required annual nursing education primary stroke center ... · pdf file•care of the...
TRANSCRIPT
Lori Massaro, RN, MSN, CRNP
Bethanne McCabe, RN, MSN, CNRN
Sue Underwood, RN, MSN, CNRN
Required Annual Nursing Education
Primary Stroke Center
For ICU, Step-Down and Floor
• RN’s caring for stroke patients will demonstrate evidence
of initial and ongoing training in the care of the Acute Stroke Patient
– New Hire Orientation
– Annually via a minimum of 8 hours continuing education with focus on
Stroke/Stroke Care
Requirement
2
This educational requirement includes information
on: •Care of the Acute Ischemic Stroke patient
•Care of the Intracerebral Hemorrhage patient
•Care of the Subarachnoid Hemorrhage patient
•Nursing care priorities on Stroke by type
•Primary Stroke Center Performance Measures
•Post-test completion
Stroke is the leading cause of Disability in the US
Stroke is the 4th leading cause of Death in the US
• The approach to acute stroke and urgent treatment has evolved
over the past 15 years
• Primary stroke Centers are recognized by the State of PA & DOH
– EMS are instructed to bring patients to the closest stroke center
• A partnership with the UPMC Stroke Institute is in place for transfer
of patients who require neurointerventional or neurosurgical
vascular services beyond what is available at the Primary Stroke
Center to UPMC PUH or UPMC Mercy
Stroke Overview
3
• Risk factors
– Hypertension
– Hyperlipidemia
– Cardiac conditions
• Atrial fibrillation
• Cardiomyopathy with low EF (< 25%)
– Diabetes
– Smoking
– Large artery atherosclerosis
• Anterior circulation
– Carotid artery – intracranial or extracranial
– Middle cerebral artery
• Posterior circulation
– Vertebral – basilar arterial system
Acute Ischemic Stroke
4
• Symptoms usually occur suddenly
• May be accompanied by a headache
• Depending on area of brain affected/experiencing
ischemia
– Anterior versus posterior
– Left versus right
– Cerebral dominance
Acute Ischemic Stroke
Anterior circulation: ACA and MCA Posterior circulation: PCA and Cerebellar arteries
6
• Anterior Circulation
– Unilateral hemiparesis (may
range from mild weakness to
complete paralysis)
– Unilateral sensory disturbance
(numbness, tingling, loss of
sensation)
– Speech abnormality (aphasia,
dysarthria)
– Visual loss (quadrant loss,
homonymous hemianopsia)
– Incoordination or arm, hand or
leg
– Neglect syndromes, sensory or
visual are most common in right
hemisphere strokes
Symptoms by Location
7
• Posterior Circulation
– Balance or Gait changes
(dizziness, spinning sensation,
vertigo, lightheadedness)
– Ataxia
– Diplopia
– Dysarthria
– Hemiparesis
– Hemi sensory symptoms
– Alternating weakness or
sensory symptoms
– Nausea and Vomiting
Symptoms by Location
8
Cerebral Dominance
• Left Hemisphere is dominant in 90% of adults for motor function, 96% of adults for language functions – Speech/language function
– Right body control for sensory/motor function
– Right visual field
• Left middle cerebral artery strokes result in right hemiplegia,
aphasia and right visual field cut
• Right hemisphere is dominant in only 6-10% of adults
• Right hemisphere is considered non dominant hemisphere
Left Middle Cerebral Artery Functions
• Aphasia can range from expressive to receptive or global
aphasia
• Intellectual impairment (difficulty reading, writing, or
calculating)
• Right sided hemiparesis or hemiplegia
• Right sided sensory loss
• Right visual field defect
Right Middle Cerebral Artery Functions
• Motor and sensory control of left side of body
• Left visual field
• Visual and/or sensory neglect syndromes
• Much higher fall risk with right middle cerebral artery (MCA)
stroke patient because they are unaware of deficits
• NIHSS is the standard quantitative assessment use for
stroke patients
• Assessment should also include
– Cranial nerves
– Orientation
– Motor strength evaluation
– Sensory evaluation
– GCS
– Gait if able to assess
Neurologic Assessment
12
Imaging in Acute Ischemic Stroke: What are the Options?
• CT Scan
– CT angiography
– CT perfusion
• MRI Scan
– Diffusion Weight Imaging (DWI) for acute changes
– MR angiography
– MR perfusion
Imaging Priorities and Time Parameters
• < 3 hours - 4.5 hours
– Goal to exclude hemorrhage and assess for ischemic changes
– CT non contrast
• Performed in the ED initially to rule out evidence of hemorrhage
or early ischemic changes
• Frank hypodensity in 1/3 or more of MCA territory is a strong
contraindication for IV t-PA
– MRI obtained for same reason if doesn’t cause a delay in treatment
– CTA/MRA may be obtained to determine large artery patency if it
doesn’t cause delay in treatment
– CT perfusion/MR perfusion may be obtained to determine if there is
a mismatch between area infarcted versus what is at risk if doesn’t
cause a delay in treatment
Imaging Priorities and Time Parameters
• >4.5 hours is used when assessing for large artery
occlusion/stenosis and need for intervention
- CT with vessel study (CTA)
- MRI with vessel study (MRA/P)
• Assessing for tissue viability
- Perfusion diffusion mismatch
Left Posterior Parietal Lobe Hypodensity
16
Hyperdense Left Middle Cerebral Artery Sign
17
CT at 3 Hours - Hypodensity
Left Posterior Cerebral Artery (PCA) Occlusion
CT Perfusion
• Performed over 2 cuts of brain tissue
• 3 pieces of information can be obtain to develop quantitative
maps of:
– Cerebral blood flow (CBF)
– Cerebral blood volume (CBV)
– Mean transit time (MTT)
• Measure of circulatory dysfunction
vessel
occlusion
tissue at risk
hypoperfused
tissue
infarct core
Mismatch
MRI Imaging in the Acute Phase
• Available 24/7 at PUH, SHY and Mercy for acute stroke
evaluation
– Patient stability and cooperation are sometimes a factor
• More sensitive to detecting early ischemic changes
– Diffusion weighted imaging (DFI) sequence
• Also able to obtain vessel information MR angiography
(MRA) and MR perfusion (MRP) information
• Contrast enhanced with gadolinium
– Newer and more accurate to determine if arterial and
venous vessel patency
Gadolinium Enhanced MRA - Left MCA Branch Occlusion
MR Perfusion or Perfusion Weighted Imaging
• Used to evaluate infarcted tissue versus tissue at risk if
perfusion is not restored
• Perfusion diffusion mismatch
vessel
occlusion
tissue at risk
hypoperfused
tissue
infarct core
Mismatch
Calculate Diffusion Perfusion Mismatch –
the higher the number - more likely to intervene
with Intra-Arterial (IA) therapy Pink = area infarcted Green = area at risk
No mismatch: large core infarcted area compared to area at risk = Poor IA candidate
Large mismatch: small core infarction with large area at risk = Excellent IA candidate
Nursing Care Priorities across the Continuum
• Know how to perform a complete neurological examination
– Know the patients baseline
– Recognize and report changes ASAP
• Read the chart and understand the diagnosis, etiology of
stroke/TIA
• Understand potential complications for the neuroscience
patient and intervene to prevent them
• Perform NIHSS and neurologic assessment according to
orderset/unit protocol to determine baseline exam
• Assess for neurologic changes and communicate to medical
team
• Implement secondary stroke prevention measures
– Antithrombotic, anticoagulant and statin
• Implement measures to prevent complications related to
stroke
– Dysphagia screening and speech evaluation
– DVT prophylaxis and early mobilization
– Rehabilitation evaluation
• Education for patients and families
Nursing Care Priorities across the Continuum
30
Stroke Mimics
• Seizure
– Todds’ paralysis or post ictal focal neurologic symptoms
• Hypoglycemia
– Low circulating glucose = lack of glucose getting to brain cells
causing cellular dysfunction
• Metabolic disturbance
– Elevated ammonia in liver disease, elevated Cr in renal failure
• Narcotics/sedatives
• Establish last known normal time
• Prioritize diagnostics – CT imaging and lab testing
• Perform and monitor NIHSS/neurologic exam
• Obtain IV access, obtain 2 peripheral IV’s
• Continuous cardiac monitoring, identify rhythm
• BP and SaO2 monitoring
• Administer weight based thrombolytic therapy if indicated
• Monitor the post tPA patient every 15 min with vital signs
and NIHSS
• Observe for bleeding complications, neurologic changes
• Report and hand-off to ICU nursing team
ED RN Care Priorities
32
ED Priorities
• Minimize door to CT time
– Target is 25 minutes or less
• Minimize time to results
– Target order to CT results and Lab results < 45 minutes
• Minimize door to treatment times (IV tPA)
– Target is 60 minutes or less
• Earlier treatment with thrombolytics goal is to restore blood
flow and improve patient outcomes
Inclusion Criteria
• Check blood sugar and treat if
abnormal
• Present w/in 3 hours symptom
onset (witnessed onset)
• CT of head to rule out
hemorrhage
• Review patient history for
contraindications
• Treatment of patients with rapidly
improving symptoms NOT
RECOMMENDED
• Normal coagulation profile
Exclusion Criteria
• Evidence of hemorrhage
• Recent trauma, stroke or MI
• Brain or spine surgery with in last
3 months
• BP>185/110
Ok to start IV infusion to lower BP prior to IV
t-PA and continue during and after infusion
for optimal BP control
• Seizure at onset of stroke
• Intracranial neoplasm
• INR < 1.7 if on warfarin, use of
dabigatran (pradaxa) within 48
hours
Review Inclusion/Exclusion Criteria for Thrombolysis
34
• History of prior stroke and diabetes
• Age greater than 85
• History of previous stroke
• NIHSS greater than 25
• Age > 80
• Any anticoagulant use prior to admission (even if INR <1.7)
• CT findings involving more than 1/3 of the MCA territory
Additional Inclusion/Exclusion Criteria for tPA Administration 3-4.5 hours
35
IV Thrombolytics – Tissue Plasminogen Activase (tPA)
• IV tPA is dosed based on weight
• 0.9 mg kg total dose
– Not to exceed 90 mg
– 10% given as bolus over 1 minute
– Remainder given by infusion pump over 1hour
– Excess should always be removed from bottle
– 50-100cc NSS bag to flush line after infusion complete
Nursing Care During Thrombolytics
• No vena punctures or invasive procedures
• Insert Foley catheter prior to IV tPA or wait 1 hour after completion
• NIHSS/neuro checks and vital signs every 15 minutes for 2 hours, then every 30 minutes X 6 hours then every 1hour for remaining of 24 hour time period
• Watch for potential adverse reactions such as: – Bleeding
– Angioedema,
– Neurologic decline
– New onset headache
• Types of Patient who need ICU care
– Patients who may need more aggressive monitoring or who are
unstable hemodynamically
– Post IV tPA
– After Intra-arterial intervention
• Mechanical clot removal
• Manual aspiration
• Intra-arterial tPA
ICU Nursing Care
38
• Perform NIHSS and complete neurologic exam
• Follow Post tPA orders when appropriate
• Recognize and communicate
– Changes in neurologic status
– Hemodynamic parameters to maintain cerebral blood flow
– Neurologic or hemodynamic changes associated with increased
intracranial pressure
• Prevention of complications
– DVT
– Pneumonia
– Recurrent stroke
– Skin breakdown
• Initiate patient and family education for stroke
ICU Care Priorities
39
BP Management in the Acute Phase - Ischemic
• If treated with thrombolytics you must aggressively control
BP for first 24 hours to reduce risk of hemorrhagic
conversion
• Agents to consider
– Beta Blockers such as IV Labetalol
– Calcium Channel Blockers such as IV Nicardipine
• Avoid Nipride if possible
BP Management in the Acute Phase - Ischemic
• If no thrombolytics, in general, may let BP run a little higher
until vessel patency established
– In the setting of large artery occlusion or stenosis, higher blood
pressure may be needed to perfuse brain
– May allow SBP to rise to 220 mmHG temporarily
• Perform NIHSS and complete neurologic exam
• Recognize and communicate changes in neurologic status
• Prevention of complications from stroke/immobility
– DVT
– Pneumonia
– Recurrent stroke
– Skin breakdown
• Assessment and facilitate transition post hospital
– Rehabilitation or home
– Family or caregiver support/capacity
– Safety
• Education for patients and family/caregiver
Stroke Unit Priorities
42
Patient and Family Education
• Education should be ongoing from entry to discharge
• Organized system of providing information to patients/family
– SKAT documentation form located in ERecord
• Document that education is personalized
• Education must include
– Signs and symptoms of stroke
– The need to activate 911
– Education on risk factors and strategies for modification
– Education on medications
– Need for follow up appointment
Dysphagia Screening
• Bedside dysphagia screen (BSD) must be performed on all
ischemic, hemorrhagic and TIA stroke patients and
documented prior to giving oral meds/fluids
• Presence or absence of gag is not enough
• If patient fails BSD, repeat test in 12 hours and keep NPO
• Include speech therapy consultation in admission order
• Bedside evaluation is not intended to replace speech
therapy evaluation
• Ensure results of BSD are communicated during hand off
• Form located in adhoc “Bedside Dysphagia Screen”
• All stroke nurses are required to complete dysphagia
ULearn
Hyperglycemia and Stroke
• Hyperglycemia at the time of stroke and post stroke
worsens prognosis for recovery
• Treat hyperglycemia aggressively
• Insulin infusion protocols widely used to maintain
therapeutic glucose range
Fevers and Stroke
• Efforts to diagnose fever and treat aggressively are important in stroke prognosis and outcome
• Fever increases the brain’s oxygen demands 6-10% for every degree above normal
• Treat fevers aggressively with external cooling measures, Acetaminophen, and Ibuprofen
• Do not rely on axillary temperatures, rectal or core temperatures preferred
Neurologic Decline after Stroke
• May be due to increased intracranial pressure – Edema due to stroke
– Extension of stroke
– Hemorrhagic transformation
• Other potential causes – Seizures
– Fever/Infection
Diagnostic Work-up for Source of Stroke
• To examine arterial patency and/or rule out large artery
stenosis/occlusion
– Non-invasive carotid duplex
– CT angiography (CTA)
– MR angiogram (MRA)
– Cerebral angiogram
Diagnostic Work-up for Source of Stroke
• To rule out cardioembolic source
– TTE – transthoracic echocardiogram with bubble study
– TEE – transesophageal echo with bubble study
– 24 hour holter monitor
• Fasting lipid profile
• Hgb A1C
• Hypercoagulable profile is limited to patients without
detected etiology and higher degree of suspicion
• Responsible for 20% of all stroke types
• Symptoms often mimic those of an ischemic stroke
presentation
• May also present with headache and elevated BP
• Urgent neuroimaging is needed to determine if hemorrhage
is present
Intracerebral Hemorrhage
50
Intracerebral Hemorrhagic
• Patient with intracerebral hemorrhage may present similar to
ischemic stroke
– Lateralized weakness, sensory symptoms, aphasia, visual field cuts
– Headache is often present also
– Vomiting
– Elevated Systolic Blood Pressure
– Coma and/or decreases LOC
– Progressive decline in LOC
Right parietal Intracerebral Hemorrhage
Right Occipital Intracerebral Hemorrhage
53
Intracerebral Hemorrhage Care
• Medical Priorities are to prevent hematoma expansion
– Reverse anticoagulants
• Vitamin K, FFP, Factor VIIa
– Blood pressure management
• If SBP > 200 mm HG or MAP > 150 mm Hg consider infusion
• If SBP > 180 mm Hg or MAP > 130 mm HG with suspected
increase in ICP consider intermittent or continuous agents
• Maintain cerebral perfusion pressure> 60 mm Hg if monitoring ICP
– If concern for high ICP, consider ICP monitoring and target BP 160/90
and MAP 110 while maintaining CPP 60
• BP management continued
– If SPB > 180 or MAP > 130 and no evidence if elevated ICP
• Modest BP reduction using intermittent or Infusions
• Clinically re-examine patient every 15 minutes
• Toxicology screen in young or middle age patients
– Cocaine
– Sympathomimetic drugs
Intracerebral Hemorrhage Care
55
• Frequent neurologic exams and hemodynamic monitoring
– ICP monitoring
– CPP monitoring
• Fever prevention – maintain normothermia
• Maintain therapeutic glucose levels
• Seizures – treat if clinically present
• Prevention of complications
– Aspiration
– DVT
ICH Care
56
• Cerebellar hemorrhage
– Larger than 3 cm in diameter
– Neurologic deterioration
– Brainstem compression with or without hydrocephalus
• Hemispheric hemorrhage
– Lobar clots > 30cc that are more superficial
• Minimally invasive clot removal techniques
– Endoscopic aspiration
ICH – Surgical Clot Evacuation
57
• Hypertensive vasculopathy
– Basal ganglia, thalamus, brainstem
• Cerebral amyloid angiopathy
– Seen in older patient with history of dementia
– Lobar location of ICH
• Anticoagulation associated
– Lobar and/or intraventricular
Cause and Location of ICH
58
Hypertensive ICH
59
52 yo male with
HTN, Smokes
2 PPD. Not seen
For 2 days. Found
down by sister
SBP 230 mmHg
DBP 110 mmHg
Cerebral Amyloid Angiopathy Hemorrhage
60
• Incidence of aneurysmal SAH ranges depending on
ethnicity
– 9.7 per 100,000 adults in the US
• Increased incidence in women
• Risk factors
– Hypertension
– Smoking
– Alcohol abuse
– Use of sympathomimetic drugs (cocaine)
– History of familial aneurysms
– Autosomal dominant polycystic kidney disease
– Type IV Ehlers-Danlos Syndrome
Aneurysmal Subarachnoid Hemorrhage
61
Subarachnoid Hemorrhage
• Patient presentation is classic – Sudden severe headache “worst headache of life” or thunderclap
headache
– May have loss of consciousness, brief or sustained
– Nuchal rigidity or stiff neck
– Focal neurologic deficits or cranial nerve palsies
– Photophobic, photophonic
– Nausea/vomiting
• 12% of patients die before receiving medical attention
• Non contrast CT scan of Brain
– If non diagnostic – consider LP
• Lumbar puncture
– Analysis of spinal fluid to identify Xanthochromia (red blood cell
breakdown)
• MRI – more sensitive than previously
– Use fluid attenuated inversion recovery, proton density, DWI, and
gradient echo sequences
• CTA to detect aneurysm
• Cerebral angiography is the gold standard for aneurysm
detection
SAH – Diagnostic Evaluation
63
Aneurysmal Subarachnoid Hemorrhage
64
Subarachnoid Hemorrhage
65
• If hydrocephalus present – may require EVD insertion
• Blood pressure monitoring and management
– To prevent re-bleeding
– Prevent vasospasm
– Balance risk of stroke
– Maintain cerebral perfusion
• Frequent neurologic assessment and monitoring
• Anticonvulsants to prevent seizures in the early post bleed
period
• Transport to center where ICU care and treatment is
available
Nursing Care of the SAH Patient
66
• Cerebral Vasospasm
– Occurs 4-14 days post SAH in 40-70% patients
– Prevention: Triple H Hypertention /Hypervoemia /Hemodilution
– Nimodopine : Calcium Channel Blocker to relax vessels
– Neurointervention to open vessels if spasm present
• Fluid and Electrolyte disturbances
• Hydrocephalus
– Caused by blood in the subarachnoid blocking re-absorption of CSF
– EVD to drain CSF
– tPA may be injected into EVD by MD to clear blood
• Increased Intracranial Pressure
– Monitor with EVD in place
Complications of SAH
67
• GOAL is complete obliteration of aneurysm
• Endovascular coiling is accomplished in the interventional
suite
• Surgical clipping in the OR with open craniotomy
Medical Management of Aneurysmal SAH
68
69
6 mm R PCA
aneurysm
70
R PCA
aneurysm
post coil
with EV3
platinum
coils
Open Surgical Aneurysm Clipping
71
Patient and Family Education
• Organized system of providing information to
patients/family – SKAT documentation form
ERecord
• Document that education is personalized
• Education must include
– Signs and symptoms of stroke
– The need to activate 911
– Education on risk factors and strategies for modification
– Education on medications
– Need for follow up appointment
• Assessment of family/caregiver capacity
• Care giver and stroke survivor support group information
• Options for respite care
• Post hospital care services
– Home health
– SNIF
– Rehabilitation
– PT/OT/Speech language therapy
Post Hospital Care
73
Patient and Family support
• Important to us as nurses and health care providers to look
at the family needs and develop a plan to meet the needs of
the patient/family unit
• Families respond to the stress of illness and unexpected
nature of stroke differently
• Venous Thromboembolism Prophylaxis for ischemic or
hemorrhagic stroke, DVT prophylaxis initiated and
documented by day 2
• Discharged on Antithrombotic Therapy for ischemic
stroke or TIA
• Anticoagulation Therapy for Atrial fibrillation/flutter on
ischemic stroke or TIA
• Thrombolytic Therapy for ischemic stroke for patients who
present within 2 hours of symptom onset tpa is provided. If
not eligible/excluded document reason why
Performance Measures for Primary Stroke Centers
75
• Antithrombotic Therapy is initiated by the end of hospital
day 2 for ischemic stroke
• Discharged on a Statin Medication for ischemic stroke
and TIA patients if LDL > 99
• Stroke Education provided for all patients and must include
5 components
• Assessed for Rehabilitation prior to discharge for
ischemic and hemorrhage patients
• Dysphagia screening prior to PO medications on all
patients with persistent neurologic symptoms
Performance Measures for Primary Stroke Centers
76
• Door to CT times
• Door to tPA times
• Outcomes after tPA
– Symptomatic intracranial hemorrhages
– 90 day modified Rankin scores (disability scores)
Additional Measures to Review and Report
77
• Comprehensive Overview of Nursing and Interdisciplinary
Care of the Acute Ischemic Stroke Patient: A Scientific
Statement from the AHA - Stroke 2009;40;2911-2944.
• Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage: A Guideline for Healthcare
Professionals from the AHA/ASA Stroke 2010;41;2108-
2129.
• Guidelines for the Management of Aneurysmal
Subarachnoid Hemorrhage: A Guideline for Healthcare
Professionals from AHA/ASA Stroke 2012;43;1711-1737.
References
78