Nursing care across the acute stroke

1
Acute Inpatient Stroke Care
Best PracticeBest Practice
Nursing CareNursing Care
Across theAcross the
Acute StrokeAcute Stroke
ContinuumContinuum
N S
N C

Acute Inpatient Stroke CareAcute Inpatient Stroke Care
 This session includes presentations andThis session includes presentations and
activities to enhance your learningactivities to enhance your learning
 The focus is on working with colleagues toThe focus is on working with colleagues to
discover best ways of using the tools in yourdiscover best ways of using the tools in your
clinical settingsclinical settings
 So, sit back (or stand up) and have fun!!!So, sit back (or stand up) and have fun!!!
Welcome!
07/08/14 2

 So, what do you want to get out of this module?
07/08/14 3
Expectations?

 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
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 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
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Prevention of stroke
Public awareness & patient education
Prevention of stroke
Public awareness & patient education
Hyperacute stroke
management
Hyperacute stroke
management
Acute inpatient stroke careAcute inpatient stroke care
Stroke rehabilitation
& community reintegration
Stroke rehabilitation
& community reintegration
Continuum of Stroke Care

 Synthesis of best practice recommendations
for 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

07/08/14 8
Intended only
for audiences
with no previous
knowledge of
stroke.
Intended only
for audiences
with no previous
knowledge of
stroke.
Stroke 101Stroke 101

Best Practice RecommendationsBest Practice Recommendations
07/08/14 9
45 min

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
OVERVIEWOVERVIEW

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TABLE DISCUSSIONTABLE DISCUSSION
1. 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

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

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

Let’s take a break…Let’s take a break…
15 min

Components of Acute Inpatient CareComponents of Acute Inpatient Care
Best Practice RecommendationsBest Practice Recommendations
07/08/14 15
60 min

1. 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
2. Base your notes on Best Practice Recommendation 4.2
Components of acute inpatient care
3. Venous thromboembolism, temperature, mobilization,
continence, nutrition and oral care
4. When done, we’ll conduct our meeting with
each table getting a turn to present
Interdisciplinary Meeting
TABLE ACTIVITYTABLE ACTIVITY

 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
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
Case Study

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
REVIEWREVIEW

4.2a Venous Thromboembolism Prophylaxis4.2a Venous Thromboembolism Prophylaxis

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
REVIEWREVIEW

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
REVIEWREVIEW

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

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Clots in Legs Or sTockings after StrokeClots in Legs Or sTockings after Stroke
Trial 1:Trial 1:
Do graduated compressionDo graduated compression
stockings reduce the risk ofstockings reduce the risk of
DVT in stroke patients?DVT in stroke patients?
Trial 2:Trial 2:
Are full length graduatedAre full length graduated
compression stockingscompression stockings
more effective than belowmore effective than below
knee stockings in reducingknee stockings in reducing
the risk of DVT? (QEII )the risk of DVT? (QEII )
07/08/14

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ConclusionsConclusions
 DVT occurred equally in patients with andDVT occurred equally in patients with and
without stockings.without stockings.
 Alteration in skin integrity was seen more oftenAlteration in skin integrity was seen more often
in the stocking group.in the stocking group.
 Data does not support use of (thigh length)Data does not support use of (thigh length)
stockings in patients admitted to hospital withstockings in patients admitted to hospital with
acute stroke.acute stroke.
 Guidelines will be revised!Guidelines will be revised!
07/08/14

4.2b Temperature Management

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
REVIEWREVIEW

4.2c Mobilization

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
REVIEWREVIEW
Mobilization
is defined as
the act of
getting a
patient to
move in the
bed, sit up,
stand, and
eventually
walk.

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AVERT TrialAVERT Trial
 Within the first 3 days after stroke, blood pressure, oxygen saturation,Within the first 3 days after stroke, blood pressure, oxygen saturation,
and heart rate should be monitored before each mobilizationand heart rate should be monitored before each mobilization
 If during mobilization, there is a drop in blood pressure of greater thanIf during mobilization, there is a drop in blood pressure of greater than
30 mmHg this mobilization attempt should cease. If a drop of greater30 mmHg this mobilization attempt should cease. If a drop of greater
than 30 mmHg occurs on 3 consecutive attempts, further medicalthan 30 mmHg occurs on 3 consecutive attempts, further medical
assessment is required.assessment is required.
Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). AJulie 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 beforeVery Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before
print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363
Mobilization: Physiological Monitoring
07/08/14
REVIEWREVIEW

32
 Deterioration in the person’s condition in the firstDeterioration in the person’s condition in the first
hour of admission that:hour of admission that:
 resulting in direct admission to ICU,resulting in direct admission to ICU,
 a documented clinical decision for palliativea documented clinical decision for palliative
treatment (e.g. those with devastating stroke)treatment (e.g. those with devastating stroke)
 immediate surgery.immediate surgery.
 Unstable coronary or other medical condition.Unstable coronary or other medical condition.
 A suspected or confirmed lower limb fracture atA suspected or confirmed lower limb fracture at
the time of stroke preventing mobilizationthe time of stroke preventing mobilization
 Systolic blood pressure less than 110, or greaterSystolic blood pressure less than 110, or greater
than 220mmHg.than 220mmHg.
*Contraindications to Mobilization
07/08/14REVIEWREVIEW
*AVERT Trial recommendations

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 Oxygen saturation of less than 92% withOxygen saturation of less than 92% with
supplementation.supplementation.
 Resting heart rate of less than 40 or greater thanResting heart rate of less than 40 or greater than
110 beats per minute.110 beats per minute.
 Temperature of greater than 38.5°C.Temperature of greater than 38.5°C.
 Persons who have received rt-PA can bePersons who have received rt-PA can be
mobilized if the attending physician permits.mobilized if the attending physician permits.
*Contraindications to Mobilization
*AVERT Trial recommendations

4.2d Continence

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
REVIEWREVIEW

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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

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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

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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

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07/08/14
Assessment of Incontinence
 Post residual volume
 Urine culture
 Vaginal examination
 Rectal examination
 Incontinence history
 Fluid intake
 Medical history
 Medications
 Functional ability

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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

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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)

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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

43
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

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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/

4.2e Nutrition

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
REVIEWREVIEW

47
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

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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

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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)

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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 excludeThe presence of a gag reflex does not exclude
the possibility of dysphagiathe possibility of dysphagia

4.2f Oral Care

4.2f Oral care
 All stroke patients should have an oral/dental assessment,
which includes screening for obvious signs of dental disease,
level of oral care and appliances, upon or soon after admission
 For patients wearing a full or partial denture it must be determined if
they have the neuromotor skills to safely wear and use the
appliance(s)
 An oral care protocol should be established and include:
 Frequency
 Types of oral care products
 Strategies for patients with dysphagia
 Consultation with dentistry
REVIEWREVIEW

53
Oral Care
 Consider consulting dentistry, occupational therapy, speech
language pathologists, and/or a dental hygienist to develop an
oral care protocol
 A referral to dentistry for consultation and management of oral
health and/or appliances should be made as soon as possible

4.2g Discharge planning
 Discharge planning should be initiated as soon as possible
after patient admission to hospital (emergency department or
inpatient care)
 A process should be established to ensure involvement of patients
and caregivers in the development of the care plan, management
and discharge planning
 Discharge planning discussions should be ongoing throughout
hospitalization to support a smooth transition from acute care
 Information about discharge issues and possible needs of patients
following discharge should be provided to patients and caregivers
soon after admission
REVIEWREVIEW

Check Up QuizCheck Up Quiz
QUIZQUIZ

Check Up
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In one clinical study, stroke unit
care reduced the odds of what
three outcomes?
1. Death at final follow up
2. Death or institutionalized care
3. Death or dependency

Check Up
07/08/14 57
Name two common
complications related to stroke.
Aspiration Pneumonia 40%
Urinary tract infection 40%

Check Up
07/08/14 58
In what type of unit shouldIn what type of unit should
patients admitted to hospitalpatients admitted to hospital
with acute stroke or TIA bewith acute stroke or TIA be
treated?treated?
In an interdisciplinary stroke unitIn an interdisciplinary stroke unit

Check Up
07/08/14 59
What type of planning should be
included as part of the initial
assessment and ongoing care of acute
stroke patients?
Discharge planningDischarge planning

Check Up
07/08/14 60
What type of treatment should
patients who are identified as high
risk for venous thromboembolism be
considered for?
Prophylaxis provided there are no
contraindications

Check Up
07/08/14 61
In addition to secondary stroke
prevention, what type of therapy
should be used for people with
ischemic stroke to prevent VTE?
Antiplatelet therapy

Check Up
07/08/14 62
What action should be taken if a
patient’s temperature rises to more
than 38°C?
Identify and treat source (site andIdentify and treat source (site and
etiology) of fever in order to startetiology) of fever in order to start
tailored antibiotic treatment andtailored antibiotic treatment and
antipyreticsantipyretics

Check Up
07/08/14 63
How often should the temperature of
a stroke patient 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)

Check Up
07/08/14 64
When should acute stroke patients be
mobilized?
As early and as frequently as
possible preferably within 24 hours of
stroke
symptom onset, unless
contraindicated

Check Up
07/08/14 65
Mobilization of stroke patients isMobilization of stroke patients is
contraindicated when systolic bloodcontraindicated when systolic blood
pressure is less than or greater thanpressure is less than or greater than
what values?what values?
Systolic blood pressure less thanSystolic blood pressure less than
110mm Hg or greater than 220mm110mm Hg or greater than 220mm
Hg.Hg.

Check Up
07/08/14 66
What percentage of stroke patientsWhat percentage of stroke patients
have urinary incontinence?have urinary incontinence?
40-60% of stroke patients have40-60% of stroke patients have
urinary incontinenceurinary incontinence

Check Up
07/08/14 67
What does the use of a portableWhat does the use of a portable
ultrasound (bladder scanner) toultrasound (bladder scanner) to
access bladder function eliminate?access bladder function eliminate?
Risk of introducing urinary infectionRisk of introducing urinary infection
or causing urethral trauma byor causing urethral trauma by
catheterizationcatheterization

Check Up
07/08/14 68
What are three strategies for treatingWhat are three strategies for treating
overflow incontinence?overflow incontinence?
1.1. Double voidingDouble voiding
2.2. Crede maneuverCrede maneuver
3.3. Intermittent catheterizationIntermittent catheterization

Check Up
07/08/14 69
Bowel incontinence occurs in whatBowel incontinence occurs in what
percentage of stroke patients andpercentage of stroke patients and
what percentage regain control withinwhat percentage regain control within
one year?one year?
Bowel incontinence occurs in 30% ofBowel incontinence occurs in 30% of
stroke patients and 97% regainstroke patients and 97% regain
control within one yearcontrol within one year

Check Up
07/08/14 70
What should a bowel function riskWhat should a bowel function risk
factor assessment include?factor assessment include?
Mobility, inactivity, adequate fluid andMobility, inactivity, adequate fluid and
food intake, polypharmacyfood intake, polypharmacy

Check Up
07/08/14 71
Identify four things you can do toIdentify four things you can do to
manage bowel incontinence.manage bowel incontinence.
1.1. Increase dietary fibre and fluidsIncrease dietary fibre and fluids
2.2. Increase mobilityIncrease mobility
3.3. Maintain a bowel recordMaintain a bowel record
4.4. Establish a regular toiletingEstablish a regular toileting
routineroutine

Check Up
07/08/14 72
The nutritional and hydration status of
stroke patients should be screened
within what period of time after
admission and using what tool?
WithinWithin the first 48 hours of admission
using a valid screening tool

Check Up
07/08/14 73
Maintain all patients with stroke NPOMaintain all patients with stroke NPO
(including oral medications) within 24(including oral medications) within 24
hours of patient being awake andhours of patient being awake and
alertalert
What should be done with allWhat should be done with all
patients with stroke until apatients with stroke until a
swallowing screen has beenswallowing screen has been
administered and interpreted?administered and interpreted?

Check Up
07/08/14 74
The presence of a gag reflex does not
exclude the possibility of dysphagia
The presence of a gag reflex does
not exclude the possibility of
what?

Early Assessment &Early Assessment &
Stroke RehabilitationStroke Rehabilitation
15 min

When should stroke rehabilitation start?

When Should Stroke Rehabilitation Start
 Priorities are :
 Manage stroke sequelae to optimize recovery
 Prevent post-stroke complications that may interfere with recovery
process
 Acute stroke accounts for the longest length of stay in
Canadian hospitals and places a significant burden on inpatient
resources, which increases further when complications are
experienced.

When Should Stroke Rehabilitation Start
 Consider that rehabilitation is a process, not a place.
Rehabilitation and discharge planning begins
at the time of admission to acute care

What are the benefits of early
assessment and rehabilitation?

Benefits of Early Assessment & Rehabilitation
 Assessment should start as early as possible in the ER and
continue through the inpatient and community reintegration
phases

Benefits of Early Assessment & Rehabilitation
 Early consultation with rehab professionals:
 Contributes to reductions in complications from immobility such as
joint contracture, falls, aspiration pneumonia and deep vein
thrombosis
 Contributes to early discharge planning for transition from acute
care to specialized rehabilitation units or to the community
 Should reduce the overall cost of care through improved outcomes
and reduced time to discharge (BPG 5.1)

Examples of Assessment Tools
 Clinicians should use standardized, valid assessment tools to
evaluate stroke-related impairments and functional status
Domain Selected Measure
 Measures of stroke
severity
 Orpington Prognostic Scale (OPS)
 National Institute of Health Stroke Scale
 Upper/lower
extremity structure
and function
 Chedoke-McMaster Stroke Assessment (CMSA)
 Language  Screening in acute care and follow-up, with
Frenchay Aphasia Screening Test (FAST)
 Boston Diagnostic Aphasia Examination (BDAE)
 Cognition  Montreal Cognitive Assessment (new addition
by Canadian Stroke Strategy cognitive working
group, January 2008)
 Self-care activities
of daily living
 Functional Independence Measure (FIM)

Your Role in Early Assessment &Stroke Rehabilitation
When done,
we'll review
some of your
pearls of
wisdom!
 At your tables discuss
 What are the benefits of early assessment and
stroke rehabilitation at your institution?
 Where can you make a difference in realizing
these benefits?
 What is the role of the nurse in stroke
rehabilitation?
 What barriers and enablers do you see?

Family & Patient EducationFamily & Patient Education
15 min

From the Patient and Family’s Perspective:From the Patient and Family’s Perspective:

Where You Can Make a Difference!
Did you know that
skills training of
caregivers makes
a huge difference
in patient
outcomes in areas
of functionality
and depression!
1. At your tables, discuss
 What would be your role in educating
and supporting patients and caregivers
about acute inpatient stroke care?
1. When done, we'll debrief the whole
group to identify some best practices

Patient and Family Education
 Content should be specific to;
 The phase of care
 Patient/caregiver readiness
 Patient/caregiver needs
 Education should be timely, interactive, up to date and provided in a
variety of formats, languages including aphasia friendly
 Processes should be established by clinical teams for
education including designating team members for provision
and documentation of education
REVIEWREVIEW

REVIEWREVIEW
 Education content should include:
 The nature of the stroke and its manifestations
 Signs and symptoms of stroke
 Impairments and their impact on the person
 Caregiver training to manage
 Risk factors
 Post-stroke depression
 Cognitive impairment
 Discharge planning and decision making
 Community resources
 Home adaptations

www.heartandstroke.ca

Putting It All TogetherPutting It All Together
30 min

Case Study
1. Review the case study in your PW
2. With your team, answer the questions on the worksheet at
the end of the study
3. We’ll review when done to share some best practices and get
ready to create a Stroke Care Action Plan

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

Case Study Questions
 What would be the priority areas for Mrs. C’s care plan
development?
 What education would you provide for the family?
 What complications would you be monitoring for with Mrs. C?

Case Study Questions
1. With the case study we just reviewed in mind, create a stroke
care action plan
 Identify 1-2 key learnings from today that you could take back to
help kick start your change initiatives
1. Use the Stroke Care Action Plan worksheet in your PW to
record your plan

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Nursing care across the acute stroke

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