Thrombolysis Nursing Session

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Thrombolysis Nursing Session

• Amanda Jones, Stroke Nurse Consultant Sheffield
  Teaching Hospitals NHS FT
• Jo Sayles, Stroke Sister
• Doncaster Royal Infirmary
• Keith Endean, Stroke Prevention Nurse Sheffield
  Teaching Hospitals NHS FT

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Nursing Agenda

• 1.15- Introduction- Amanda Jones
• 1.25- The thrombolysis pathway at Doncaster- Jo
  Sayles
• 1.45pm- The thrombolysis pathway at Sheffield-
  Keith Endean
• 2.05- Nursing care of the thrombolysis patient
  (including when things dont go to plan)- Keith
  Endean and Jo Sayles
• 2.25- Its a miracle!- Jo Sayles
• Its a tragedy!- Keith Endean
• 2.45- Education/training and skills needed, and
  discussion re future study days- Amanda Jones

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Thrombolysis and implications for nursing

• Currently only approximately 2 of patients are
  being thrombolysed nationally- need to aim for a
  maximum of 20 although more realistically aiming
  for 10/15 (approx 4-5 per week per 1000 strokes)
  
• The general public are aware of treatments and
  are demanding thrombolysis now
• Significant national inequality-more hospitals
  are not thrombolysing than are.
• In South Yorkshire Sheffield and Doncaster are
  thrombolysing, Barnsley, Rotherham and
  Chesterfield are not (although plans are in
  place)

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Implications for nursing

• Nurses have a key role in thrombolysis
  management.- the effective coordination and
  implementation of the thrombolysis pathway is key
  to its success, without this it will not happen

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ACT FAST

• Heightened public awareness

• Time lost is brain lost- for every minute when a
  stroke first happens, approximately 1.9 million
  neurones are lost!
• Vital to get to hospital and treated urgently to
  try to save as much brain as possible!

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Developments in immediate stroke management

• Direct admission to an acute stroke unit (direct
  is seen as within 4 hours of coming through the
  hospital door)
• 24/7 thrombolysis services
• Stroke networks
• Hub and spoke models
• Medical rotas- virtual supervision
• 24/7 stroke nurse triage- stroke nurse
  specialists based in AE/ protocols in place for
  stroke nurse triage to immediately identify,
  assess and implement thrombolysis pathway
• Telemedicine

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What all stroke units looked like
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What more stroke units looking like- level 2 HDU
nursing
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Future of nursing in thrombolysis

• Nurses will be the key people who will be
  assessing/managing and administering
  thrombolysis, under the supervision (virtual or
  physical) of the medical consultant
• What skills and knowledge are needed?

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Skills, education and training

• Stroke Specific Education Framework (SSEF, DoH
  2009)- out for consultation until 12th June-
  section on assessment (stroke) Emergency
  assessment and management-
• The neurological and physiological effects of
  stroke and the time frame of changes during and
  after stroke
• How to monitor and act upon neurological and
  physiological changes during and after a stroke
• Assessing swallow

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Skills, education and training

• Addressing nutrition, hydration, medication
  administration
• Moving and positioning
• How to deal with complications

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Core competencies

• Basic awareness- very limited and generalised
  understanding that something exists but an
  individual would not need to know details
• Factual awareness- a knowledge that is detailed
  on a factual level, but does not involve any more
  than a superficial understanding of any
  principles or theories
• Working knowledge- the application of factual
  knowledge in a manner that takes into account of
  widely understood technical principles and
  applications within the field

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Core competencies

• In-depth knowledge- a broad and detailed
  understanding of the theoretical underpinning of
  an area of practice, including conflicting
  theories and constructs
• Critical knowledge- the ability to evaluate and
  devise approaches to situations

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Underpinning knowledge

• Know the -
• national documents relevant to stroke
• classification of stroke
• principles of chronic disease management
• use of barthel, ABCD2 score, NIHSS
• issues of consent (Mental capacity Act)

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Immediate care of a stroke patient

• Describe
• The basic AP and functions of the brain
• The circulatory system of the brain
• The effects of stroke presentation
• Immediate signs (FAST)
• Physical
• Cognitive
• Sensory
• Perceptual
• Behavioural
• Psychological and emotional

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Immediate care of a stroke patient

• Describe
• The types of stroke
• How treatment differs in different stroke types
• Management of TIA
• Effects of stroke (including long-term)
• Specific investigations- why they are carried out
• The use of results to direct assessment and
  treatment
• Normal parameters for all monitored vital signs
• Appropriate management of BP and how stroke type
  could affect this

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Immediate care of a stroke patient

• Demonstrate ability to interpret patients vital
  signs and recognise abnormalities
• Accurately perform and document GCS
• Demonstrate how to interpret results and
  recognise and act on abnormalities
• Complete NIHSS training
• Safely administer drug therapy
• Immediate care including anti-platelet treatment

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Immediate care of a stroke patient

• Identify patients who may require oral suction
  and safely demonstrates the procedure
• Demonstrates competence to assess a patient's
  oxygen requirements and safely administers this
• Demonstrates how to set up local monitoring
  equipment

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Immediate care of a stroke patient

• Recognise basic ECG rhythms-
• Sinus rhythm
• Atrial Fibrillation
• Tachycardia
• Bradycardia
• Ventricular ectopics
• Ventricular Fibrillation
• Asystole
• Discuss appropriate actions for above rhythms

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Immediate care of a stroke patient

• Describe importance of a swallowing screen and
  demonstrate the procedure
• Demonstrate ability to assess a stroke patients
  hydration and nutrition status and the rationale
  for this
• Describe the importance of moving and handling
  stroke patients correctly, and demonstrate moving
  and handling skills
• Discuss blood results an abnormalities in stroke
  patients

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Immediate care of a stroke patient

• Additional skills to be considered in immediate
  nursing care-
• Cannulation
• IV additive procedure
• Male catheterisation
• Insertion of NG tube
• Venapuncture
• Nurse prescribing (PGDs)

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Any questions?