1. 2014 Stroke/TIA Care Guidelines

2. The Stroke care guidelines were created to help guide nursing care based on best practice and evidence intended to optimize patient care. The rationale/evidence is provided that supports the care elements for this population of patients. These care guidelines should be initiated with rule out stroke patients, patients that present with stroke like symptoms, or confirmed stroke or TIA patients. Stroke/TIA Care Guidelines 2014

3. When caring for the stroke patient the initial plan for the nursing and medical management of an acute stroke patient is to control vital signs, prevent any deterioration of the patient, and prevent any medical complications of the stroke. Medical complications occurring in the acute stages of a stroke have shown to worsen the patient’s neurological outcome. Nursing management should focus on the prevention of complications of stroke. Stroke/TIA Care Guidelines 2014

4. Assessment (expected care, not requiring physician order) Perform NIHSS on admission, with any acute neurological change, transfers from the ICU (with ICU RN), and upon discharge.  The NIHSS is a valid, efficient, and reliable measure of the patient’s status after a stroke and in assessing outcome after treatment. Perform dysphagia screening before the patient eats, drinks, or receives oral medications.  Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended. (Nothing by mouth, including medications if dysphagia screening failed.) Impairments of swallowing are associated with a high risk of pneumonia. Neuro checks and vital signs Q 30 minutes x 4 then Q 4 hours  After the airway, breathing, and circulation have been assessed and specific vital signs determined, such as blood pressure, heart rate, oxygen saturation, and temperature, a more deliberate and detailed physical examination is performed. Frequent and consistent monitoring is important to help assess for change in patient condition.

5. Stroke Education Stroke education is an essential element of the multidisciplinary care plan for post-stroke patients. Clinical practice guidelines include recommendations for patient and family education during hospitalization. Stroke education has been shown to be an effective tool in secondary prevention of recurrent stroke and should be started as soon as possible. Families and patients face many challenges after a stroke. Nurses play a key role in providing education for patients and their families and should ensure their understanding. Every stroke survivor will have unique needs and will require individualized education. The type of stroke experienced and the resulting outcomes will play a large role in determining not only the course of treatment but also what education will be required. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes.

6. Stroke Education Stroke patients and/or their caregivers should be provided with education and educational material addressing all of the following: Patient specific information around personal risk factors related to stroke (hyperlipidemia, diabetes, smoking, hypertension, diet, sedentary lifestyle, alcohol, etc.) The need to call 911 Signs and symptoms of stroke (Instruct on FAST- Face, arms, speech, time) Medications prescribed at discharge and the importance of compliance The need for physician follow up after discharge Willingness to change modifiable personal risk factors

7. Patient Management/ General Supportive Care These are all key points to monitor that may lead to treatment in order to prevent complications and/or poor outcomes. In these instances collaborating with our physicians is necessary. Blood pressure; maintain systolic blood pressure to be <220 mm Hg or the diastolic blood pressure is <120 mm Hg  In patients with markedly elevated blood pressure who do not receive tPA, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg. An elevated BP in stroke patients is a compensatory mechanism to try to perfuse blood to the ischemia in the brain.

8. Patient Management/ General Supportive Care Treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL.  Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after stroke is associated with worse outcomes. According to the American Diabetes Association inpatient glycemic control guidelines, initiating therapy to achieve glucose targets of 140 to 180 mg/dL if fasting glucose is greater than 140 mg/dL or random glucose is consistently higher than 180 mg/dL. Lower glucose targets (<140 mg/dL) may be appropriate for patients with well-controlled diabetes and those with stress hyperglycemia who were not known to be diabetic before admission, but glucose levels less than 80 mg/dL should be avoided.

9. Patient Management/ General Supportive Care Oxygen therapy: Supplemental oxygen should be provided to maintain oxygen saturation >94%.  It is not apparent that routine supplemental oxygen is required acutely in non-hypoxic patients with mild or moderate strokes. Cardiac monitoring for the first 24 hours  Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. Cardiac monitoring should be performed for at least the first 24 hours

10. Patient Management/ General Supportive Care Infection prevention  Pneumonia and UTIs are frequently seen in the acute phase after stroke. Indwelling catheters should be avoided if possible. If a catheter is in place it should be removed as soon as the patient is medically and neurologically stable. Screening for dysphagia and early management of nausea and vomiting can help prevent aspiration pneumonia. Head of the bed elevated at least 30° for patients at risk for airway obstruction or aspiration and those with suspected elevated ICP  Positioning of the head of the bed must be individualized for each patient. When patient position is altered, close monitoring of the airway, oxygenation, and neurological status is recommended, and adjustment to changing clinical parameters may be required.

11. Patient Management/ General Supportive Care Maintenance of patient’s temperature less than 100°F during the first 48 hours following stroke  In the setting of acute ischemic stroke, hyperthermia is associated with poor neurological outcome, possibly secondary to increased metabolic demands, enhanced release of neurotransmitters, and increased free radical production. Nutrition and Hydration  Sustaining nutrition is important because dehydration or malnutrition may slow recovery. Dehydration is a potential cause of DVT after stroke.

12. Patient Management/ General Supportive Care Bowel management and bladder management  Early bowel and bladder care should be instituted to prevent complications such as constipation and urinary retention or infection. Skin Care  Stroke patients are at risk for skin breakdown because of loss of sensation and impaired circulation, older age, decreased level of consciousness, and inability to move themselves because of paralysis. Frequent turning should be instituted in bedridden patients to prevent skin breakdown Fall Precautions  Fall precautions should be initiated, and the stroke patient should be told not to ambulate without assistance. Use of a gait belt is important when ambulating the patient.

13. Stroke Core Measures DVT prophylaxis  Subcutaneous administration of anticoagulants is recommended for treatment of immobilized patients to prevent deep vein thrombosis. The use of intermittent external compression devices is reasonable for treatment of patients who cannot receive anticoagulants. SCDs should be ordered, applied, and documented if the patient cannot be on anti-coagulants. Anticoagulation therapy for atrial fibrillation/flutter  Ischemic stroke patients with atrial fibrillation/flutter should be prescribed anticoagulation therapy at hospital discharge. If anticoagulation therapy is not ordered at discharge a reason must be documented by MD/APN/PA.

14. Stroke Core Measures Antithrombotic by the end of day 2 of hospitalization  Oral or rectal administration of aspirin (initial dose is 300mg-325 mg) within 24 to 48 hours after stroke onset is recommended for treatment of most patients. Discharged on a statin  Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable. Ischemic stroke patients with LDL greater than or equal to 100mg/dl, or LDL not measured, or who were on a lipid lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

15. Stroke Core Measures Stroke education:  Patients with ischemic or hemorrhagic stroke or their caregivers who were given education and educational materials during the hospital stay addressing all of the following: personal risk factors for stroke, warning signs for stroke, activation of emergency medical system, need for follow-up after discharge, and medications prescribed at discharge. Patient assessed for rehab  Rehab therapy should start as early as possible once medical stability is reached.

16. Depression Screening Nursing Department Patient Health Questionnaire should be given to the patient on day 2 of their admission as part of the Stroke protocol. Once completed, the front side of this tool should be faxed to the Christian Hospital Recovery Center. A Mental Health RN will follow up with the patient within 24 hours or via phone interview if the patient Completion of this tool may be on patient self-report or with assistance of the assigned RN if needed. All responses should be verified by the assigned RN to ensure comprehension of the tool and accuracy of responses by the patient.

17. Please Note These guidelines are recommended by Christian Hospital/Northwest Healthcare for the clinical management of stroke patients. These guidelines are not intended as a substitute for clinical judgment. Clinical circumstances may necessitate deviation from these guidelines.

18. A Wise Person Once Said: “Rule them in before you rule them out” Don’t look for reasons why your patient might not have had a stroke. It’s best for the patient if we care for them as if they had a stroke until they are ruled out.

19. References Baker L, Juneja R, Bruno A. Management of hyperglycemia in acute ischemic stroke. Current Treat Options Neurology. 2011;13:616–628. Jauch, E., Sever, J., Abrams, H. & et. al. (2013). Guidelines for the Early Management of Patients with Acute Ischemic Stroke. Stroke 44: 870-947. Summers, D., et al. (2009). Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement from the American Heart Association. Stroke 40, (8), pp.2911-2944. The Joint Commission. (2013). Disease - Specific Care Certification Manual 2013.