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Role of Nurses in Stroke Care: Journey of a Stroke Patient

Explore the important role of nurses in stroke care, from the emergency department to rehabilitation. Learn about the chain of survival and how nurses can make a difference. Case scenario and NINDS recommendations included.

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Role of Nurses in Stroke Care: Journey of a Stroke Patient

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  1. CHĂM SÓC ĐỘT QUỴ Vai trò của điều dưỡng và chăm sóc ban đầu 1 D R N G WA I MAY ADVANCEDPRACTICENURSE/DEPUTYDIRE CTOR,NURSING NATIONALNEUROSCIENCEINSTITUTE WAI_MAY_NG@NNI. COM.SG

  2. Journey of a STROKEpatient

  3. Stroke:Chainof Survival Where can Nurses play apart? Emergency Department Homepic StrokeUnit Rehabilitation ? ? ? ? ? ? 3

  4. CaseScenario MrTan 72 years old/Male Past Medical History: Hypertension, DM,Hyperlipidaemia, atrialfibrillation Developed right sided weakness and unabl eating lunch at1pm e to speakwhile 4

  5. NINDSRecommendations Faster =Better

  6. In theAmbulance History ECG BloKodngoluwcoswelhevaetl your paramedic canor Bloodpressure cannotdo • Prehospitalnotification • If Cincinnati Prehospital Stroke Scalepositive • Onset less than 5hours

  7. CallCentre Onset: 30minsago Paramedics notifyhospital Hospital operatoractivate doctor andnurse 17 Nov 2017,9.32am Stroke Activation: 45 year old, Male, S1234567F/ETA 14mins

  8. Emergency Department(ED) Important to have clear definedroles

  9. Emergency Department(ED)

  10. Nurses’Role • Receive notification fromED • Standby EDresuscitation • bay • Standby weighingtrolley • Stroke team will go toED to standbytoo

  11. ED Nurse’sRole • Assess airway, breathing,circulation • IfSpO2<95%, administer oxygen • Check blood pressure every 5minutes • Mr Tan’sBPis 196/105mmHg • Nitroglycerine patch 5mggiven • Standby IVanti-hypertensives • e.g. nicardipine,labetalol

  12. ED Nurse’sRole • Set IV cannulas (preferably 2) Take blood forinvestigation • blood sugarlevel** • INR if onwarfarin What doesthe stroke nurse do? • Optional • ECG • Chestx-ray

  13. Stroke Nurse’sRole • Usually senior and experiencednurse • Advanced Practice Nurse or specialtynurse • Performhistorytakingeitherfrompatientorfamily • Onset or last seen well or lastdiscovered ** • Past medical history andmedications • MrTanhashypertension,diabetes,hyperlipidaemia,atrial fibrillation. Defaulted medications for 1month

  14. Stroke Nurse’sRole • Perform National Institute of HealthStrokeScale (NIHSS) • measures neurologicalimpairment • 11items • Level of Consciousness, Horizontal gaze, Visualfield, • Facial palsy, Motor arms, Motor legs, Ataxia,Sensory • Language, Speech, Extinction andinattention • Score 0 -42

  15. NIHSSAssessment • Score 0 to42 • 0-4: mildstroke • 5-15: moderatestroke • >16 severestroke • Mr Tan has NIHSS11 Moderatestroke

  16. Stroke Nurse’sRole • Assess for Mr Tan’s eligibility for tPA and/orendovascular therapy(EVT) • Multipleriskfactors, defaultedmedications • AtrialFibrillation** • NIHSS11 • Left hemispheric syndrome tPA?EVT?

  17. CT Scanbrain CT scanbrain CT angiography (from arch of aorta to circle ofwillis) Nurse standby tPA for dilution. Calculatedbolus doserequired

  18. tPABox

  19. To minimise errors and improve efficiency DoseChart

  20. CT/CTABrain CT BRAIN CTANGIOGRAPHY

  21. Nurse’s Role after tPADecision • InformDrofpatient’sweight(ifavailable) • Dilute tPA with diluentprovided • Dosage = 0.9 mg x weight (kg) [max dose90mg] • Drwillcalculatebutnursetodoublecheck • 10% bolus (Ensure that BP <185/110mmHg), 90% to be infused over 1hour • Monitor neurological status and vitalsigns • BP ** to keep<180/105mmHg

  22. Mr Tan has large vessel occlusion in M1. May need Endovascular therapy (EVT). Need to activate angioteam Need to transferto another hospital forEVT? Is ambulance ready? Activate Neuro-interventionalist Neuroradiologynurse Anaesthetist

  23. Next KIV MRIBRAIN ANGIOSUITE

  24. OngoingMonitoring • Monitor for neurologicalstatus • Sometimesvesselsre-cannalised, EVT may beavoided • Caution on BPcontrol • Do continue tocontrolBP. To keep<180/105mmHg • If patient is undergoinggeneralanaesthesia, bewareof potentialhypotension.

  25. EndovascularTherapy PRE-EVT POST-EVT

  26. Audits &Feedback Identify a team lead doctor ornurses Once a month audit meetings on door-to-needle anddoor- to-punctureindicator Opportunity to feedback onchallenges

  27. Emergency DepartmentNurse Set IV cannulas, Send offblood Assess Airway,breathing, investigations circulation (Vital signs*BP). Blood glucose stat, ECGif needed Start anti-hypertensives whenBP >185/110mmHg Arrange for CXR ifneeded, Arrange for transfer to scanroom • Prepare transportmonitor, • equipment • Call CT scanroom • Arrange forporter Weighpatient

  28. StrokeNurse Take History from patient/family Monitor neurologicalstatus Review eligibility for tPA or/and EVT. Watch BPclosely Obtain tPA from pharmacy Dilute tPA accordingly, administer safely Safetycheck**

  29. Nurses’Characteristics Excellent teamplayer Possess good strokeknowledge Know your protocols or guidelines verywell Understand your processeswell Speak up for safetyreasons

  30. Journey of a STROKEpatient

  31. Patients are more likely to survive and to be, independent and living at home 1 year after thestroke. 34

  32. SocialWorker Nurse Doctor/ Rehab Physicians Physiotherapist Pharmacist Patient &NOK Occupational therapist Dietician Case Manager Speechtherapist 35

  33. Cluster randomised controlledtrial Developed and implemented a multidisciplinary team building intervention to improveevidence- based management of fever, hyperglycaemia and swallowing dysfunction in patients following acutestroke Slide from: AngelsInitiative MIDDLETON S, MCELDUFF P, WARD J, GRIMSHAW JM, ET AL. LANCET2011;378(9804):1699-1706.

  34. Background:Swallow PREDICTORS & OUTCOMES OF DYSPHAGIA SCREENING ONTARIO STROKE REGISTRY DATA: PREDICTORS AND OUTCOMESOF DYSPHAGIA SCREENING IN ACUTE STROKE PATIENTS(N=7171)2 ONE IN 5 AIS PATIENTS DID NOT RECEIVE DYSPHAGIA SCREENING(19.2%) FAILING DYSPHAGIA SCREENING ASSOCIATED WITH POOROUTCOMES: UP TO 78%OF STROKE In-hospitalpneumonia OR, 4.71; 95% CI,3.43-6.47 PATIENTSHAVE DYSPHAGIA1 Severe disability(mRS 4-5) OR, 5.19; 95% CI,4.48-6.02 Discharge tolong-termcare OR, 2.79; 95% CI,2.11-3.79 1-yearmortality OR, 2.42; 95% CI,2.09-2.80 IMPORTANTLY, ASSOCIATIONS WITH POOROUTCOMES WERE MAINTAINED IN PATIENTS WITH MILDSTROKES AIS, ACUTE ISCHAEMIC STROKE; OR, ODDSRATIO 1MIDDLETON S, MCELDUFF P, WARD J, GRIMSHAW JM, ET AL. LANCET2011;378(9804):1699-1706. 2JOUNDI RA, ET AL. STROKE2017;48(4):900-906. Slide from: AngelsInitiative

  35. FeSSIntervention • All nurses need to undergo educational programabout dysphagia screening by the speechtherapist • All nurses must complete the competencyassessment (written knowledge test and clinical competency assessment by the speechtherapists) • Use a validated dysphagia screening tool and document in patients’record • Iffailscreeningrefertothespeechtherapist Middletonet al (2017).Mortalityreductionforfever,hyperglycaemia,andswallowing nurse-initiatedstroke intervention. QASC Trial (Quality in acute stroke care) follow-up. Strokem 48,1331-1336 36

  36. When to doDysphagia Screening? Patients with acute stroke should havetheir swallowing screened, using a validated screening tool before being given any oral food, fluid ormedication Screening of swallowing should be done first 24hours afterstroke America Heart Association Council On Cardiovascular Nursing and the stroke council.(2009). Comprehensive overview of nursing and inter disciplinary care of the acute ischemic stroke patient. Stroke; 40:2911-2944. 37

  37. Dysphagia Screening(Local) • Any exclusioncriteria? • E.g. bilateral/brainstem stroke, drowsy, cognitiveimpairment • Perform dysphagiascreen • Sit patient upright, Assessor’s eye level is atneck Refer ST iffailWST. KIV startmodified diet or NGTinsertion • Give 30ml from medicine cup “drinknormally” • Observe for signs ofaspiration • Cough, choke, throat clearing more than once, no swallow attempts, excessive drooling, multiple swallows. Breathless after swallow, wet gurglyvoice • Continue with 90ml WST, to finish wthin oneminute • Observe for signs ofaspiration 38

  38. HOW to doit? EXCLUSION CRITERIA • 30mls + 90mlsWater • Assessor’s eye at patient’sneck • Sit patient upright with headslightly • forward • Give 30ml ofwater • Instruct to drink (normallydrink) • Observe for signs ofaspiration Adopted from Tan Tock Seng Hospital Stroke Carepath, Water Swallow TestWorkf4lo1w *Based on localpractice

  39. HOW to doit? Signs ofAspiration • • • • • • • • Coughing Choking Throat clearing morethan once No attempts to swallow Excessive drooling Multiple swallows foreach mouthful Breathlessnessafter swallows Wet/gurgly voicepost- swallow • Continue with90mls ofwater • To finish water withinone minute • Observe for signs of aspiration Adopted from Tan Tock Seng Hospital Stroke Carepath, Water Swallow TestWorkf4lo2w *Based on localpractice

  40. Glucose levels at admission and casefatality UP TO 50%INCIDENCE IN THE FIRST48HRS7,8 ACROSS ALLSTROKE SUBTYPES8,9 GLUCOSE >8 MMOL/L PREDICTOR INCREASED MORTALITY & POORER FUNCTIONALOUTCOME10 HYPERGLYCAEMIC NON- DIABETIC PATIENTSADMITTED TO HOSPITAL WITH STROKE ARE ~3X MORE LIKELY TO DIE THAN THOSE WHO ARE NOT HYPERGLYCAEMIC9 50 45 40 35 30 25 20 15 10 5 0 non-diabetic diabetic Case fatality(%) 5.7 –7.1 7.2 –9.2 Serum glucoselevels (mmol/L) <5.7 >9.2 StöllbergerC,etal.AnnMed2005;37(5):357-364. 7ALLPORT L, ET AL. DIABETES CARE 2006;29(8):1839-1844; 8SCOTT JF, ET AL. LANCET1999;353(9150):376- 377. 9CAPES SE, ET AL. STROKE 2001;32(10):2426-2432; 10WEIR CJ, ET AL. BR MED J1997;314(7090):1303-1306. Slide from: AngelsInitiative

  41. Sugar AHA(2018).2018GuidelinesfortheEarlyManagementofPatientsWithAcute IschemicStroke.AGuidelineforHealthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49:e46–e99. DOI: 10.1161/STR.0000000000000158 42

  42. FeSSInterventions • Venous and finger-pricked glucose on admission toStroke unit AND finger pricked every 1-6H for first72H • Start IV saline infusionif • DM patient: sugar is8-11mmol/L • Non-DM patient : sugar8-16mmol/L • Start insulin infusionif • DM patient: sugar is ≥11mmol/L • Non-DM patient: sugar is ≥16mmol/L Middletonet al (2017).Mortalityreductionforfever,hyperglycaemia,andswallowing nurse-initiatedstroke intervention. QASC Trial (Quality in acute stroke care) follow-up. Strokem 48,1331-1336 43

  43. FEVERWITHIN THE FIRST 24 HOURSOF HOSPITALISATIONIS ASSOCIATED WITHA DOUBLING OFODDS Background:Fever OFSHORT-TERM MORTALITY Odds ratio (fixed) 95%CI Weight % Odds ratio (fixed) 95%CI Study or sub-category Log [Odds ratio](SE) Azzimondi 1995 Hanchaiphiboolkul Jorgensen 1996 Prasad2008 Reith1996 1.2240(0.5280) 1.3740(0.3900) 0.7420(0.3680) -0.0800(0.7280) 0.5880(0.2390) 9.71 17.80 19.99 5.11 47.39 3.40 [1.21,9.57] 3.95 [1.84,8.49] 2.10 [1.02,4.32] 0.92 [0.22,3.85] 1.80 [1.13, 2.88] Total (95%CI) Test for heterogeneity: χ2 = 5.08, df = 4 (P = 0.28), I2 = 21.2% Test for overall effect Z = 4.78 (P <0.00001) 100.00 2.20 [1.59,3.03] 0.0010.01 0.1 1 10 1001000 Feverdecreases risk Feverincreases risk Slide from: AngelsInitiative PRASAD K, KRISGHNAN P. ACT NEUROL SCAND2010;122:404-408.

  44. FEVER AHA (2018). 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke . A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke.2018;49:e46–e99. DOI:10.1161/STR.0000000000000158 45

  45. FeSSInterventions • Monitorandcharttemperatureevery4Hinthefirst72H • Temperature≥37.5,treatwithparacetamolifno contraindications Source of fever should be identifiedand treated 46

  46. INTERVENTION: FESSPROTOCOLS SWALLOWI NG FEVER SUGAR (N=2 ELEMENTS) (N=5 ELEMENTS) (N=2 ELEMENTS) 4 - 6 HOURLYTEMPERATURE READINGS FOR 72HOURS EDUCATION PROGRAM AND COMPETENCY ASSESSMENT FOR NURSES RUN BYSPEECH PATHOLOGISTS SCREEN WITHIN 24 HOURSOF STROKE UNITADMISSION REFERRAL TO SPEECH PATHOLOGIST FOR FULL ASSESSMENT FOR THOSE WHO FAILED THESCREEN TEMPERATURE≥37.5°C TREATED WITH PARACETAMOL Slide from: AngelsInitiative MIDDLETON S, MCELDUFF P, WARD J, GRIMSHAW JM, ET AL. LANCET2011;378(9804):1699-1706.

  47. INTERVENTION: FESSPROTOCOLS SWALLOWI FEVER SUGAR NG (N=2 (N=5 ELEMENTS) ELEMENTS) (N=2 ELEMENTS) FORMALVENOUSGLUCOSE EDUCATION PROGRAM AND ON ADMISSION COMPETENCYASSESSMENT FOR NURSES RUN BYSPEECH 4 -6 HOURLYTEMPERATURE1-6 HOURLYFINGER-PRICKPATHOLOGISTS READINGS FOR72HOURS GLUCOSE FOR 72HOURS ON ADMISSION: 8-16MMOL/L (ND) OR 8-11MMOL/L(D): SCREEN WITHIN 24 HOURSOF SALINE INFUSIONFOR THE STROKE UNITADMISSION FIRST SIXHOURS TEMPERATURE≥37.5°C GLUCOSE ≥16 MMOL/L (ND): TREATEDWITH IV INSULIN REFERRAL TOSPEECH PARACETAMOL PATHOLOGIST FORFULL GLUCOSE ≥11MMOL/L(D): ASSESSMENT FOR THOSE IVINSULIN WHO FAILED THESCREEN ALL ELEMENTS OF THE INTERVENTION RAN FOR THE FIRST 72 HOURS OF ADMISSION TO THE STROKEUNIT Slide taken from: AngelsInitiative MIDDLETON S, MCELDUFF P, WARD J, GRIMSHAW JM, ET AL. LANCET2011;378(9804):1699-1706.

  48. Results DECREASED MEAN TEMPERATURE (P=0.001) AND BLOOD GLUCOSE (P=0.02) [72 HOURS OF SU ADMISSION] 15.7% REDUCTIONIN DEATH AND DISABILITY90 DAYS POST- STROKE (P=0.002;MRS) 19 STROKE UNITS (SU) THROUGHOUT NEW SOUTH WALES, AUSTRALIA IMPROVED SWALLOW SCREENING (P≤0.001) [24 HOURS OFSU ADMISSION] REDUCED LENGTH OF STAY BY TWO DAYS(P=0.144) Slide from: AngelsInitiative

  49. ClinicalSignificance 1% Aspirin 5% StrokeUnit 10% Thrombolysis <4.5hrs 23%Hemicraniectomy 31% Endovascular Rx (rt-PA plusthrombectomy) DHAMIJA RK, ET AL. AUST FAM PHYSICIAN2005;36(11):892-895. Slide from: AngelsInitiative

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