STROKE: Order Sets & Nursing Interventions Module IV

1. STROKE: Order Sets & Nursing InterventionsModule IV K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

2. Stroke Module IV Objectives: • Identify key nursing assessments and interventions to prevent complications after stroke • Identify stroke education resources appropriate for patient and family and the means to document education K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

3. Ischemic stroke (complete) & “mini” admission order sets & Transient ischemic attack (TIA) admission order set Order sets include: • Anti-thrombotic medications • Blood pressure management • DVT prophylaxis • Fall risk • Neuro assessment • NPO/Aspiration precautions • Rehabilitation needs • Tobacco cessation K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

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6. After stabilization the highest priorities are to: (1) prevent recurrence of stroke, (2) prevent complications and, (3) begin mobilization • Observe changes in the patient's condition that might prompt different medical or surgical interventions • Facilitate medical and surgical measures aimed at improving outcome after stroke • Institute measures to prevent sub acute and long term complications • Implement therapies to prevent recurrent stroke • Begin efforts to restore neurological function through rehabilitation or other techniques • Family and patient support and anticipatory guidance K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08) AHA 1994

7. Prevention of complications: Interventions • Skin breakdown: Use of Braden scale, skin assessments per stroke standard, pressure relief via repositioning and devices, skin care, incontinence care • Falls: Fall risk assessment and use of fall precautions; special attention to toileting needs • Aspiration pneumonia: NPO until dysphagia screen is completed and patient cleared for diet; aspiration precautions, oral hygiene before and after meal K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

8. Prevention of complications: Interventions (continued) • Deep vein thrombosis: Mobilize as soon as possible, use of elastic compression hose or pneumatic pressure devices if low molecular weight heparin or unfractionated heparin contraindicated • Painful hemi-paretic shoulder: Proper positioning and support of affected limb during ambulation, transfers, and when lying in bed or sitting in chair; use of slings, lap trays/troughs, range of motion as directed by therapy K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

9. Rehabilitation & Restorative Care • Studies show clear advantages of treatment of patients in the acute phase of stroke in a dedicated stroke unit: • At MMC: CICU, SCU, R4, P3CD and R6/608 are dedicated units • Rehabilitation after stroke is a continuum, starting within days of stroke onset and ending only when it no longer produces any positive effect: • At MMC: Physical, Occupational and Speech therapy are available. Physiatry consultation is also available. Rehabilitation is coordinated and uses a multidisciplinary team approach. Med J Aust 2002 K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

10. Rehabilitation & Restorative Care(continued) • Rehabilitation services post-acute care include those offered by New England Rehabilitation Hospital of Portland, Skilled Nursing Facilities, and Home Health. • Improvements in function after stroke are the result of recovery within the ischemic penumbra (potentially viable tissue), resolution of cerebral edema, neuroplasticity, and compensatory strategies learnt by the patient. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

11. Education Resources for: Patients, Families & Significant Others • American Heart Association (AHA) materials • Micromedex • Interactive television/video • MMC library Complete lists can also be found at the Stroke Program Intranet site: https://my.mmc.org/C19/C5/American%20Stroke%20Association%20Ed/default.aspx https://my.mmc.org/C0/C6/Maine%20Medical%20Center%20-%20In%20Hous/default.aspx K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

12.  Complications after Stroke  Driving after Stroke  Emotional changes after Stroke  Feeling tired after Stroke  Living at home after Stroke  Stroke & Aphasia  Stroke & Rehabilitation  Stroke Diagnosis  The Stroke Family Caregiver  Changes caused by stroke  Anticoagulant & antiplatelet agents  Carotid Endarterectomy  Children & Stroke  Hemorrhagic Stroke & Causes  High Blood Pressure & Stroke  Ischemic Stroke & Causes  Risk Factors for Stroke  Stroke, TIA & Warning Signs  Lifestyle Changes American Heart Association (AHA) Educational Materials Complete lists can also be found at the Stroke Program Intranet site: https://my.mmc.org/C19/C5/American%20Stroke%20Association%20Ed/default.aspx https://my.mmc.org/C0/C6/Maine%20Medical%20Center%20-%20In%20Hous/default.aspx K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

13. Micromedex Resources (not all inclusive) • ATRIAL FIBRILLATION (THROMBOTIC STROKE) • CAROTID ARTERY DISEASE (STROKE AND CEREBROVASCULAR ACCIDENT UNSPECIFIED) • CEREBROVASCULAR ACCIDENT (EMBOLIC STROKE) • HEALTHY HEART DIET (ELEVATED BLOOD PRESSURE (NOT HYPERTENSION)) • HYPERTENSION • CHOLESTEROL AND YOUR HEALTH • HEALTHY HEART DIET (CHOLESTEROL-LOWERING DIET) • LIPID PROFILE (SERUM CHOLESTEROL LEVEL) • LOW FAT DIET (CHOLESTEROL-LOWERING DIET) • 1200 CALORIE DIABETIC DIET, BASIC (ADULT DIABETES DIET) • 1500 CALORIE DIABETIC DIET, BASIC (ADULT DIABETES DIET) • 1800 CALORIE DIABETIC DIET, BASIC (ADULT DIABETES DIET) • DIABETIC EXCHANGE DIET (ADULT DIABETES DIET) • CIGARETTE SMOKING AND ITS HEALTH RISKSHOW TO STOP SMOKING • APHASIA K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08) http://micromedex.mmc.org/

14. Interactive TV Video Titles • Daily decisions: A guide to diabetes self management • Diabetes and nutrition: Eating for health • Atrial fibrillation • Introduction to heart disease risk factors • Stroke: What every person needs to know • Understanding anticoagulant medications: Coumadin • Understanding the MRI adventure: Adults • Guide to stop smoking • How to beat cigarettes • AHA: Quitting smoking • Smoking cessation—health views K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

15. Joint Commission required measures for: Ischemic and Hemorrhagic Strokes Tobacco cessation should be entered for anyone who has smoked a cigarette in the last year for reinforcement to continue cessation. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

16. Nursing Input & Advocacy: It DOES make a difference! Follow up on missing documentation and quality measures. K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

17. DOCUMENT EDUCATIONStandard of Care: Specifics may include: • Stroke location, type and mechanism • Diagnostic tests for stroke/TIA workup • Medications: antithrombotics, anti-hypertensive, lipid-lowering agents, Warfarin, anti-hyperglycemic • Diet: Low fat, low cholesterol, low salt, diabetic • Risk factor management to lower primary or secondary stroke risk ** • Signs and symptoms of stroke and emergent nature of these ** • Rehabilitation and discharge plan • Handouts/resources given Use education plan on Stroke Standard and brief focus notes to address learning for patient and/or family K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

18. DOCUMENT EDUCATIONJoint Commission REQUIRED education: • Personal Risk Factors • Warning Signs for Stroke • Activation of EMS • Need for Follow Up after discharge • Medications prescribed K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

19. Standard of Care for Patient with a Stroke (example) NOTE: Will need to be updated early 2008 with revised Standard of Care K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

20. Discharge Instructions • USE of Stroke Discharge Instruction Sheet • Reinforce stroke signs and symptoms and emergent nature of these • Risk factor management • Rehabilitation plan • Medical follow-up • Community resources K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

21. Stroke Discharge Instruction Sheet K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

22. Test Questions: • Ms. LH has had a left middle cerebral artery distribution stroke and is hemiplegic on the right side. She is allergic to heparin. To prevent deep vein thrombosis, care will include: • Performance of frequent neurologic checks • Application of pneumatic compression devices • Elevation of the foot of the bed 30 degrees • Maintenance of bed rest for about 3 days Ans. b K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)

23. 2. To reduce the risk of pneumonia in Mrs. WO, a stroke patient who has dysphagia, the following is recommended: Keep her N.P.O. until a swallowing evaluation has been completed  Elevate the head of her bed 20 degrees when providing feeding assistance Avoid performing mouth care as this can make her gag Keep her supine to decrease episodes of coughing  Ans. a Test Questions: K:\STROKE CENTER\Staff Learning Opportunities\eLearn\MOD4 (rev. 01.18.08)