Early nutritional screening and support can benefit recovery after stroke by decreasing complications like infections, pressure ulcers and gastrointestinal bleeding. Several deficits from stroke can impair eating, such as inability to sit upright, loss of arm function, and swallowing problems. While malnutrition is common after stroke and worsens outcomes, current practice lacks standardized screening and nutrition is not prioritized. Early nutritional assessment and intervention could improve stroke recovery and reduce mortality risk.

1. Early Nutritional Intervention
and its Benefits for Stroke
Patients
Dimas Cortez, Breanna Schmidt, Cady Latshaw, & Jessie Sypinski

2. MISSION MOMENT
• https://www.youtube.com/watch?v=YN1M2t4Gf-Q

3. PICO QUESTION
• In acute stroke patients on a medical-surgical floor, what is the benefit
of early nutritional screening and support on recovery after stroke?
• POPULATION: Acute stroke patients on a medical-surgical floor.
• INTERVENTION: Early nutritional screening and support.
• COMPARISION: Prolonging nutritional assessment.
• OUTCOME: Recovery after stroke.

4. LEARNING OBJECTIVES
1. The learner will develop a clear understanding of the impact of early nutritional screening
on outcomes for patients after a stroke.
2. The learner will be able to identify stroke deficits that would hinder appropriate nutritional
intake.
3. The learner will be able to recognize multiple feeding strategies in order to obtain optimal
nutritional status in patients that suffered from a stroke.
4. The learner will be able to compare and contrast different nutritional assessment tools for
the use of dysphagia screening.

5. DEFICITS THAT IMPAIR EATING
• Inability to maintain upright posture.
• Loss of upper extremity movement
or sensation.
• Problems with chewing or
swallowing.
• Communication deficits.
• Visual deficits.
• Depression.
(Perry et al., 2012).
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6. SIGNIFICANCE TO PRACTICE
• The reported frequency of malnutrition after stroke has varied from 8% to 34%
(American Heart Association, 2003).
• Studies have shown that malnutrition increases the risk of several
complications including infections, pressure ulcers, and gastrointestinal
bleeding. It is also associated with lower functional ability and mortality
(Mosselman et al., 2013).
• Although the effects of malnutrition are well-recognized, nutritional
intervention is not considered a priority (Perry et al., 2012).
• Tools such as the Mini Nutritional Assessment (MNA) identified that
malnutrition post-stroke ranged from 16% to 26% within the first week
(Creasey, 2012).
• Post-stroke patients often suffer from a range of disabilities that effect
nutritional intake, like postural, upper limb, and visual impairments (Nip et al.,
2011).

7. CURRENT PRACTICE
Literature
• There is a lack of standardization of
assessment of nutritional status (American
Heart Association, 2003).
• The screening of nutritional status and
support is not a standard of practice
depsite known complications for
malnutrition (Mosselman, 2013)
• There is a lack of nutrition-related
information in nursing literature (Mosselman,
2013).
• The nursing role in nutrition is often thought
of mealtime management and enteral
tube feedings (Perry et al., 2012).
Good Samaritan
• During a stroke admission, there is no
specific nutritional assessment done.
• The admitting nurse does a quick
swallowing evaluation.
• Nutritional consults are only given
automatically to patients presenting
with low Braden scores.
• A full nutritional assessment is usually not
done for several days post-admission.

8. CURRENT PRACTICE
• No standardization among
assessment tools.
• Different parameters for use.
• None specific to stroke and
dysphagia patients.
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9. LITERATURE REVIEW
• Databases searched: EBSCO Health, Google Scholar, PubMed, Cochrane
Library, Medline Plus.
• Keywords used: nutrition, stroke outcome, prognosis, acute cerebrovascular
accident, malnutrition, dysphagia, nursing, feeding, eating, eating
difficulties, outcomes, risk factors, early nutritional supplementation.
• Year limits: 2003- 2013.
• Other search limits used: clinical guidelines, systematic review, meta-analysis,
randomized controlled trial.
• Number of articles reviewed: 12 articles reviewed.

10. SUMMARY OF EVIDENCE
• Early nutritional support can decrease morbidity and mortality, reduce
complications, and reduce further risks and deterioration of patient (Wang
et al., 2013).
• Early nutritional status is associated with long term outcomes (Garibella,
2003).
• There is an increased prevalence of dysphagia that is consistent among
stroke patients (Martino et al., 2005).
• Nutritional supplementation decreased the prevalence of pressure sores in
the majority amount of patients in a study that included over 6,000 patients
(Geeganage, Beavan, Ellender, & Bath, 2012).

11. SUMMARY OF EVIDENCE
…CONTINUED
• Nutritional Supplementation that started earlier rather than later revealed a
lower end-of study fatality percentage (Geeganage, Beavan, Ellender, &
Bath, 2012).
• Acute stroke patients nutritional needs should be the primary focus with a
special focus on the delivery of protein (Creasey, 2012).
• A dietician consult should be implemented in order to provide adequate
nutrition (Wirth et al., 2013).

12. CONSIDERATIONS FOR PRACTICE
• The use of behavioral interventions and acupuncture reduced dysphagia
and pharyngeal electrical stimulation decreased pharyngeal transit time
(Geeganage, Beavan, Ellender, & Bath, 2012).
• Women become more malnourished after experiencing a stroke compared
to men (Medin et al., 2011).
• Stroke patients should have more supervision during mealtimes and
assessments on food consumption should be utilized (Medin et al., 2011).
• Dysphagia should not be the only eating difficulty that is assessed in stroke
patients. Stroke patients should also be assessed for arm movement, lip
closure, and the ability to swallow (Westergren, 2006).

13. RECOMMENDATIONS FOR
NURSING PRACTICE
• Early nutritional assessment and detection is recommended to ensure safe
swallowing (Westergren, 2006).
• For patients requiring long-term nutritional support, PEG feeding results in
decreased complications (Geeganage, 2012).
• Evaluating food consumption and how patients manage food on a plate
would help decrease the prevalence of malnutrition (Medin et al., 2011).
• Early screening of malnutrition risks should be completed within the first 10
days of admission (Mosselman et al., 2013).

14. REFERENCES
• American Heart Association. (2003). Poor nutritional status on admission predicts poor outcomes after stroke:
Observational data from the FOOD trial. Stroke, 34, 1450-1456. doi: 10.1161/01.S TR.0000074037.49197.8C
• Crary, M., Humphrey, J., Carnaby-Mann, G., Sambandam, R., Miller, L., & Silliman, S. (2009). Dysphagia, Nutrition, and
Hydration in Ischemic Stroke Patients at Admission and Discharge from Acute Care. Dysphagia, 69-76. doi:
10.1007/s00455-012-9414-0
• Creasey, L. (2012). Impact of nutrition practice on acute ischemic stroke outcome. Support Line, 34, 20-26. http://0-
web.a.ebscohost.com.alvin.iii.com/ehost/detail/detail?vid=4&sid=5d239db9-2e7b-4542-af79-
bb10155c48bc%40sessionmgr4001&hid=4106&bdata=JnNjb3BlPXNpdGU%3d#db=c8h&AN=2011513393
• Geeganage, C., Beavan, J., Ellender, S., Bath, PMW. (2012). Interventions for dysphagia and nutritional support in acute
and subacute stroke (Review). The Cochrane Collaboration, 10, 1-16.
http://www.bibliotecacochrane.com/pdf/CD000323.pdf
• Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia After Stroke: Incidence,
Diagnosis, and Pulmonary Complications. Stroke,36, 2756-2763. doi: 10.1161/01.STR.0000190056.76543.eb
• Medin, J., Windahl, J., Magnus, A., Tham, K., Wredling, R. (2011). Eating difficulties among stroke patients in the acute
state: A descriptive, cross-sectional, comparative study. Journal of Clinical Nursing, 20, 2563-2572.
http://doi:10.1111/j.1365-2702.2011.03812.x

15. REFERENCES
•Mosselman, M., Kruitwagen, C., Schuurmans, M., & Hafsteinsdottir, T. (2013). Malnutrition and risk of malnutrition in
patients with stroke: Prevalence during hospital stay. Journal of Neuroscience Nursing, 194-204. doi:
10.1097/JNN.0b013e31829863cb
•Nip, W. F. R., Perry, L., McLaren, S., & Mackenzie, A. (2011). Dietary intake, nutritional status and rehabilitation outcomes
of stroke patients in hospital. Journal of Human Nutrition and Dietetics, 24, 460-469. http://doi:10.1111/j.1365-
277X.2011.01173.x
•Perry, L., Hamilton, S., Williams, J., & Jones, S. (2012). Nursing interventions for improving nutritional status and outcomes of
stroke patients: Descriptive reviews of processes and outcomes. World views on Evidence-Based Nursing, 17-39.
http://doi:10.1111/j.1741-6787.2012.00255.x
•Wang, X., Dong, Y., Han, X., Qi, X., Huang, C., Hou, L., & Kline, A. (2013). Nutritional support for patients sustaining
traumatic brain injury: A systematic review and meta-analysis of prospective studies. PLOS ONE, 8(3). Retrieved
from www.plosone.org
•Westergren, A. (2006). Detection of eating difficulties after stroke: A systematic review. International Nursing
Review, 53, 143-149. doi:10.1111/j.1365-2648.2008.04915.x
•Wirth, R., Smoliner, C., Jäger, M., Warnecke, T., Leischker, A., & Dziewas, R. (2013). Guideline clinical nutrition in
patients with stroke. Experimental & Translational Stroke Medicine, 5(14), 14-14. doi:10.1186/2040-7378-5-14