end of the day…. How would you want to be treated?

Stroke Camp

Stroke Camp