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Thrombolysis Nursing Competencies

Thrombolysis Nursing Competencies. Objectives Nursing Care of a Thrombolysed patient. What informed the Stroke Strategy. RCP Sentinel Audits (2002-2006) NAO Report (Nov 2005) Stroke strategy framework 2007 Nice.

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Thrombolysis Nursing Competencies

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  1. Thrombolysis Nursing Competencies Objectives Nursing Care of a Thrombolysed patient

  2. What informed the Stroke Strategy • RCP Sentinel Audits (2002-2006) • NAO Report (Nov 2005) • Stroke strategy framework 2007 • Nice

  3. “There is a massive and regular failure to respond to the emergency of stroke” (NAO 2005) • Low public awareness of symptoms, prevention & management • Slow admission to hospital, Difficult access to imaging, Insufficient specialist resources • Less than 1% of pts thrombolysed compared to 9% in Australia

  4. Stroke is a Medical Emergency ’Time is Brain’ • Speedy diagnosis • Rapid access to imaging • Thrombolysis • Rapid access to supportive therapy (HASU) • Rapid secondary prevention • Rapid surgical/ radiological intervention in arterial disease (carotid / vertebral)

  5. 80% of Strokes = Ischaemic • 80% of Ischaemic stroke caused by embolism from • Heart • Aortic arch • Extracranial arteries to the brain

  6. Thrombolysis • Thrombus= clot • Lysis = destruction of cells • Thrombolysis is achieved by using rt-PA (alteplase) • rt-PA reverses underperfusion, allowing ischaemic penumbra to recover

  7. Thrombolysis • rt-PA= recombinant tissue plasminogen activator • Plasmin is the enzyme that degrades fibrin, the protein which is the main constituent of blood clots • rt-PA activates the release of plasmin as plasminogen

  8. 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

  9. Thrombolysis • Must be given within 4.5 hours of stroke • Strict inclusion criteria • Licensed for IV use in under 80’s • Consultant decision: intra-arterial, 80+ • Dramatic increase in post-stroke quality of life

  10. Cerebral infarct - onset Onset Infarct Ischaemic penumbra

  11. Cerebral infarct – 6 hours 6 Hours Infarct Ischaemic penumbra

  12. Cerebral infarct – 24 hours 24 Hours Infarct Ischaemic penumbra

  13. Without thrombolysis 2hrs

  14. Thrombolysis - The Evidence • NINDS trial 1995 (National Institute of Neurological Diseases & Stroke) • ECASS 1 and ECASS 2 (European Co-operative Stroke Study) up to 3 hours • ECASS 3 showed benefit up to 4.5 hours • 2009 American stroke association widens use of rTPa to 4.5 hours

  15. RCP Audit 2006 - Thrombolysis • Only 10% admitted directly to unit with acute facilities • 18% of hospitals do thrombolysis • 30 hospitals thrombolysed 218 patients

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

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

  18. Thrombolysis - The Evidence • Fewer complications • Frequently, dramatic lack of disability • Quicker recovery • Reduction in LOS

  19. ‘Time is Brain’ - Stroke Pathway • Triage, FAST test • Speedy call to Stroke Team (whatever severity) • Rapid admission to ASU

  20. 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

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

  22. ABC • Airway • Breathing • Circulation

  23. After ABC GCS ECG Blood glucose Fluid access Hydration Bloods Nil by Mouth Transfer to CT-continue ABC

  24. Time is brain 1.9 million neurons are lost each minute after a stroke Protect ischaemic penumbra Stroke 2006

  25. CT Known time of symptoms <4 hours NIHSS score No haemorrhage No contraindications Consent Age

  26. Thrombolysis Alteplase rTPA 0.9mg /Kg 10% of total dose –Bolus 2-3 mins 90% of total dose –Infuse over 60 mins

  27. rTPA Alteplase • Do not mix t-PA with any other medications. • Do not use IV tubing with infusion filters. • All patients must be on a cardiac monitor • When infusion is complete, saline flush with Normal saline • t-PA must be used within 8 hours of mixing when stored at room temperature or within 24 hours if refrigerated

  28. Complications of Thrombolysis Intra -cerebral haemorrhage-1.7% (1 in 77 patients) 0.28% fatal SITS MOST 2007 Bleeding-minor bleeding is common (IV site) Anaphylaxis- 1% Ace inhibitors Frontal & insular lesions Angiodoema 1.3% Canadian study 1,135 pts Major Heamorrhage 0.4%

  29. Angioedema

  30. Patient Story Mr X 88 years of age Jet pilot in the war & last flew in 1986 Collapsed right sided weakness Unable to talk . Couldn’t think clearly. 999 ambulance to A%E “Clock work military precision like gun team at Earls court”

  31. First 24 hours 30% of all stroke patients will deteriorate in the first 24hours Stroke 2009

  32. Monitor GCS Ability to engage with immediate surroundings Standardised stimuli E1-E4 V1-V5 M1-M6

  33. Best and Worst Score GCS 15- E4 V5 M6 Awake, alert and fully responsive GCS 3-E1 V1 M1 No cerebrally mediated response to stimulus

  34. NIHSS - A Research Tool Fifteen item impairment scale Neurological outcome Degree of recovery

  35. Physiological Monitoring 1. Hypoxia Respirations Saturations <92% Associated with neurological deterioration 2. Temperature >38C must be treated. -associated with infarct volume 3. Arrhythmias Continuous ECG Early detection and treatment of AF Right hemisphere /insular lesions

  36. Physiological Monitoring contd 4.Blood pressure Non thrombolysed patients BP Not treated unless: Systolic >220mmHg or Diastolic >120mmHg with 2 consecutive readings Thrombolysed patients BP is treated if: Systolic >185mmHg or Diastolic >110mmHg with 2 consecutive readings Abrupt fall in BP may affect cerebral perfusion pressure

  37. Physiological Monitoring contd 5.Blood Sugar Hyperglycaemia BM>10 treat & monitor Hypoglycaemia –immediate treatment with glucose Hyperglycaemia is associated with poor clinical outcome

  38. Physiological Monitoring Contd 6.Hydration Glucose Cerebral perfusion 7. Anuria Polyuria Circulatory failure

  39. Complications of Stroke Aspiration Pneumonia Urinary infection DVT Pulmonary Embolus Shoulder subluxation Depression Malnourishment Pressure sores Falls Seizures

  40. Swallow Complications(Dysphagia) Chest Infection Aspiration Pneumonias 50% are silent Swallow screen Nil by mouth first 24hours Guided eating & drinking regime Encourage to cough Sitting out of bed Mobilisation

  41. Mouth Care Increased risk of infection Pain and discomfort Effects swallow Gentle mouth care Adequate hydration Gentle tooth brushing

  42. Head Position Controversial Head in a neutral position Flat if tolerated. Or 30 –40 degrees Aids venous drainage & improves cerebral perfusion

  43. Bladder &Bowels Urinary incontinence Urinary infection Avoid catheters Early plan of care Adequate hydration Bowels Privacy & dignity

  44. Psychological Support Assess mood Recognise grief/loss Talk Engage with family Interests Timely realistic goals Refer

  45. Pressure Sores Air mattress Two hourly turns Nutrition Hydration Personal hygiene

  46. Deep Vein Thrombosis Early mobilisation Low molecular weight heparin Compression devices TED stockings not beneficial in stroke patients Clots Trial 2009

  47. Positioning Loss of sensation Loss of power Subluxation Supportive IV lines and BP cuffs avoided on affected limb Assess moving and handling Good technique

  48. Nutrition Malnourishment associated with poor outcome Weight MUST assessment Naso gastric tube History of patients eating habits Controversial When to commence invasive feeding regime

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