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Nursing care across the acute stroke

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Nursing care across the acute stroke

Nursing care across the acute stroke

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  • The Canadian Best Practice Recommendations are a result of an extensive review of both international and national stroke research and of published evidence-based best practice guidelines
    The first edition was released in 2006 with a commitment to formally update the recommendations every two years to ensure currency and coordination with both national and international initiatives.
    The 2008 edition includes updates to the original recommendations and the addition of 4 new recommendations.
    Each edition underwent a rigorous development and review process
  • usually defined as symptom onset within the previous 4.5 hours
  • Transcript

    • 1. 1 Acute Inpatient Stroke Care Best PracticeBest Practice Nursing CareNursing Care Across theAcross the Acute StrokeAcute Stroke ContinuumContinuum N S N C
    • 2. Acute Inpatient Stroke CareAcute Inpatient Stroke Care  This session includes presentations andThis session includes presentations and activities to enhance your learningactivities to enhance your learning  The focus is on working with colleagues toThe focus is on working with colleagues to discover best ways of using the tools in yourdiscover 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! 07/08/14 2
    • 3.  So, what do you want to get out of this module? 07/08/14 3 Expectations? Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 4.  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 07/08/14 4 Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 5.  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 07/08/14 5 Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 6. Prevention of stroke Public awareness & patient education Prevention of stroke Public 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
    • 7. Acute Inpatient Stroke CareAcute Inpatient Stroke Care  Synthesis of best practice recommendations for 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
    • 8. 07/08/14 8 Intended only for audiences with no previous knowledge of stroke. Intended only for audiences with no previous knowledge of stroke. Stroke 101Stroke 101 Acute Inpatient Stroke Care
    • 9. Best Practice RecommendationsBest Practice Recommendations 07/08/14 9 Acute Inpatient Stroke Care 45 min
    • 10. 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
    • 11. Acute Inpatient Stroke CareAcute Inpatient Stroke Care 07/08/14 11 TABLE 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
    • 12. 1.1. Compared with alternative care,Compared with alternative care, stroke unit care showed a reductionstroke unit care showed a reduction in the odds of:in the odds of:  Death at final follow upDeath at final follow up  Death or institutionalized careDeath or institutionalized care  Death or dependencyDeath 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
    • 13.  Stroke unit care can reduceStroke unit care can reduce the likelihood of death andthe likelihood of death and disability by as much as 30%disability by as much as 30%  Evidence suggests patientsEvidence suggests patients treated in stroke units havetreated in stroke units have fewer complications, earlierfewer complications, earlier recognition of pneumonia andrecognition 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.
    • 14. Let’s take a break…Let’s take a break… 15 min
    • 15. Components of Acute Inpatient CareComponents of Acute Inpatient Care Best Practice RecommendationsBest Practice Recommendations 07/08/14 15 Acute Inpatient Stroke Care 60 min
    • 16. 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
    • 17.  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
    • 18.  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
    • 19. 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
    • 20. 4.2a Venous Thromboembolism Prophylaxis4.2a Venous Thromboembolism Prophylaxis
    • 21. 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
    • 22. 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
    • 23. Hot Off the Press!Hot Off the Press! Lancet May 27, 2009Lancet May 27, 2009
    • 24. 24 Clots in Legs Or sTockings after StrokeClots in Legs Or sTockings after Stroke Trial 1:Trial 1: Do graduated compressionDo graduated compression stockings reduce the risk ofstockings reduce the risk of DVT in stroke patients?DVT in stroke patients? Trial 2:Trial 2: Are full length graduatedAre full length graduated compression stockingscompression stockings more effective than belowmore effective than below knee stockings in reducingknee stockings in reducing the risk of DVT? (QEII )the risk of DVT? (QEII ) 07/08/14
    • 25. 25 ConclusionsConclusions  DVT occurred equally in patients with andDVT occurred equally in patients with and without stockings.without stockings.  Alteration in skin integrity was seen more oftenAlteration 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 withstockings in patients admitted to hospital with acute stroke.acute stroke.  Guidelines will be revised!Guidelines will be revised! 07/08/14
    • 26. 4.2b Temperature Management Best Practices Recommendations Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 27. 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
    • 28. Let’s take a break…Let’s take a break… 15 min
    • 29. 4.2c Mobilization Best Practices Recommendations Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 30. 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.
    • 31. 31 AVERT TrialAVERT 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 thanIf during mobilization, there is a drop in blood pressure of greater than 30 mmHg this mobilization attempt should cease. If a drop of greater30 mmHg this mobilization attempt should cease. If a drop of greater than 30 mmHg occurs on 3 consecutive attempts, further medicalthan 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). AJulie 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 beforeVery 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 07/08/14 Acute Inpatient Stroke CareAcute Inpatient Stroke Care REVIEWREVIEW
    • 32. 32  Deterioration in the person’s condition in the firstDeterioration 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 palliativea 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 atA 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 greaterSystolic blood pressure less than 110, or greater than 220mmHg.than 220mmHg. *Contraindications to Mobilization 07/08/14REVIEWREVIEW Acute Inpatient Stroke CareAcute Inpatient Stroke Care *AVERT Trial recommendations
    • 33. 33  Oxygen saturation of less than 92% withOxygen saturation of less than 92% with supplementation.supplementation.  Resting heart rate of less than 40 or greater thanResting 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 bePersons who have received rt-PA can be mobilized if the attending physician permits.mobilized if the attending physician permits. *Contraindications to Mobilization 07/08/14REVIEWREVIEW Acute Inpatient Stroke CareAcute Inpatient Stroke Care *AVERT Trial recommendations
    • 34. 4.2d Continence Best Practices Recommendations Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 35. 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
    • 36. 36 Incontinence 07/08/14REVIEWREVIEW 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
    • 37. 37 Bladder Incontinence 07/08/14REVIEWREVIEW 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
    • 38. 38 Bladder Incontinence 07/08/14REVIEWREVIEW 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
    • 39. Acute Inpatient Stroke CareAcute Inpatient Stroke Care 39 07/08/14 Assessment of Incontinence  Post residual volume  Urine culture  Vaginal examination  Rectal examination  Incontinence history  Fluid intake  Medical history  Medications  Functional ability
    • 40. 40 Strategies for Urinary Incontinence 07/08/14REVIEWREVIEW 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
    • 41. 41 Strategies for Urinary Incontinence 07/08/14REVIEWREVIEW 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)
    • 42. 42 Bowel Incontinence 07/08/14REVIEWREVIEW 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
    • 43. 43 Bowel Incontinence 07/08/14REVIEWREVIEW 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
    • 44. 44 Establishing a Bowel Program 07/08/14REVIEWREVIEW 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/
    • 45. 4.2e Nutrition Best Practices Recommendations Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 46. 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. 47 Nursing Interventions for Dysphagia/Nutrition 07/08/14REVIEWREVIEW 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
    • 48. 48 Dysphagia/Nutrition 07/08/14REVIEWREVIEW 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
    • 49. 49 Nursing Interventions for Dysphagia 07/08/14REVIEWREVIEW 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)
    • 50. 50 Dysphagia – Points to Remember 07/08/14REVIEWREVIEW 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 excludeThe presence of a gag reflex does not exclude the possibility of dysphagiathe possibility of dysphagia
    • 51. 4.2f Oral Care Best Practices Recommendations Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 52. 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
    • 53. 53 Oral Care 07/08/14REVIEWREVIEW 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
    • 54. 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
    • 55. Check Up QuizCheck Up Quiz QUIZQUIZ Acute Inpatient Stroke CareAcute Inpatient Stroke Care
    • 56. Check Up 07/08/14 56 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
    • 57. Check Up 07/08/14 57 Acute Inpatient Stroke CareAcute Inpatient Stroke Care Name two common complications related to stroke. Aspiration Pneumonia 40% Urinary tract infection 40%
    • 58. Check Up 07/08/14 58 Acute Inpatient Stroke CareAcute Inpatient Stroke Care In what type of unit shouldIn what type of unit should patients admitted to hospitalpatients admitted to hospital with acute stroke or TIA bewith acute stroke or TIA be treated?treated? In an interdisciplinary stroke unitIn an interdisciplinary stroke unit
    • 59. Check Up 07/08/14 59 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
    • 60. Check Up 07/08/14 60 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
    • 61. Check Up 07/08/14 61 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
    • 62. Check Up 07/08/14 62 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 andIdentify and treat source (site and etiology) of fever in order to startetiology) of fever in order to start tailored antibiotic treatment andtailored antibiotic treatment and antipyreticsantipyretics
    • 63. Check Up 07/08/14 63 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)
    • 64. Check Up 07/08/14 64 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
    • 65. Check Up 07/08/14 65 Acute Inpatient Stroke CareAcute Inpatient Stroke Care Mobilization of stroke patients isMobilization of stroke patients is contraindicated when systolic bloodcontraindicated when systolic blood pressure is less than or greater thanpressure is less than or greater than what values?what values? Systolic blood pressure less thanSystolic blood pressure less than 110mm Hg or greater than 220mm110mm Hg or greater than 220mm Hg.Hg.
    • 66. Check Up 07/08/14 66 Acute Inpatient Stroke CareAcute Inpatient Stroke Care What percentage of stroke patientsWhat percentage of stroke patients have urinary incontinence?have urinary incontinence? 40-60% of stroke patients have40-60% of stroke patients have urinary incontinenceurinary incontinence
    • 67. Check Up 07/08/14 67 Acute Inpatient Stroke CareAcute Inpatient Stroke Care What does the use of a portableWhat does the use of a portable ultrasound (bladder scanner) toultrasound (bladder scanner) to access bladder function eliminate?access bladder function eliminate? Risk of introducing urinary infectionRisk of introducing urinary infection or causing urethral trauma byor causing urethral trauma by catheterizationcatheterization
    • 68. Check Up 07/08/14 68 Acute Inpatient Stroke CareAcute Inpatient Stroke Care What are three strategies for treatingWhat are three strategies for treating overflow incontinence?overflow incontinence? 1.1. Double voidingDouble voiding 2.2. Crede maneuverCrede maneuver 3.3. Intermittent catheterizationIntermittent catheterization
    • 69. Check Up 07/08/14 69 Acute Inpatient Stroke CareAcute Inpatient Stroke Care Bowel incontinence occurs in whatBowel incontinence occurs in what percentage of stroke patients andpercentage of stroke patients and what percentage regain control withinwhat percentage regain control within one year?one year? Bowel incontinence occurs in 30% ofBowel incontinence occurs in 30% of stroke patients and 97% regainstroke patients and 97% regain control within one yearcontrol within one year
    • 70. Check Up 07/08/14 70 Acute Inpatient Stroke CareAcute Inpatient Stroke Care What should a bowel function riskWhat should a bowel function risk factor assessment include?factor assessment include? Mobility, inactivity, adequate fluid andMobility, inactivity, adequate fluid and food intake, polypharmacyfood intake, polypharmacy
    • 71. Check Up 07/08/14 71 Acute Inpatient Stroke CareAcute Inpatient Stroke Care Identify four things you can do toIdentify four things you can do to manage bowel incontinence.manage bowel incontinence. 1.1. Increase dietary fibre and fluidsIncrease dietary fibre and fluids 2.2. Increase mobilityIncrease mobility 3.3. Maintain a bowel recordMaintain a bowel record 4.4. Establish a regular toiletingEstablish a regular toileting routineroutine
    • 72. Check Up 07/08/14 72 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? WithinWithin the first 48 hours of admission using a valid screening tool
    • 73. Check Up 07/08/14 73 Acute Inpatient Stroke CareAcute Inpatient Stroke Care Maintain all patients with stroke NPOMaintain all patients with stroke NPO (including oral medications) within 24(including oral medications) within 24 hours of patient being awake andhours of patient being awake and alertalert What should be done with allWhat should be done with all patients with stroke until apatients with stroke until a swallowing screen has beenswallowing screen has been administered and interpreted?administered and interpreted?
    • 74. Check Up 07/08/14 74 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?
    • 75. Early Assessment &Early Assessment & Stroke RehabilitationStroke Rehabilitation 15 min
    • 76. Acute Inpatient Stroke CareAcute Inpatient Stroke Care When should stroke rehabilitation start?
    • 77. 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.
    • 78. 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
    • 79. Acute Inpatient Stroke CareAcute Inpatient Stroke Care What are the benefits of early assessment and rehabilitation?
    • 80. 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
    • 81. 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)
    • 82. 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)
    • 83. 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?
    • 84. Family & Patient EducationFamily & Patient Education 15 min
    • 85. From the Patient and Family’s Perspective:From the Patient and Family’s Perspective:
    • 86. 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? 1. When done, we'll debrief the whole group to identify some best practices
    • 87. 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
    • 88. 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
    • 89. Patient and Family Education Acute Inpatient Stroke CareAcute Inpatient Stroke Care www.heartandstroke.ca
    • 90. Putting It All TogetherPutting It All Together 30 min
    • 91. 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
    • 92. 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
    • 93. 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?
    • 94. 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 1. Use the Stroke Care Action Plan worksheet in your PW to record your plan
    • 95. Our views have increased theOur views have increased the mark of the 10,000mark of the 10,000  Thank you viewers  Looking forward to franchise, collaboration, partners.
    • 96. This platform has been started byThis platform has been started by Parveen Kumar Chadha with theParveen Kumar Chadha with the vision that nobody should suffervision that nobody should suffer the way he has suffered becausethe way he has suffered because of lack and improper healthcareof lack and improper healthcare facilities in India. We need lots offacilities in India. We need lots of funds manpower etc. to make thisfunds manpower etc. to make this vision a reality please contact us.vision a reality please contact us. Join us as a member for a nobleJoin us as a member for a noble cause.cause.
    • 97. Contact us:- 011-25464531, 9818569476 E-mail:- nursingnursing@yahoo.in
    • 98. Best Practice Nursing Care AcrossBest Practice Nursing Care Across the Acute Stroke Continuumthe Acute Stroke Continuum Thank you for your participation!