The Role of the Advanced Nurse Practitioner in Stroke Care' Imelda Noone,MSc,RGN,RM' St' Vincents Un

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The Role of the Advanced Nurse Practitionerin
Stroke Care.Imelda Noone,MSc,RGN,RM.St.
Vincents University Hospital,Elm Park,Dublin
4.i.noone_at_st-vincents.ie
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Introduction

• Commission of Nursing (1998)
• CNS /ANP (2001)
• CNS 1,796
• ANP 39 (2006)
• 6 CNS in Stroke Care (ROI)
• New Post developed in relation to service needs
  through intermediate pathway

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St.Vincents University Hospital

• ECA pop. 333,500
• gt 65 yrs 36,928
• 475 beds in SVUH
• 255 - 316 Strokes annually
• lt 65yrs - 11
• Stroke Team (Keating,D et al, IMJ,85,4,1992)

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Stroke Team

• Patients referred
• seen within 24 ?
• 25 Stroke Patients per week
• Team meet weekly
• Stroke Minimum data sheet
• Goal Setting

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Falls Risk Assessment Tool
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Definition

• The world health organization(WHO) defines stroke
  as a sudden neurological deficit which is
  vascular in origin,with rapidly developed
  clinical signs of focal or global disturbances of
  cerebral function and persists for more than 24
  hours or leading to death (1989)

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O.C.S.P Classification of Stroke
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Common signs and symptoms

• Carotid (ant) Circulation
• Unilateral Paralysis
• Numbness
• Language disturbances
• Visual disturbances
• Monocular Blindness

• Vertebrobasillar (pos) Circulation
• Vertigo
• Visual disturbances
• Diplopia
• Paralysis
• Dysarthria
• Ataxia

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Members of the MDT

• ANP (1)
• Clinical Nurse Specialist in Stroke Care (1)
• Registrar (1)
• Physiotherapist (1.5)
• Occupational Therapist (1.5)
• Speech and language therapist (2)

• Geriatrician with an interest in Stroke
• Consultant Physician in Rehabilitation
• Psychiatrist
• Dietician (0.5)
• Social Worker(0.5)

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Stroke Unit

• 9 bedded Unit in a 28 bedded care of the elderly
  ward.
• Admissions through A E
• Other wards
• Acute Stroke Guidelines
• Participate in the regular review of all stroke
  patients

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Purpose of Post

• Improve quality, effectiveness and efficiency
• Rapid assessment
• Specialist stroke nursing services
• Interdisciplinary support and education

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Core Concepts of CNS ANP

• (Post reg. education relevant to specialist
  practice)
• Clinical Focus
• Patient Advocate
• Education and Training
• Audit and Research
• Consultant

• (Masters Degree)
• Autonomy in Clinical Practice
• Pioneering Professional and Clinical Leadership
• Expert Practitioners
• Researcher

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Autonomy in Clinical Practice

• Accept accountability/ responsibility for
  clinical decision making at advanced practice
  level.
• Conduct comprehensive health assessment, plans /
  initiates care and tx.
• Uses professional judgement to refer pts

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Reflected within

• Protocols for practice and policies for
  intervention for each identified service need
• Protocol for the monitoring of physiological
  parameters of stroke patients within 72 hours of
  the event.
• Anti-platelet use in acute stroke.
• Protocol for the supply and administration of
  identified medications

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Acute management of stroke

• Oxygen (Williams,1998)
• Antipyretics (Bhalla,2001)
• IV access fluid replacement
• Correction of electrolytes
• Tight glucose control (www.gist-uk.org)
• Protection of airway (Nil p.o if swallow unsafe)
• Graduated support stockings (TEDS)
• Catheter - avoid
• NG (not for 1st 24 hours)
• IV antibiotics if indicated
• Hold anti platelet agent until after CT Scan

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GUIDELINES

• Practice of providing a comprehensive adult
  Health History.
• Practice of undertaking a review of systems and
  physical examination of the patient.
• Requesting of diagnostic imaging by ANP in Stroke
  Care.
• Requesting of diagnostic blood assays by the ANP
  in Stroke Care.
• The management of constipation.
• Management for Secondary Prevention of Stroke.

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• Clinical Examination
•  
•  
• Phase 1 History Taking
  (Information Gathering)
• Phase 2 Examination Physical Mental
  (Objective Findings)
• Phase 3 Explanation (Information giving,
  decision making)
• (Munro Campbell 2000)

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• Comprehensive History
• Date and time of history
• Identifying Data age, gender, marital status,
  occupation
• Past Medical History
• Current Medications Known Drug / Food Allergies
• Current Health Status smoking, alcohol, drugs,
  exercise, and immunizations.
• Family History

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Review of Systems

• General
• Skin
• Head
• Eyes / Ears
• Nose / Mouth / Throat
• Neck
• Breasts
• Respiratory
• Cardiac

• Gastrointestinal
• Urinary
• Genital
• Peripheral Vascular
• Musculoskeletal
• Neurologic
• Haematologic
• Endocrine
• Psychiatric

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Professional and clinical leadership

• Articulates/ communicates a vision of areas of
  nursing practice that can be developed beyond the
  current scope of nursing practice
• Contributes to professional and health policy at
  local, regional, national level
• Contributes to service planning
• Demonstrates mentorship, preceptorship, teaching,
  facilitation, professional supervisory skills
• Identifies need and leads development of clinical
  standards

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Expert practitioner

• Demonstrates advanced clinical- decision making
  skills to manage a pt workload
• Identifies health promotion priorities
• Implements health promotion strategies for
  patients

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Nurse - led stroke follow-up clinic

• Secondary Prevention
• (B/P, weight, diet, information re-smoking etc)
• Physical/ medical status
• (medications, complications, pressure areas,
  continence, falls, etc)
• Functional Ability (Barthel, O.H.S,MMSE)
• Social/environmental issues
• ( equipment, benefits, support)
• Mood (HADS)
• Carer/family issues (CSI)

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Research

• Identifies research priorities for the area of
  practice
• Leads, conducts, disseminates and publishes
  nursing research which shapes and advances
  nursing practice educ.and policy
• Identifies, critically analyses, disseminates
  nursing and other evidence into the area of CP
• Uses the outcome of audit to improve service
  provision
• Contributes to service planning and budgetary
  processes through use of audit data and
  specialist knowledge

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Research projects

• Screening for Visual Impairment in Elderly Rehab
  Patients
• 2. The implementation of a falls risk
  assessment tool
• 3. THE Use of Cotsides in an Irish Hospital
• 4. The outcome of Stroke in the very old.
• F.U of stroke survivors in ENC
• 6. Factors associated with delay in acute stroke
  management
• CLOTS

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FALLS RISK ASSESSMENT TOOLcircle the relevant
answer and give total score below

• YES 1 NO 0
• YES 1 NO 0
• YES 1 NO 0
• YES 1 NO 0
• YES 1 NO 0
• Signature.
• Date

• Was the patient adm. with a fall or have they
  fallen since adm?
• Is the patient agitated?
• Is everyday function affected by visual
  impairment?
• Is frequent toileting required?
• Is help/ supervision needed to transfer or walk?
• TOTAL SCORE..
• If 2 or more the patient is at risk of falling.

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FALLS REDUCTION(n 400)
No. of falls
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• Assessment for Cotsides

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Factors Associated with Delays in Acute Stroke
Management.

• 100 patients
• 51 female, mean age 76yrs
• (95, CI, 74 to 78)
• Mean time from onset of symptoms to
• arrival in AE 10hrs
• AE to CT 12 hrs
• CT to APT 15 hrs

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Comparison of outcomes data (1997 2006)

• 1997
• n 183 (50 weeks)
• Mean age 72
• lt65 yrs 22
• CT 94.5
• Mean L.O.S 35 days
• Mortality 25.7
• Discharge destination
• Institutional care 16.9
• rehabilitation 11.5
• Community 41.5

• 2006
• n 240 (50 weeks)
• Mean age 75.5
• lt 65yrs 11
• CT Brain 100
• Mean L.O.S. 28 days
• Mortality 14
• Discharge destination
• Institutional care 5.4 rehabilitation 13.3
• Community 62

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Future Plans

• 20 bedded Stroke Rehabilitation Unit
• Post- Registration Education
• Nurse led clinic
• F.U ENC patients

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of aspects of hospital costs on stroke care
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Conclusion

• Significant developments in the specialist role
• The role of the nurse has been key in leading the
  care pathway
• The flexibility of the specialist role has
  ensured that stroke patients and carers are
  assessed promptly and transferred to the most
  appropriate rehabilitation setting

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St.Vincents University Hospital 2006
Thank you