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  • But acute means diffferent things, not always that acute, staff not acutely trained
  • Loosemore

    1. 1. Thrombolysis NursingThrombolysis NursingCompetenciesCompetenciesObjectivesObjectives Nursing Care of a Thrombolysed patientNursing Care of a Thrombolysed patient
    2. 2. What informed the Stroke StrategyWhat informed the Stroke Strategy RCP Sentinel Audits (2002-2006)RCP Sentinel Audits (2002-2006) NAO Report (Nov 2005)NAO Report (Nov 2005) Stroke strategy framework 2007Stroke strategy framework 2007 NiceNice
    3. 3. ““There is a massive and regularThere is a massive and regularfailure to respond to the emergencyfailure to respond to the emergencyof stroke” (NAO 2005)of stroke” (NAO 2005) Low public awareness of symptoms,Low public awareness of symptoms,prevention & managementprevention & management Slow admission to hospital, DifficultSlow admission to hospital, Difficultaccess to imaging, Insufficient specialistaccess to imaging, Insufficient specialistresourcesresources Less than 1% of pts thrombolysedLess than 1% of pts thrombolysedcompared to 9% in Australiacompared to 9% in Australia
    4. 4. Stroke is a Medical EmergencyStroke is a Medical Emergency’Time is Brain’’Time is Brain’ Speedy diagnosisSpeedy diagnosis Rapid access to imagingRapid access to imaging ThrombolysisThrombolysis Rapid access to supportive therapyRapid access to supportive therapy(HASU)(HASU) Rapid secondary preventionRapid secondary prevention Rapid surgical/ radiological intervention inRapid surgical/ radiological intervention inarterial disease (carotid / vertebral)arterial disease (carotid / vertebral)
    5. 5. 80% of Strokes = Ischaemic80% of Strokes = Ischaemic 80% of Ischaemic stroke caused by80% of Ischaemic stroke caused byembolism fromembolism from HeartHeart Aortic archAortic arch Extracranial arteries to the brainExtracranial arteries to the brain
    6. 6. ThrombolysisThrombolysis Thrombus= clotThrombus= clot Lysis = destruction of cellsLysis = destruction of cells Thrombolysis is achieved by usingThrombolysis is achieved by usingrt-PA (alteplase)rt-PA (alteplase) rt-PA reverses underperfusion, allowingrt-PA reverses underperfusion, allowingischaemic penumbra to recoverischaemic penumbra to recover
    7. 7. ThrombolysisThrombolysis rt-PA= recombinantrt-PA= recombinant tissue plasminogentissue plasminogenactivatoractivator Plasmin is the enzyme that degradesPlasmin is the enzyme that degradesfibrin, the protein which is the mainfibrin, the protein which is the mainconstituent of blood clotsconstituent of blood clots rt-PA activates the release of plasmin asrt-PA activates the release of plasmin asplasminogenplasminogen
    8. 8. Rational for giving ThrombolysisReduces the size of Ischaemic damage( infarct) by restoring blood flowCells in the brain ie. Neurons die overtime .Prompt treatment with a thrombolyticagent ( rTPa –Alteplase) may promotereperfusion & improve functional outcomes
    9. 9. ThrombolysisThrombolysis Must be given within 4.5 hours of strokeMust be given within 4.5 hours of stroke Strict inclusion criteriaStrict inclusion criteria Licensed for IV use in under 80’sLicensed for IV use in under 80’s Consultant decision: intra-arterial, 80+Consultant decision: intra-arterial, 80+ Dramatic increase in post-strokeDramatic increase in post-strokequality of lifequality of life
    10. 10. Cerebral infarctCerebral infarct - onset- onsetCerebral infarctCerebral infarct - onset- onsetOnsetInfarctIschaemicpenumbra
    11. 11. Cerebral infarctCerebral infarct – 6 hours– 6 hoursCerebral infarctCerebral infarct – 6 hours– 6 hours6 HoursInfarctIschaemicpenumbra
    12. 12. Cerebral infarctCerebral infarct – 24 hours– 24 hoursCerebral infarctCerebral infarct – 24 hours– 24 hours24 HoursInfarctIschaemicpenumbra
    13. 13. Without thrombolysis2hrs
    14. 14. Thrombolysis - The EvidenceThrombolysis - The Evidence NINDS trial 1995 (National Institute ofNINDS trial 1995 (National Institute ofNeurological Diseases & Stroke)Neurological Diseases & Stroke) ECASS 1 and ECASS 2 (European Co-ECASS 1 and ECASS 2 (European Co-operative Stroke Study) up to 3 hoursoperative Stroke Study) up to 3 hours ECASS 3 showed benefit up to 4.5 hoursECASS 3 showed benefit up to 4.5 hours 2009 American stroke association widens2009 American stroke association widensuse of rTPa to 4.5 hoursuse of rTPa to 4.5 hours
    15. 15. RCP Audit 2006 - ThrombolysisRCP Audit 2006 - Thrombolysis Only 10% admitted directly to unit withOnly 10% admitted directly to unit withacute facilitiesacute facilities 18% of hospitals do thrombolysis18% of hospitals do thrombolysis 30 hospitals thrombolysed 218 patients30 hospitals thrombolysed 218 patients
    16. 16. ratios (with 95% CIs) of an unfavourable outcome withtPA given within 3 hrs of onset of strokeOdds ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs ofonset of stroke
    17. 17. Odds ratios (with 95% CIs) of an unfavourable outcomewith tPA given within 3 hrs of onset of stroke
    18. 18. Thrombolysis - The EvidenceThrombolysis - The Evidence Fewer complicationsFewer complications Frequently, dramatic lack of disabilityFrequently, dramatic lack of disability Quicker recoveryQuicker recovery Reduction in LOSReduction in LOS
    19. 19. ‘‘Time is Brain’ - Stroke PathwayTime is Brain’ - Stroke Pathway Triage, FAST testTriage, FAST test Speedy call to Stroke Team (whateverSpeedy call to Stroke Team (whateverseverity)severity) Rapid admission to ASURapid admission to ASU
    20. 20. CAPACITY The Mental Capacity Act 2005, which came fully into force in October 2007, provides the legalframework for acting and making decisions on behalf of individuals who lack the capacity to makespecific decisions for themselves in relation to personal welfare, healthcare and financialmatters.  It applies to persons age 16 and over.  The Mental Capacity Act (MCA) applies to England and Wales.  Principles of the Act The Act sets out five principles which guide the legislation.  These are:  ·           ‘A person must be assumed to have capacity unless it is established that he lackscapacity. ·           (3) A person is not to be treated as unable to make a decision unless all practicable stepsto help him to do so have been taken without success. ·           (4) A person is not to be treated as unable to make a decision merely because he makesan unwise decision. ·           (5) An act done, or decision made, under this Act for or on behalf of a person who lackscapacity must be done, or made, in his best interests. ·           (6) Before the act is done, or the decision is made, regard must be had to whether thepurpose for which it is needed can be as effectively achieved in a way that is less restrictive ofthe person’s rights and freedom of action
    21. 21. Testing Capacity The Functional Test The person must be able to: understand the information relevant to the decision,   retain that information,  weigh that information as a part of the process of making a decision,   communicate his/her decision (whether by talking, using sign language orany other means) . This test must be complete and recorded; the documentation mustdemonstrate the above process
    22. 22. ABCABC AirwayAirway BreathingBreathing CirculationCirculation
    23. 23. After ABCAfter ABC GCSGCS ECGECG Blood glucoseBlood glucose Fluid accessFluid access HydrationHydration BloodsBloods Nil by MouthNil by Mouth Transfer to CT-continue ABCTransfer to CT-continue ABC
    24. 24. Time is brainTime is brain 1.9 million neurons are lost1.9 million neurons are losteach minute after a strokeeach minute after a stroke Protect ischaemic penumbraProtect ischaemic penumbraStroke 2006Stroke 2006
    25. 25. CTCT Known time ofKnown time ofsymptoms <4 hourssymptoms <4 hours NIHSS scoreNIHSS score No haemorrhageNo haemorrhage No contraindicationsNo contraindications ConsentConsent AgeAge
    26. 26. ThrombolysisThrombolysisAlteplase rTPAAlteplase rTPA0.9mg /Kg0.9mg /Kg10% of total dose –Bolus 2-3 mins10% of total dose –Bolus 2-3 mins90% of total dose –Infuse over 6090% of total dose –Infuse over 60minsmins
    27. 27. rTPA Alteplase Do not mix t-PADo not mix t-PA with any other medications.with any other medications. Do notDo not use IV tubing with infusion filters.use IV tubing with infusion filters. All patients must be on aAll patients must be on a cardiac monitorcardiac monitor When infusion is complete, saline flush withWhen infusion is complete, saline flush withNormal salineNormal saline t-PA must be used within 8 hours of mixing whent-PA must be used within 8 hours of mixing whenstored at room temperature or within 24 hours ifstored at room temperature or within 24 hours ifrefrigeratedrefrigerated
    28. 28. Complications of ThrombolysisComplications of Thrombolysis Intra -cerebral haemorrhage-1.7%Intra -cerebral haemorrhage-1.7% (1 in 77 patients) 0.28% fatal(1 in 77 patients) 0.28% fatal SITS MOST 2007SITS MOST 2007 Bleeding-minor bleeding is commonBleeding-minor bleeding is common(IV site)(IV site) Anaphylaxis- 1%Anaphylaxis- 1%Ace inhibitors Frontal & insular lesionsAce inhibitors Frontal & insular lesions Angiodoema 1.3% Canadian studyAngiodoema 1.3% Canadian study1,135 pts1,135 pts Major Heamorrhage 0.4%Major Heamorrhage 0.4%
    29. 29. Angioedema
    30. 30. Patient StoryPatient Story Mr X 88 years of ageMr X 88 years of age Jet pilot in the war & last flewJet pilot in the war & last flewin 1986in 1986 Collapsed right sidedCollapsed right sidedweaknessweakness Unable to talk . Couldn’t thinkUnable to talk . Couldn’t thinkclearly.clearly. 999 ambulance to A%E999 ambulance to A%E ““Clock work military precisionClock work military precisionlike gun team at Earls court”like gun team at Earls court”
    31. 31. First 24 hoursFirst 24 hours30% of all stroke patients will deteriorate in30% of all stroke patients will deteriorate inthe first 24hoursthe first 24hoursStroke 2009Stroke 2009
    32. 32. Monitor GCSMonitor GCS Ability to engage withAbility to engage withimmediate surroundingsimmediate surroundings Standardised stimuliStandardised stimuliE1-E4E1-E4V1-V5V1-V5M1-M6M1-M6
    33. 33. Best and Worst ScoreBest and Worst Score GCS 15- E4 V5 M6GCS 15- E4 V5 M6Awake, alert and fullyAwake, alert and fullyresponsiveresponsive GCS 3-E1 V1 M1GCS 3-E1 V1 M1No cerebrally mediatedNo cerebrally mediatedresponse to stimulusresponse to stimulus
    34. 34. NIHSS - A Research ToolNIHSS - A Research ToolFifteen item impairmentFifteen item impairmentscalescale Neurological outcomeNeurological outcome Degree of recoveryDegree of recovery
    35. 35. Physiological MonitoringPhysiological Monitoring1.1. HypoxiaHypoxiaRespirationsRespirationsSaturations <92%Saturations <92%Associated with neurologicalAssociated with neurologicaldeteriorationdeterioration2.2. TemperatureTemperature>38C must be treated.>38C must be treated.-associated with infarct volume-associated with infarct volume3.3. ArrhythmiasArrhythmiasContinuous ECGContinuous ECGEarly detection and treatment of AFEarly detection and treatment of AFRight hemisphere /insular lesionsRight hemisphere /insular lesions
    36. 36. Physiological Monitoring contdPhysiological Monitoring contd4.Blood pressure4.Blood pressureNon thrombolysed patientsNon thrombolysed patientsBP Not treated unless:BP Not treated unless:Systolic >220mmHg orSystolic >220mmHg orDiastolic >120mmHg with 2Diastolic >120mmHg with 2consecutive readingsconsecutive readingsThrombolysed patientsThrombolysed patientsBP is treated if:BP is treated if:Systolic >185mmHg orSystolic >185mmHg orDiastolic >110mmHg with 2Diastolic >110mmHg with 2consecutive readingsconsecutive readingsAbrupt fall in BP may affect cerebralAbrupt fall in BP may affect cerebralperfusion pressureperfusion pressure
    37. 37. Physiological Monitoring contdPhysiological Monitoring contd5.Blood Sugar5.Blood Sugar Hyperglycaemia BM>10 treat &Hyperglycaemia BM>10 treat &monitormonitor Hypoglycaemia –immediateHypoglycaemia –immediatetreatment with glucosetreatment with glucoseHyperglycaemia is associated withHyperglycaemia is associated withpoor clinical outcomepoor clinical outcome
    38. 38. Physiological Monitoring ContdPhysiological Monitoring Contd6.6. HydrationHydrationGlucoseGlucoseCerebral perfusionCerebral perfusion7. Anuria7. AnuriaPolyuriaPolyuriaCirculatory failureCirculatory failure
    39. 39. Complications of StrokeComplications of Stroke Aspiration PneumoniaAspiration Pneumonia Urinary infectionUrinary infection DVTDVT Pulmonary EmbolusPulmonary Embolus Shoulder subluxationShoulder subluxation DepressionDepression MalnourishmentMalnourishment Pressure soresPressure sores FallsFalls SeizuresSeizures
    40. 40. Swallow ComplicationsSwallow Complications(Dysphagia)(Dysphagia)Chest InfectionChest InfectionAspiration PneumoniasAspiration Pneumonias50% are silent50% are silent Swallow screenSwallow screen Nil by mouth first 24hoursNil by mouth first 24hours Guided eating & drinking regimeGuided eating & drinking regime Encourage to coughEncourage to cough Sitting out of bedSitting out of bed MobilisationMobilisation
    41. 41. Mouth CareMouth CareIncreased risk of infectionIncreased risk of infectionPain and discomfortPain and discomfortEffects swallowEffects swallow Gentle mouth careGentle mouth care Adequate hydrationAdequate hydration Gentle tooth brushingGentle tooth brushing
    42. 42. Head PositionHead PositionControversialControversialHead in a neutral positionHead in a neutral position Flat if tolerated.Flat if tolerated. Or 30 –40 degreesOr 30 –40 degrees Aids venous drainage &Aids venous drainage &improves cerebral perfusionimproves cerebral perfusion
    43. 43. Bladder &BowelsBladder &BowelsUrinary incontinenceUrinary incontinenceUrinary infectionUrinary infection Avoid cathetersAvoid catheters Early plan of careEarly plan of care Adequate hydrationAdequate hydration BowelsBowels Privacy & dignityPrivacy & dignity
    44. 44. Psychological SupportPsychological Support Assess moodAssess mood Recognise grief/lossRecognise grief/loss TalkTalk Engage with familyEngage with family InterestsInterests Timely realistic goalsTimely realistic goals ReferRefer
    45. 45. Pressure SoresPressure Sores Air mattressAir mattress Two hourly turnsTwo hourly turns NutritionNutrition HydrationHydration Personal hygienePersonal hygiene
    46. 46. Deep Vein ThrombosisDeep Vein Thrombosis Early mobilisationEarly mobilisation Low molecular weight heparinLow molecular weight heparin Compression devicesCompression devices TED stockings not beneficial inTED stockings not beneficial instroke patientsstroke patientsClots Trial 2009Clots Trial 2009
    47. 47. PositioningPositioningLoss of sensationLoss of sensationLoss of powerLoss of powerSubluxationSubluxation SupportiveSupportive IV lines and BP cuffs avoidedIV lines and BP cuffs avoidedon affected limbon affected limb Assess moving and handlingAssess moving and handling Good techniqueGood technique
    48. 48. NutritionNutritionMalnourishmentMalnourishmentassociated with poorassociated with pooroutcomeoutcome WeightWeight MUST assessmentMUST assessment Naso gastric tubeNaso gastric tube History of patients eatingHistory of patients eatinghabitshabitsControversialControversial When to commence invasiveWhen to commence invasivefeeding regimefeeding regime