>> Klein: Now we're going to do the first of two modules
on Nursing Care for the Stroke Patient.
The objectives of this module
is that you will be able to list the three interventions
that improve stroke patient outcomes,
and you'll be able to perform
a bedside swallow screen evaluation.
With regards to stroke centers and the care they provide,
at the creation of stroke centers around 1996,
we have now created acute care plans and standards
that have benefited all patients that have a stroke,
regardless of whether they get TPA
or thrombolytic therapy or not.
The three interventions that have demonstrated
to improve outcomes of stroke patients
with a number needed to treat of six.
And what that means is that
for every six patients that get these three interventions,
it benefits one patient.
In comparison for the number needed
to treat for IV alteplase, this is between six to 18.
You might have to treat up to 18 people with TPA
before there's a benefit seen in one.
So you have even better outcomes
and more people are helped out
with these three interventions.
The three interventions are,
performing a swallowing screen, temperature control,
and glucose control following a stroke.
Let's first go over temperature control.
So we know that fever worsens outcomes for patients
after they've had a stroke.
For every one degree Celsius rise in temperature,
there is an increased risk of poor outcomes and it doubles.
We know that fever increases
the metabolic needs of the brain.
And it really has the greatest effect or detrimental effects
in the first 24 hours following a stroke.
When a patient has a fever,
we wanna make sure we are treating the fever aggressively
with acetaminophen and any other physical means
such as ice packs or cooling blankets.
The goal is to have a stroke patient be afebrile,
and we also want to prevent shivering.
We know that shivering
is associated with an increase expenditure of energy,
also it increases consumption of oxygen,
and it produces carbon dioxide,
which is a potent vasodilator.
So we wanna make sure we prevent fever
but also prevent shivering.
Next up is glucose control.
So we also know that there are worse outcomes
after a stroke for diabetics,
and whenever the patient has an acute hyperglycemic,
has acute hyperglycemia at the time of the infarct.
We know that we see an increase in infarct size and edema
that occurs with acute and chronic hyperglycemia.
We also know that high serum glucose
is an independent risk factor for a hemorrhage
when a stroke is treated with TPA.
With our patients, we always took a blood sugar on admission
because sometimes a patient can just be hypoglycemic
and it might be mimicking that the patient's had a stroke.
In the inpatient setting,
the goal for your patient's blood sugar
is to be less than 140 or 180 depending on the location.
As well, we always get a hemoglobin A1C on patients.
And this is so we can get a three month picture
of how well your patient
is actually controlling the blood sugars.
Plenty of times you ask your patient
how well have you been doing controlling your blood sugar,
and they say they've been doing great.
But when you get to A1C and it's a 12,
you know that that is not the case.
And we can do better management of their blood sugars.
Lastly, in the section is the swallow screen.
So our patients after having a stroke,
they are a greater risk of aspiration.
We know that swallowing
involves a coordinated sequence of contractions
and relaxation of muscles.
And we have here cranial nerves
five, seven, nine, 10 and 12,
along with the swallowing center of our reticular formation,
that really control your ability to swallow.
We think of the risk of,
you know, aspiration for our patients,
we wanna make sure we set up the bedside to be safe.
So we wanna make sure suctioning is set up
that if it's appropriate for your patient
to have one to one supervision during meals,
to make sure that the head of the bed is at least 30 degrees
for those on enteral tube feeds.
And if your patient can eat, you also wanna make sure
they're sitting up close to 90 degrees.
You wanna also monitor your patients
for any signs of aspiration.
And we have a very low threshold to make a patient NPO
and stop giving them anything to eat or drink
to have our speech language pathologists
come see the patient
to ensure we're gonna have them be safe
with having them take any meds or oral intake.
So the best practice is for our stroke patients
is that we perform a 90 milliliter swallow screen
on admission.
And we make sure this is done before there's any oral intake
either medications, fluids or food.
So let's go over the swallow screen.
So we have a two page screen for the swallow screen
that the bedside nurse can do, the resident can do,
or even the attending fellow can do.
This is done either in the emergency department
or on the floor.
Let's go through each section.
The first section are the prerequisites.
So if your patient has any of these exclusions,
we're going to fail the patient
and have SLP consulted to do a formal evaluation on them.
So if a patient has had an esophagectomy, lung transplant,
they have a tracheostomy,
or they've been intubated
greater than three days during this hospitalization,
we do not perform a bedside swallow screen,
we have SLP do it and the patient is NPO.
Next up we look at any functional concerns.
So if the patient has any of these,
we also once again will fail them, have them be NPO,
and get SLP involved.
So does the patient
have an altered level of arousal or alertness?
If they're not awake,
we're not gonna put anything in their mouth.
Are they unable to follow simple commands?
It's gonna be very difficult
to have them follow the commands
that we asked them to do for the swallow screen.
Are they unable to sit up right?
Are they NPO for a procedure?
Or are they intubated or have a mask on
that prevents them from doing a swallow screen
because they require that mask for their oxygenation?
If any of these are true,
fail the patient and SLP will be involved.
They're going to be NPO.
For step one for the swallow screen,
this is when you're looking
at any swallowing concerns for the patients.
So does the patient have a wet or gurgly voice or quality,
or after extubation they have no voice?
Or does the patient require frequent oral suctioning
or they're unable to manage
the oral secretions with drooling?
We're not gonna test them.
If we add additional fluid to their mouth,
we know they're not gonna be able to manage it.
And then if your patient has alternative nutrition,
because of dysphasia,
whether it's a PEG, NG tube,
or any other alternative nutrition,
we're gonna get SLP involved.
So if your patient has any of these three,
you're not going to do an actual,
you're not actually going to give them any liquid.
We're gonna make the patient NPO
and ensure that SLP sees the patient.
Before we present the patient with any fluid,
we wanna make sure the patient is sitting upright
at 80 to 90 degrees.
And then we wanna do oral care.
Why?
We have a lot of bacteria in the mouth,
and we want to make sure
that we are cleaning it out as much as possible
to make it as clean as possible.
So with patients,
we don't wanna just swab them with some mouthwash,
we wanna make sure we're brushing their teeth and suctioning
and getting their mouth as clean as possible
before we give them any water.
For step two,
this is where we're gonna give a teaspoon of water
and then cue the patient to say "ah" afterwards.
Then we're gonna notice the patient
and see if they either have a cough or choke response
following the swallow.
Or when they say "ah"
it's a wet gurgly voice quality when saying it.
If either of these are true, we will stop the screen here,
we will make the patient NPO and then get SLP involved.
The last step if the patient passes all the prior ones
is step three.
This is where we're going to see
if the patient can manage 90 milliliters of water.
And with this we say without interruption
so that when we give it to them,
we wanna make sure they're not sipping and talking
and sipping and talking.
We want them to continue to drink
the entire amount the whole time until it is all swallowed.
So the patient,
we need to make sure they're still at 80 to 90 degrees,
we'll present them with a cup of water,
they can hold it or I can hold it,
you can use a straw or no straw,
and you're going to instruct the patient
to drink the entire contents without interruption,
then you're going to observe them for a full minutes
and then cue the patient say "ah".
And I usually like to have the patient say "ah" right away
and "ah" at the end of the full minute.
Something to keep in mind
at any time during that minute if the patient coughs,
you can see that they have any wet gurgly voice
as you're talking to them,
that means they fail,
and you would have SLP involved and you would make them NPO.
The last and actually one of the most important things
when having being a stroke center. So we have to make sure
we're documenting the swallow screen extremely well.
So we wanna make sure
we document the date and time performed.
Because when the Joint Commission comes
and they are auditing,
they will ask the nurse to show
when was the swallow screen performed,
and you're going to have to look into the chart
to show them the date and time it was performed.
And then they will ask you
to go to the MAR or the I's and O's,
they wanna see the first time
any oral medications were given or any oral fluid.
And they are stickler
and wanna make sure that the time without swallow screen
is done before any oral presentation of anything.
And this is truly a best practice
to have safe care of stroke patients
when they're in the hospital.
So we wanna make sure they can swallow appropriately.
Before I go to the next lecture
which will be the second one on additional nursing care
for stroke patients and education,
I'm going to become live
and show you how to perform a swallow screen.
So let me say stop this video for a second.
And let me start my video.
Hi there, I have Denise here who is a nurse
who's gonna be portraying a patient in this situation.
So to do the swallow screen you need a spoon,
we like to use a medicine cup because these are 30 mls,
you need an empty cup,
and then you have to have a cup of some water in it.
So the first pass swallow screen
was seeing if she had any functional concerns.
She passed step one.
We're gonna pretend we did
we brushed her teeth in this situation.
So now we're ready to present her with a teaspoon of water.
So what I say to my patient,
I'm gonna give you a teaspoon of water.
And when you're done
I'm gonna have you say "ah" for me, okay?
Here we go.
>> Ah.
>> Very good.
Nice clear voice, so she passed that step.
Next up, using the measuring cup,
I'm gonna measure out three cup fulls into the other cup
to give her 90 mls.
Just give me a second.
One,
two,
three.
Now I'm going to hand it to the patient and instruct her.
So I'd like you to drink the entire cup
without any pauses.
Of course if I notice her coughing at any time,
I would take the cup away and be like, we're done there.
>> Ah.
>> Good.
So that was nice and clear.
Then I'm going to stay in the patient's room,
I can still be doing other interacting things,
it was just an admission,
so it could be getting other vital signs or whatnot.
And let's say a minute has passed
and I'll just have the patient say "ah" again.
>> Ah.
>> And then during that minute once again,
if you see any coughing,
if you see any gurgly voice quality
when you're talking to them,
you wanna make the patient NPO
and then you fail them and document it
and then get SLP involved.
Thanks for watching.