STROKE: Order Sets

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STROKE Order Sets Nursing InterventionsModul
e IV
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Stroke Module IV Objectives

• Identify key nursing assessments and
  interventions to prevent complications after
  stroke
• Identify stroke education resources appropriate
  for patient and family and the means to document
  education

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Ischemic stroke (complete) mini admission
order sets Transient ischemic attack (TIA)
admission order set

• Order sets include
• Anti-thrombotic medications
• Blood pressure management
• DVT prophylaxis
• Fall risk
• Neuro assessment
• NPO/Aspiration precautions
• Rehabilitation needs
• Tobacco cessation

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After stabilization the highest priorities are
to (1) prevent recurrence of stroke, (2)
prevent complications and, (3) begin mobilization

• Observe changes in the patient's condition that
  might prompt different medical or surgical
  interventions
• Facilitate medical and surgical measures aimed at
  improving outcome after stroke
• Institute measures to prevent sub acute and long
  term complications
• Implement therapies to prevent recurrent stroke
• Begin efforts to restore neurological function
  through rehabilitation or other techniques
• Family and patient support and anticipatory
  guidance
•  

AHA 1994
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Prevention of complications Interventions

• Skin breakdown Use of Braden scale, skin
  assessments per stroke standard, pressure relief
  via repositioning and devices, skin care,
  incontinence care
• Falls Fall risk assessment and use of fall
• precautions special attention to toileting
  needs
• Aspiration pneumonia NPO until dysphagia screen
  is completed and patient cleared for diet
  aspiration precautions, oral hygiene before and
  after meal

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Prevention of complications Interventions
(continued)

• Deep vein thrombosis Mobilize as soon as
  possible, use of elastic compression hose or
  pneumatic pressure devices if low molecular
  weight heparin or unfractionated heparin
  contraindicated
• Painful hemi-paretic shoulder Proper
• positioning and support of affected limb
  during
• ambulation, transfers, and when lying in bed or
  sitting in chair use of slings, lap
  trays/troughs, range of motion as directed by
  therapy

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Rehabilitation Restorative Care

• Studies show clear advantages of treatment of
  patients in the acute phase of stroke in a
  dedicated stroke unit
• At MMC CICU, SCU, R4, P3CD and R6/608 are
  dedicated units
• Rehabilitation after stroke is a continuum,
  starting within days of stroke onset and ending
  only when it no longer produces any positive
  effect
• At MMC Physical, Occupational and Speech
  therapy are available. Physiatry consultation is
  also available. Rehabilitation is coordinated and
  uses a multidisciplinary team approach.

Med J Aust 2002
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Rehabilitation Restorative Care(continued)

• Rehabilitation services post-acute care include
  those offered by New England Rehabilitation
  Hospital of Portland, Skilled Nursing Facilities,
  and Home Health.
• Improvements in function after stroke are the
  result of recovery within the ischemic penumbra
  (potentially viable tissue), resolution of
  cerebral edema, neuroplasticity, and compensatory
  strategies learnt by the patient.

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Education Resources for Patients, Families
Significant Others

• American Heart Association (AHA) materials
• Micromedex
• Interactive television/video
• MMC library
• Complete lists can also be found at the Stroke
  Program Intranet site
• https//my.mmc.org/C19/C5/American20Stroke20Asso
  ciation20Ed/default.aspx
• https//my.mmc.org/C0/C6/Maine20Medical20Center
  20-20In20Hous/default.aspx

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American Heart Association (AHA) Educational
Materials

•  Complications after Stroke
•  Driving after Stroke
•  Emotional changes after Stroke
•  Feeling tired after Stroke
•  Living at home after Stroke
•  Stroke Aphasia
•  Stroke Rehabilitation
•  Stroke Diagnosis
•  The Stroke Family Caregiver

•  Changes caused by stroke
•  Anticoagulant antiplatelet agents
•  Carotid Endarterectomy
•  Children Stroke
•  Hemorrhagic Stroke Causes
•  High Blood Pressure Stroke
•  Ischemic Stroke Causes
•  Risk Factors for Stroke
•  Stroke, TIA Warning Signs
•  Lifestyle Changes

Complete lists can also be found at the Stroke
Program Intranet site https//my.mmc.org/C19/C5/A
merican20Stroke20Association20Ed/default.aspx h
ttps//my.mmc.org/C0/C6/Maine20Medical20Center2
0-20In20Hous/default.aspx
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Micromedex Resources (not all inclusive)

• ATRIAL FIBRILLATION (THROMBOTIC STROKE)
• CAROTID ARTERY DISEASE (STROKE AND
  CEREBROVASCULAR ACCIDENT UNSPECIFIED)
• CEREBROVASCULAR ACCIDENT (EMBOLIC STROKE)
• HEALTHY HEART DIET (ELEVATED BLOOD PRESSURE (NOT
  HYPERTENSION))
• HYPERTENSION
• CHOLESTEROL AND YOUR HEALTH
• HEALTHY HEART DIET (CHOLESTEROL-LOWERING DIET)
• LIPID PROFILE (SERUM CHOLESTEROL LEVEL)
• LOW FAT DIET (CHOLESTEROL-LOWERING DIET)
• 1200 CALORIE DIABETIC DIET, BASIC (ADULT DIABETES
  DIET)
• 1500 CALORIE DIABETIC DIET, BASIC (ADULT DIABETES
  DIET)

http//micromedex.mmc.org/
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Interactive TV Video Titles

• Daily decisions A guide to diabetes self
  management
  
• Diabetes and nutrition Eating for health
• Atrial fibrillation
• Introduction to heart disease risk factors
• Stroke What every person needs to know
• Understanding anticoagulant medications Coumadin
• Understanding the MRI adventure Adults
• Guide to stop smoking
  
• How to beat cigarettes
• AHA Quitting smoking
• Smoking cessationhealth views

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Joint Commission required measures for Ischemic
and Hemorrhagic Strokes
Tobacco cessation should be entered for anyone
who has smoked a cigarette in the last year for
reinforcement to continue cessation.
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Nursing Input Advocacy

• It DOES make a difference!
• Follow up on missing documentation and quality
  measures.

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DOCUMENT EDUCATION Standard of Care

• Specifics may include
• Stroke location, type and mechanism
• Diagnostic tests for stroke/TIA workup
• Medications antithrombotics, anti-hypertensive,
  lipid-lowering agents, Warfarin,
  anti-hyperglycemic
• Diet Low fat, low cholesterol, low salt,
  diabetic
• Risk factor management to lower primary or
  secondary stroke risk
• Signs and symptoms of stroke and emergent nature
  of these
• Rehabilitation and discharge plan
• Handouts/resources given

Use education plan on Stroke Standard and brief
focus notes to address learning for patient
and/or family
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DOCUMENT EDUCATION Joint Commission REQUIRED
education

• Personal Risk Factors
• Warning Signs for Stroke
• Activation of EMS
• Need for Follow Up after discharge
• Medications prescribed

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Standard of Care for Patient with a Stroke
(example)
NOTE Will need to be updated early 2008 with
revised Standard of Care
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Discharge Instructions

• USE of Stroke Discharge Instruction Sheet
• Reinforce stroke signs and symptoms and emergent
  nature of these
• Risk factor management
• Rehabilitation plan
• Medical follow-up
• Community resources

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Stroke Discharge Instruction Sheet
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Test Questions

• Ms. LH has had a left middle cerebral artery
  distribution stroke and is hemiplegic on the
  right side. She is allergic to heparin. To
  prevent deep vein thrombosis, care will include
• Performance of frequent neurologic checks
• Application of pneumatic compression devices
• Elevation of the foot of the bed 30 degrees
• Maintenance of bed rest for about 3 days
• Ans. b

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Test Questions

• 2. To reduce the risk of pneumonia in Mrs. WO, a
  stroke patient who has dysphagia, the following
  is recommended
• Keep her N.P.O. until a swallowing evaluation has
  been completed 
• Elevate the head of her bed 20 degrees when
  providing feeding assistance
• Avoid performing mouth care as this can make her
  gag
• Keep her supine to decrease episodes of coughing 
• Ans. a