>> Lisa: Now we're going to go over
some additional nursing care for stroke patients,
and also patient education.
Our objectives will be that you will be able
to identify the heart rhythm
that places people at risk for ischemic stroke,
list two complications following a stroke
that nursing care can prevent,
and list the five required patient education topics
for stroke centers.
First off we have is blood pressure management
for ischemic strokes.
And really there is no proven optimal range
of blood pressure in acute stroke.
Our goal is to maintain perfusion
to the ischemic area and the ischemic penumbra.
We know that we want to avoid hypotension
because hypotension is more detrimental than hypertension,
and hypotension causes more deaths following a stroke.
When we're treating hypertension,
we treat it definitely if it gets higher
than a systolic blood pressure
of greater than 220 millimeters of mercury,
or if the diastolic blood pressure gets greater
than 120 millimeters of mercury.
We also wanna treat it if we see any signs
of end organ damage.
And also if the patient is a candidate for alteplase,
and their systolic blood pressure is greater than 185,
or the diastolic is greater than 110,
we can treat those as well.
With the blood pressure,
we also wanna remember that if the patient has
an ischemic penumbra is that we have
what's called permissive hypertension in our stroke center.
So with this,
that salvageable brain tissue
around the area of core infection,
we wanna make sure we're treating it and treating it well
by allowing permissive hypertension,
and allows up to a systolic, and I apologize,
it should say 220 as the highest systolic blood pressure.
And we might also put patients in trendelenburg positioning
to keep blood flowing to the brain.
As well, these patients may be assessment dependent,
meaning that for patients that are sitting up,
they actually have more deficits
than if we lower the head of the bed.
And that's why we might put them in trendelenburg.
As well, we wanna to be cautious
with lowering patient's blood pressures after a stroke.
And usually we might lower it just gradually
by about 15% during the first 24 hours,
and then gradually controlling the blood pressure
within a few days to a week.
We wanna make sure we're maintaining
what blood pressure to the ischemic area,
but we also don't want it to be too high or too low.
For patients that have had a hemorrhagic stroke,
these patients we do wanna do better blood pressure control.
For ICH patients presenting
with the systolic blood pressure
between 150 and 220 millimeters of mercury,
and without contraindication
to acute blood pressure treatment,
acute lowering of their blood pressure
to 140 millimeters of mercury has been found to be safe
and effective for improving functional outcomes
for these patients.
For ICH patients that present with a systolic blood pressure
of greater than 220,
they say it may be reasonable
to consider aggressive blood pressure reduction
with the continuous infusion
and more frequent blood pressure monitoring.
With cardiac monitoring with these patients, as I said,
we get a 12 lead EKG,
and put these patients on cardiac monitoring
for at least 24 to 48 hours.
And we're monitoring them for atrial fibrillation.
Atrial fibrillation is the most common dysrhythmia.
And when patient has atrial fibrillation,
it's when there is a quivering or irregular heartbeat
that can lead to blood clots, stroke, heart failure,
and other heart related complications.
About 15 to 20% of people who have strokes
have this heart arrhythmia.
And this heart arrhythmia,
since it increases the risk of forming clots,
it's gonna increase the risk of having a stroke.
And there are about 35% of people with atrial fibrillation
will actually suffer a stroke.
So with these patients,
most of them are on blood thinners
or the start on blood thinners
while they're in the hospital.
And sometimes when they're in the hospital,
we don't see any atrial fibrillation.
So these patients actually might get discharged
with a cardiac monitor, a portable one,
and do it for 30 days
to see if maybe they have proximal atrial fibrillation.
Even though untreated,
atrial fibrillation actually doubles
the risk of any heart related deaths,
and is associated with a five-fold increased risk of stroke.
Many patients are unaware
if they have atrial fibrillation
until they actually get an EKG.
Now looking at the management
of complications and risk factors.
First off is dealing with the patient's lungs,
and monitoring the respirations and pulse oximetry.
We can see respiratory failure in up to 6%
of patients that have an ischemic stroke,
and much higher up to 30% of patients
that have a hemorrhagic stroke.
We want to make sure
we maintain adequate airway and oxygenation,
and support them to prevent any hypoxia.
We wanna make sure that they get enough oxygen,
as we know that hypoxia and increased CO2
are basal dilators.
And we don't wanna cause increased edema
in the patient's brain.
We also wanna make sure we prevent aspiration pneumonia
with our aspiration precautions,
and keeping the head of bed at 30 degrees.
These patients, because they're not moving around as much,
and they might have impaired sensation mobility,
they're gonna be at increased risk of skin breakdown.
So we do wanna make sure we are turning
and positioning the appropriate patients every two hours,
that we order specialty low-air loss overlays beds
to make sure they're on the best surface
to prevent any skin injury.
We wanna make sure we're floating their heels,
and we wanna do daily skin checks.
And we also wanna make sure we're monitoring
our patient's nutritional intake,
as having poor nutrition can increase
the risk of the patient getting both an infection.
But also if they get a wound here,
it's not gonna heal as well
if they have poor nutritional intake.
We also want to know our patients
can have impaired physical mobility,
and they might be impaired
in doing their activities of daily living.
So we like to promote mobility early.
But it is good to also talk to patients about fatigue.
Post-stroke fatigue is often seen after stroke
for both patients that have severe strokes.
And even patients that have less severe strokes,
they'll be amazed at how fatigued they are.
And so having rest periods throughout the day is important.
As well these patients are at risk for contractures,
from having loss of movement and extremities.
So you wanna keep in mind that once you start feeling
some more tone in those extremities,
that you let occupational therapy be involved,
so they can get braces and whatnot
to prevent contractures from happening.
As well with our patients that have a stroke,
because they have weakness,
they can have subluxation of their shoulder.
So we make sure when we're treating these patients,
we never pull them from their arms.
We always use their shoulder and their hip
and their body to turn them.
As well these patients can be deconditioned,
and we wanna do increase mobility getting these patients
out of bed to also help the respiratory status,
and making sure that we get physical therapy
and occupational therapy involved as appropriate.
Patients after stroke are at increased risk of falling.
And it's actually really common after a stroke.
About 14 to 65% of stroke survivors
may fall in the hospital,
and up to 73% fall within the first six months of discharge.
So it is something that here in the hospital,
we wanna make sure we're doing a fall risk assessment,
and we wanna provide them a fall risk education,
both for in the hospital and at home.
We also wanna make sure that our units
that are taking care of stroke patients
have fall prevention programs in place,
so we can do our due diligence
in preventing patients from falling.
We wanna make sure we prevent our patients
from having a stroke from having an infection, right?
We don't wanna have their temperature get too high.
So we wanna make sure we're doing adequate hand hygiene.
We wanna maintain isolation standards as appropriate,
and we wanna remove any urinary catheters
or invasive intravascular devices as soon as possible
to prevent them from getting an infection.
Here is a list of
the eight primary stroke center performance measures.
STK out here stands for stroke,
and these are best practices
to improve the long-term outcomes for stroke patients.
So let's go over these.
Oh, before we go over them.
When we look at the outcomes we get for stroke patients
is that we do a lot of data collection,
and we're collecting data of how well our patients do
at 90 days after stroke,
whether they got TPA or not,
whether they got a mechanical thrombectomy
or intra-arterial TPA,
cause we wanna know what are our patient outcomes
after they had a stroke?
And with that,
we use this scale called the modified Rankin scale.
And this measures functional independence
and gait stability.
And we use it to measure our stroke outcomes.
It is a scale from zero to six,
and you can see the scoring here to the right,
with a zero being no stroke symptoms,
a five being severe,
where the patient is bed-bound, incontinent,
and requiring 24-hour care.
And a six that they're not showing you there
is that at 90 days, the patient has died.
Let's go back to the stroke measures.
So the first one is VTE prophylaxis.
We need to make sure we put sequential compression devices
or SCDs on our patients to prevent VTEs.
And we need to make sure we document
that those are on our patients
within the first 24 hours
of the patient coming to the hospital,
unless it's documented that it's inappropriate
for those patients.
Some hospitals still use compression stockings for patients.
We stopped using compression stockings
after a study that showed increased risk of skin breakdown.
But if your patient is ordered for compression stockings,
we do need to make sure
they're on the patient and documented.
We also need to have providers order
the subcutaneous heparin or low-molecular weight heparin
for our patients as the pharmacological prevention of VTEs.
We also need to make sure we're monitoring
for signs and symptoms of DVTs and pulmonary embolisms.
For the stroke measures number two and number five,
these are both dealing with antithrombotic treatments.
STK-2 is that all patients that have a stroke
are discharged on an antithrombotic.
And if they're not, there's documentation of why.
And then STK-5 is that antithrombotics
are administered by end of hospital day two.
And with this, there are some differences,
so that if a patient received IV alteplase
with or without a thrombectomy,
we make sure we don't start this
to at least 24 hours after treatment.
As well, some patients may be appropriate
for dual antiplatelet therapy.
And we wanna keep that in mind.
Also, sometimes we have had it that we've missed this
because your patient loses enteral access,
and you can't give them the pills for aspirin.
And so something we try to remember
is that aspirin also comes in suppositories.
So if we can't get it into either an enteral tube
or they're not able to swallow
is that we can give them a suppository
to make sure we still give it
by the end of hospital day two.
STK number three is that for patients
that have atrial fibrillation,
they are started and treated with anticoagulation.
And if it's not appropriate for them to be anticoagulated,
there's documentation by the provider as to why.
STK-4 is thrombotic therapy,
so that all patients that show up to the hospital
that are eligible for TPA should receive TPA.
STK number six is that all patients
are discharged on a statin.
Examples would be atorvastatin, rosuvastatin, simvastatin.
And these are all used to lower cholesterol levels,
and have been told to decrease and improve outcomes
for stroke patients,
and decrease the risk of having another stroke,
or a heart attack or death from heart disease by 25 to 35%.
A big one that we focus on with nursing is the STK-8,
the patient and family education.
And we base this on the American Stroke Association Get
with the Guidelines Stroke.
These are the five mandatory educational topics
we have to go over with the patients.
First one is for how to activate
the emergency medical system once they're discharged.
We'd like to not only talk about this
while the patient's in the hospital,
but we also talk about it, especially on discharge.
We wanna make sure this verbiage
is also in the discharge paperwork.
Also in the discharge paperwork
and what we need to talk to them about
is that there needs to be follow-up after discharge.
It's not like someone has a stroke
and they should never see a doctor again.
We wanna make sure that the patient's still risk factors
remain as controlled as possible
once the patient is discharged from the hospital.
The third thing we have to educate them on
is any of their medications
that are prescribed at discharge.
And so we wanna make sure that throughout their stay,
anytime we're giving them new medications,
we document that we've given them education
about those medications.
And these will be medications for blood pressure management,
cholesterol, the anti-platelet medications, anticoagulants.
We wanna make sure we give them education on this.
We also need to give them education
on their own risk factors for stroke.
And this is something that when we document
that we've given them education on risk factors for stroke,
we need to individualize this education
so that we're documenting that we've gone
over the patient's specific risk factors for stroke.
I still, if there's family in the room,
we'll go over all the risk factors
cause I wanna let the family also know,
so they can be aware of their own risk factors for stroke.
The fifth education topic we have to give patients
is the warning signs and symptoms of the stroke.
And you wanna make sure you're repetitive with this.
As I said, fatigue and sometimes patient's memories
can be not as good when a patient is in a hospital,
and especially following the stroke.
So you wanna make sure education is started early
and it is repetitive.
Here at the bottom I have a link to a website,
and this is where we get all of our handouts
that we give to our patients for all five of these topics,
but including additional topics
from the American Stroke Association.
STK-10 is our last measure.
And this is that all patients
are assessed for rehabilitation needs.
And for us, we use the AMPAC mobility and activity scores
to help us decide whether a patient is appropriate
for physical therapy and occupational therapy.
And we do the swallow screen
to see if the patient is appropriate
for speech language pathology.
We wanna make sure as nurses,
if we see a patient and we see any need
for physical occupational therapy or speech
that we bring that to the provider's attention.
And if we find that the patient is intact
and doesn't need any of these therapies,
the providers need to document
they were assessed for their needs,
and the need for those therapies were not needed.
But otherwise, we do wanna make sure these therapies
are involved with our patient care.
Thank you so much for listening to my presentations here.
If you have any additional questions,
you can contact me here and I gave you my email address.
Thanks.