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Module 3 Acute Inpatient Stroke Care

N. S. N. C. Module 3 Acute Inpatient Stroke Care. Best Practice Nursing Care Across the Acute Stroke Continuum. 1. Acute Inpatient Stroke Care. This session includes presentations and activities to enhance your learning

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Module 3 Acute Inpatient Stroke Care

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  1. N S N C Module 3Acute Inpatient Stroke Care Best Practice Nursing Care Across the Acute Stroke Continuum 1

  2. Acute Inpatient Stroke Care This session includes presentations and activities to enhance your learning The focus is on working with colleagues to discover best ways of using the tools in your clinical settings So, sit back (or stand up) and have fun!!! Welcome! 6/3/2014 2

  3. Acute Inpatient Stroke Care So, what do you want to get out of this module? Expectations? 6/3/2014 3

  4. Acute Inpatient Stroke Care Identify the goal of acute inpatient stroke care within the stroke care continuum Review the components and Best Practice Recommendations related to acute inpatient stroke care Identify how you can help to implement these recommendations at your institution Identify the benefits of early assessment and stroke rehabilitation Identify your role in patient and caregiver education Create a stroke care action plan for acute inpatient stroke care Objectives 6/3/2014 4

  5. Acute Inpatient Stroke Care Introduction 15 min Stroke 101(optional) 15 min Acute Inpatient Stroke Care BPRs 45 min Break 15 min Components of Acute Inpatient Care BPRs 60 min Early Assessment & Stroke Rehab 15 min Patient and Family Education 15 min Putting It All Together 30 min Agenda 6/3/2014 5

  6. Acute Inpatient Stroke Care Continuum of Stroke Care Prevention of strokePublic awareness & patient education Hyperacute stroke management Acute inpatient stroke care Stroke rehabilitation & community reintegration

  7. Acute Inpatient Stroke Care Synthesis of best practice recommendationsfor stroke care across the continuum Address critical topic areas Commitment to keep current and update every two years First edition released in 2006 Current update released in 2008 With four new recommendations Elaboration of existing ones www.cmaj.ca December 2, 2008 Canadian Best Practice Recommendations for Stroke Care

  8. Stroke 101 Acute Inpatient Stroke Care Intended only for audiences with no previous knowledge of stroke. 6/3/2014 8

  9. Best Practice Recommendations Acute Inpatient Stroke Care 45 min 6/3/2014 9

  10. Acute Inpatient Stroke Care 4.1: Stroke unit care Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit Core interdisciplinary team should consist of people with appropriate levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech– language pathology, social work and clinical nutrition Interdisciplinary team should assess patients within 48 hours of admission and formulate a management plan Clinicians should use standardized, valid assessment tools to evaluate the patient's stroke-related impairments and functional status Best Practices Recommendations OVERVIEW

  11. Acute Inpatient Stroke Care TABLE DISCUSSION 6/3/2014 11 • At your tables, discuss: • What are the benefits of a dedicated stroke unit vs. a medical floor? • What are some challenges you experience in getting patients out of the ER? • Identify what’s happening in your institution now and brainstorm strategies to explore

  12. Acute Inpatient Stroke Care Compared with alternative care, stroke unit care showed a reduction in the odds of: Death at final follow up Death or institutionalized care Death or dependency Benefits of Stroke Care Unit Data demonstrated improved patient outcomes when treated in an organized stroke unit with dedicated stroke staff!

  13. Acute Inpatient Stroke Care Stroke unit care can reduce the likelihood of death and disability by as much as 30% Evidence suggests patients treated in stroke units have fewer complications, earlier recognition of pneumonia and earlier mobilization Why Is This Important? Characterized by a coordinated interdisciplinary team approach for preventing stroke complications and recurrence, and accelerating mobilization and early rehab.

  14. Let’s take a break… 15 min

  15. Acute Inpatient Stroke Care Components of Acute Inpatient Care Best Practice Recommendations 60 min 6/3/2014 15

  16. Acute Inpatient Stroke Care Referring to the case study in your PW, each table will prepare a set of Case Notes to bring to an interdisciplinary meeting to begin establishing rehabilitation goals Base your notes on Best Practice Recommendation 4.2 Components of acute inpatient care Venous thromboembolism, temperature, mobilization, continence, nutrition and oral care When done, we’ll conduct our meeting with each table getting a turn to present Interdisciplinary Meeting TABLE ACTIVITY

  17. Acute Inpatient Stroke Care Case Study Mrs. C is a 76 year old right handed woman who was admitted to the Stroke Unit post thrombolysis. She lives with her 80 year old husband who requires some assistance with ADL’s due to his Parkinsons’ disease. They live in a 2 bedroom condominium and have the support of 2 adult children nearby. On admission Mrs. C is found to have expressive aphasia, right sided weakness (arm weaker than leg) and right visual neglect. Past medical history: hypertension, hypercholesteremia, osteoporosis, gastroesophageal reflux No known allergies and does not drink or smoke

  18. Acute Inpatient Stroke Care Case Study Mrs. C’s vital signs are: BP 158/70 P-100 and irregular R-22 Temperature: 37.4’C Mrs. C appears anxious and frustrated, especially when trying to communicate. She is restless and makes attempts to get out of bed

  19. Acute Inpatient Stroke Care 4.2: Components of acute inpatient care Risk for venous thromboembolism, temperature, mobilization, continence, nutrition and oral care should be addressed in all hospitalized stroke patients Appropriate management strategies should be implemented for areas of concern identified during screening Discharge planning should be included as part of the initial assessment and ongoing care of acute stroke patients Best Practices Recommendations REVIEW

  20. 4.2a Venous Thromboembolism Prophylaxis

  21. Acute Inpatient Stroke Care 4.2a Venous thromboembolism prophylaxis All stroke patients should be assessed for their risk of developing venous thromboembolism High risk patients include patients with inability to move one or both lower limbs and those patients unable to mobilize independently Patients who are identified as high risk for venous thromboembolism should be considered for prophylaxis provided there are no contraindications Early mobilization and adequate hydration should be encouraged with all acute stroke patients to help prevent venous thromboembolism Best Practices Recommendations REVIEW

  22. Acute Inpatient Stroke Care 4.2a Venous thromboembolism prophylaxis In addition to secondary stroke prevention, antiplatelet therapy should be used for people with ischemic stroke to prevent VTE; The following interventions may be used with caution for selected people with acute ischemic stroke at high risk of VTE: Heparin in prophylactic doses (5000 units BID) or low molecular weight heparin (with appropriate prophylactic doses per agent) External compression stockings Best Practices Recommendations REVIEW

  23. Hot Off the Press! Lancet May 27, 2009

  24. Clots in Legs Or sTockings after Stroke 24 6/3/2014 Trial 1: Do graduated compression stockings reduce the risk of DVT in stroke patients? Trial 2: Are full length graduated compression stockings more effective than below knee stockings in reducing the risk of DVT?   (QEII ) 

  25. Conclusions 25 6/3/2014 DVT occurred equally in patients with and without stockings. Alteration in skin integrity was seen more often in the stocking group. Data does not support use of (thigh length) stockings in patients admitted to hospital with acute stroke. Guidelines will be revised!

  26. Acute Inpatient Stroke Care Best Practices Recommendations 4.2b Temperature Management

  27. Acute Inpatient Stroke Care 4.2b Temperature Management Should be monitored as part of routine vital sign assessments (every 4 hours for first 48 hours and then as per ward routine or based on clinical judgment) For temperature more than 37.5°C, increase frequency of monitoring and initiate temperature reducing measures For temperature more than 38°C, iidentify and treat source (site and etiology) of fever in order to start tailored antibiotic treatment and antipyretics Best Practices Recommendations REVIEW

  28. Let’s take a break… 15 min

  29. Acute Inpatient Stroke Care Best Practices Recommendations 4.2c Mobilization

  30. Acute Inpatient Stroke Care 4.2c: Mobilization Acute stroke patients should be mobilized as early and as frequently as possible preferably within 24 hours of stroke symptom onset, unless contraindicated Assessment of patients’ ability in activities of daily living should be completed and reassessed regularly Within the first 3 days after stroke, blood pressure, oxygen saturation and heart rate should be monitored before each mobilization Acute stroke patients should be assessed by rehabilitation professionals as soon as possible after admission preferably within the first 24 to 48 hours Best Practices Recommendations Mobilization is defined as the act of getting a patient to move in the bed, sit up, stand, and eventually walk. REVIEW

  31. Acute Inpatient Stroke Care AVERT Trial Within the first 3 days after stroke, blood pressure, oxygen saturation, and heart rate should be monitored before each mobilization If during mobilization, there is a drop in blood pressure of greater than 30 mmHg this mobilization attempt should cease. If a drop of greater than 30 mmHg occurs on 3 consecutive attempts, further medical assessment is required. Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). A Very Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363 Mobilization: Physiological Monitoring 31 REVIEW 6/3/2014

  32. Acute Inpatient Stroke Care Deterioration in the person’s condition in the first hour of admission that: resulting in direct admission to ICU, a documented clinical decision for palliative treatment (e.g. those with devastating stroke) immediate surgery. Unstable coronary or other medical condition. A suspected or confirmed lower limb fracture at the time of stroke preventing mobilization Systolic blood pressure less than 110, or greater than 220mmHg. *Contraindications to Mobilization *AVERT Trial recommendations 32 REVIEW 6/3/2014

  33. Acute Inpatient Stroke Care Oxygen saturation of less than 92% with supplementation. Resting heart rate of less than 40 or greater than 110 beats per minute. Temperature of greater than 38.5°C. Persons who have received rt-PA can be mobilized if the attending physician permits. *Contraindications to Mobilization *AVERT Trial recommendations 33 REVIEW 6/3/2014

  34. Acute Inpatient Stroke Care Best Practices Recommendations 4.2d Continence

  35. Acute Inpatient Stroke Care 4.2d Continence All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence and constipation Stroke patients with urinary incontinence should be assessed by trained personnel using a structured functional assessment A bladder training program should be implemented in patients who are incontinent of urine A bowel management program should be implemented in stroke patients with persistent constipation or bowel incontinence Best Practices Recommendations REVIEW

  36. Acute Inpatient Stroke Care Incontinence 40-60% of stroke patients have urinary incontinence 25% of incontinent patients will have urinary incontinence at discharge 15% will have incontinence at 1 year post stroke Urinary incontinence within 24 hours of a stroke is a predictor of functional disability 36 REVIEW 6/3/2014

  37. Acute Inpatient Stroke Care Bladder Incontinence All stroke patients should be screened for urinary incontinence and retention (with or without overflow) Urinary incontinence should be assessed by trained personnel using a structured functional assessment The use of indwelling catheters should be avoided. If used, indwelling catheters should be assessed daily and removed as soon as possible 37 REVIEW 6/3/2014

  38. Acute Inpatient Stroke Care Bladder Incontinence The use of a portable ultrasound (bladder scanner) is recommended as the preferred non-invasive painless method for assessing post void residual and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization 38 REVIEW 6/3/2014

  39. Acute Inpatient Stroke Care Assessment of Incontinence • Incontinence history • Fluid intake • Medical history • Medications • Functional ability • Post residual volume • Urine culture • Vaginal examination • Rectal examination 39 6/3/2014

  40. Acute Inpatient Stroke Care Strategies for Urinary Incontinence Ensure adequate fluid intake (1500-2000 mls) Assess post void residuals (normal is 50-100 mls) Review medications (?diuretics) Introduce a regular toileting routine 40 REVIEW 6/3/2014

  41. Acute Inpatient Stroke Care Strategies for Urinary Incontinence Encourage bladder retraining (urge incontinence) Pelvic muscle exercises – Kegal’s Double voiding, Crede maneuver and intermittent catheterization (overflow incontinence) Limit use of dietary bladder irritants ( caffeine, etoh, spicy foods) 41 REVIEW 6/3/2014

  42. Acute Inpatient Stroke Care Bowel Incontinence Bowel incontinence occurs in 30% of stroke patients and 97% regain control within one year. Incontinence may result due to the following: Altered consciousness Cognitive deficits Impaired communication Neurogenic bowel without sensation or control 42 REVIEW 6/3/2014

  43. Acute Inpatient Stroke Care Bowel Incontinence Bowel function risk factor assessment should include: mobility, inactivity, adequate fluid and food intake, polypharmacy, etc. All stroke patients should be screened for fecal incontinence A bowel management program should be implemented in stroke patients with persistent constipation or bowel incontinence 43 REVIEW 6/3/2014

  44. Acute Inpatient Stroke Care Establishing a Bowel Program Encourage appropriate fluids, diet, and activity. Choose an appropriate rectal stimulant. Provide rectal stimulation initially to trigger defecation daily. Select optimal scheduling and positioning. Select appropriate assistive techniques. Evaluate medications that promote or inhibit bowel function Source: www.guideline.gov/ 44 REVIEW 6/3/2014

  45. Acute Inpatient Stroke Care Best Practices Recommendations 4.2e Nutrition

  46. Acute Inpatient Stroke Care 4.2e Nutrition The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool Results from the screening process should guide appropriate referral to a dietitian for further assessment and the need for ongoing management of nutritional and hydration status Best Practices Recommendations REVIEW

  47. Acute Inpatient Stroke Care Nursing Interventions for Dysphagia/Nutrition Maintain all patients with stroke NPO (including oral medications) until a swallowing screen has been administered and interpreted, within 24 hours of patient being awake and alert Screening results should guide appropriate referral to a Dietician for further assessment and the need for ongoing management of nutritional and hydration status 47 REVIEW 6/3/2014

  48. Acute Inpatient Stroke Care Dysphagia/Nutrition Consideration of enteral nutrition support within 7 days of admission for patients who are unable to meet their nutrient and fluid requirements orally This decision should be made collaboratively with the multidisciplinary team, patient and their caregivers/family 48 REVIEW 6/3/2014

  49. Acute Inpatient Stroke Care Nursing Interventions for Dysphagia Assess for signs & symptoms of dysphagia Choking on food Stifled, suppressed or overt coughing during meals Nasal regurgitation Moist, wet voice Complaints of food sticking in the throat Drooling or loss of food &/or fluid from the mouth Pocketing of food in cheeks Slow, effortful eating Delay in initiating swallow (i.e. > 5 seconds) 49 REVIEW 6/3/2014

  50. Acute Inpatient Stroke Care Dysphagia – Points to Remember All stroke patients should have a nutritional screen within 48 hours of admission Many dysphagic patients aspirate without any external sign that food or liquid is entering the airway – instead ‘silent aspiration’ Although many stroke patients will recover from dysphagia spontaneously, all stroke patients should have a SLP/RD assessment The presence of a gag reflex does not exclude the possibility of dysphagia 50 REVIEW 6/3/2014

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