1. Thrombolysis NursingThrombolysis Nursing
CompetenciesCompetencies
ObjectivesObjectives
 Nursing Care of a Thrombolysed patientNursing Care of a Thrombolysed patient

3. 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

4. ““There is a massive and regularThere is a massive and regular
failure to respond to the emergencyfailure to respond to the emergency
of 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, Difficult
access to imaging, Insufficient specialistaccess to imaging, Insufficient specialist
resourcesresources
 Less than 1% of pts thrombolysedLess than 1% of pts thrombolysed
compared to 9% in Australiacompared to 9% in Australia

5. 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 in
arterial disease (carotid / vertebral)arterial disease (carotid / vertebral)

6. 80% of Strokes = Ischaemic80% of Strokes = Ischaemic
 80% of Ischaemic stroke caused by80% of Ischaemic stroke caused by
embolism fromembolism from
 HeartHeart
 Aortic archAortic arch
 Extracranial arteries to the brainExtracranial arteries to the brain

7. ThrombolysisThrombolysis
 Thrombus= clotThrombus= clot
 Lysis = destruction of cellsLysis = destruction of cells
 Thrombolysis is achieved by usingThrombolysis is achieved by using
rt-PA (alteplase)rt-PA (alteplase)
 rt-PA reverses underperfusion, allowingrt-PA reverses underperfusion, allowing
ischaemic penumbra to recoverischaemic penumbra to recover

8. ThrombolysisThrombolysis
 rt-PA= recombinantrt-PA= recombinant tissue plasminogentissue plasminogen
activatoractivator
 Plasmin is the enzyme that degradesPlasmin is the enzyme that degrades
fibrin, the protein which is the mainfibrin, the protein which is the main
constituent of blood clotsconstituent of blood clots
 rt-PA activates the release of plasmin asrt-PA activates the release of plasmin as
plasminogenplasminogen

9. Rational for giving Thrombolysis
Reduces the size of Ischaemic damage
( infarct) by restoring blood flow
Cells in the brain ie. Neurons die over
time .Prompt treatment with a thrombolytic
agent ( rTPa –Alteplase) may promote
reperfusion & improve functional outcomes

10. 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-stroke
quality of lifequality of life

11. Cerebral infarctCerebral infarct - onset- onsetCerebral infarctCerebral infarct - onset- onset
Onset
Infarct
Ischaemic
penumbra

12. Cerebral infarctCerebral infarct – 6 hours– 6 hoursCerebral infarctCerebral infarct – 6 hours– 6 hours
6 Hours
Infarct
Ischaemic
penumbra

13. Cerebral infarctCerebral infarct – 24 hours– 24 hoursCerebral infarctCerebral infarct – 24 hours– 24 hours
24 Hours
Infarct
Ischaemic
penumbra

14. Without thrombolysis
2hrs

15. Thrombolysis - The EvidenceThrombolysis - The Evidence
 NINDS trial 1995 (National Institute ofNINDS trial 1995 (National Institute of
Neurological 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 widens
use of rTPa to 4.5 hoursuse of rTPa to 4.5 hours

16. RCP Audit 2006 - ThrombolysisRCP Audit 2006 - Thrombolysis
 Only 10% admitted directly to unit withOnly 10% admitted directly to unit with
acute facilitiesacute facilities
 18% of hospitals do thrombolysis18% of hospitals do thrombolysis
 30 hospitals thrombolysed 218 patients30 hospitals thrombolysed 218 patients

17. ratios (with 95% CIs) of an unfavourable outcome with
tPA given within 3 hrs of onset of stroke
Odds ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs of
onset of stroke

18. Odds ratios (with 95% CIs) of an unfavourable outcome
with tPA given within 3 hrs of onset of stroke

19. 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

20. ‘‘Time is Brain’ - Stroke PathwayTime is Brain’ - Stroke Pathway
 Triage, FAST testTriage, FAST test
 Speedy call to Stroke Team (whateverSpeedy call to Stroke Team (whatever
severity)severity)
 Rapid admission to ASURapid admission to ASU

21. CAPACITY
 The Mental Capacity Act 2005, which came fully into force in October 2007, provides the legal
framework for acting and making decisions on behalf of individuals who lack the capacity to make
specific decisions for themselves in relation to personal welfare, healthcare and financial
matters. 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 lacks
capacity.
 · (3) A person is not to be treated as unable to make a decision unless all practicable steps
to 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 makes
an unwise decision.
 · (5) An act done, or decision made, under this Act for or on behalf of a person who lacks
capacity 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 the
purpose for which it is needed can be as effectively achieved in a way that is less restrictive of
the person’s rights and freedom of action

22. 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 or
any other means)
 .
 This test must be complete and recorded; the documentation must
demonstrate the above process

23. ABCABC
 AirwayAirway
 BreathingBreathing
 CirculationCirculation

24. 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

25. Time is brainTime is brain
 1.9 million neurons are lost1.9 million neurons are lost
each minute after a strokeeach minute after a stroke
 Protect ischaemic penumbraProtect ischaemic penumbra
Stroke 2006Stroke 2006

26. CTCT
 Known time ofKnown time of
symptoms <4 hourssymptoms <4 hours
 NIHSS scoreNIHSS score
 No haemorrhageNo haemorrhage
 No contraindicationsNo contraindications
 ConsentConsent
 AgeAge

27. ThrombolysisThrombolysis
Alteplase rTPAAlteplase rTPA
0.9mg /Kg0.9mg /Kg
10% of total dose –Bolus 2-3 mins10% of total dose –Bolus 2-3 mins
90% of total dose –Infuse over 6090% of total dose –Infuse over 60
minsmins

28. 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 with
Normal salineNormal saline
 t-PA must be used within 8 hours of mixing whent-PA must be used within 8 hours of mixing when
stored at room temperature or within 24 hours ifstored at room temperature or within 24 hours if
refrigeratedrefrigerated

29. 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 study
1,135 pts1,135 pts
 Major Heamorrhage 0.4%Major Heamorrhage 0.4%

30. Angioedema

31. 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 flew
in 1986in 1986
 Collapsed right sidedCollapsed right sided
weaknessweakness
 Unable to talk . Couldn’t thinkUnable to talk . Couldn’t think
clearly.clearly.
 999 ambulance to A%E999 ambulance to A%E
 ““Clock work military precisionClock work military precision
like gun team at Earls court”like gun team at Earls court”

32. First 24 hoursFirst 24 hours
30% of all stroke patients will deteriorate in30% of all stroke patients will deteriorate in
the first 24hoursthe first 24hours
Stroke 2009Stroke 2009

33. Monitor GCSMonitor GCS
 Ability to engage withAbility to engage with
immediate surroundingsimmediate surroundings
 Standardised stimuliStandardised stimuli
E1-E4E1-E4
V1-V5V1-V5
M1-M6M1-M6

34. Best and Worst ScoreBest and Worst Score
 GCS 15- E4 V5 M6GCS 15- E4 V5 M6
Awake, alert and fullyAwake, alert and fully
responsiveresponsive
 GCS 3-E1 V1 M1GCS 3-E1 V1 M1
No cerebrally mediatedNo cerebrally mediated
response to stimulusresponse to stimulus

35. NIHSS - A Research ToolNIHSS - A Research Tool
Fifteen item impairmentFifteen item impairment
scalescale
 Neurological outcomeNeurological outcome
 Degree of recoveryDegree of recovery

36. Physiological MonitoringPhysiological Monitoring
1.1. HypoxiaHypoxia
RespirationsRespirations
Saturations <92%Saturations <92%
Associated with neurologicalAssociated with neurological
deteriorationdeterioration
2.2. TemperatureTemperature
>38C must be treated.>38C must be treated.
-associated with infarct volume-associated with infarct volume
3.3. ArrhythmiasArrhythmias
Continuous ECGContinuous ECG
Early detection and treatment of AFEarly detection and treatment of AF
Right hemisphere /insular lesionsRight hemisphere /insular lesions

37. Physiological Monitoring contdPhysiological Monitoring contd
4.Blood pressure4.Blood pressure
Non thrombolysed patientsNon thrombolysed patients
BP Not treated unless:BP Not treated unless:
Systolic >220mmHg orSystolic >220mmHg or
Diastolic >120mmHg with 2Diastolic >120mmHg with 2
consecutive readingsconsecutive readings
Thrombolysed patientsThrombolysed patients
BP is treated if:BP is treated if:
Systolic >185mmHg orSystolic >185mmHg or
Diastolic >110mmHg with 2Diastolic >110mmHg with 2
consecutive readingsconsecutive readings
Abrupt fall in BP may affect cerebralAbrupt fall in BP may affect cerebral
perfusion pressureperfusion pressure

38. Physiological Monitoring contdPhysiological Monitoring contd
5.Blood Sugar5.Blood Sugar
 Hyperglycaemia BM>10 treat &Hyperglycaemia BM>10 treat &
monitormonitor
 Hypoglycaemia –immediateHypoglycaemia –immediate
treatment with glucosetreatment with glucose
Hyperglycaemia is associated withHyperglycaemia is associated with
poor clinical outcomepoor clinical outcome

39. Physiological Monitoring ContdPhysiological Monitoring Contd
6.6. HydrationHydration
GlucoseGlucose
Cerebral perfusionCerebral perfusion
7. Anuria7. Anuria
PolyuriaPolyuria
Circulatory failureCirculatory failure

40. 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

41. Swallow ComplicationsSwallow Complications
(Dysphagia)(Dysphagia)
Chest InfectionChest Infection
Aspiration PneumoniasAspiration Pneumonias
50% 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

42. Mouth CareMouth Care
Increased risk of infectionIncreased risk of infection
Pain and discomfortPain and discomfort
Effects swallowEffects swallow
 Gentle mouth careGentle mouth care
 Adequate hydrationAdequate hydration
 Gentle tooth brushingGentle tooth brushing

43. Head PositionHead Position
ControversialControversial

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

44. Bladder &BowelsBladder &Bowels
Urinary incontinenceUrinary incontinence
Urinary infectionUrinary infection
 Avoid cathetersAvoid catheters
 Early plan of careEarly plan of care
 Adequate hydrationAdequate hydration
 BowelsBowels
 Privacy & dignityPrivacy & dignity

45. Psychological SupportPsychological Support
 Assess moodAssess mood
 Recognise grief/lossRecognise grief/loss
 TalkTalk
 Engage with familyEngage with family
 InterestsInterests
 Timely realistic goalsTimely realistic goals
 ReferRefer

46. Pressure SoresPressure Sores
 Air mattressAir mattress
 Two hourly turnsTwo hourly turns
 NutritionNutrition
 HydrationHydration
 Personal hygienePersonal hygiene

47. 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 in
stroke patientsstroke patients
Clots Trial 2009Clots Trial 2009

48. PositioningPositioning
Loss of sensationLoss of sensation
Loss of powerLoss of power
SubluxationSubluxation
 SupportiveSupportive
 IV lines and BP cuffs avoidedIV lines and BP cuffs avoided
on affected limbon affected limb
 Assess moving and handlingAssess moving and handling
 Good techniqueGood technique

49. NutritionNutrition
MalnourishmentMalnourishment
associated with poorassociated with poor
outcomeoutcome
 WeightWeight
 MUST assessmentMUST assessment
 Naso gastric tubeNaso gastric tube
 History of patients eatingHistory of patients eating
habitshabits
ControversialControversial
 When to commence invasiveWhen to commence invasive
feeding regimefeeding regime