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Module 2Hyperacute Stroke Management
Best Practice
Nursing CareAcross theAcute Stroke
Continuum
N SN C
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Hyperacute Stroke Management
This session includes presentations andactivities to enhance your learning
The focus is on working with colleagues todiscover best ways of using the tools in yourclinical settings
So, sit back (or stand up) and have fun!!!
Welcome!
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Hyperacute Stroke Management
So, what do you want to get out of this module?
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Expectations?
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Hyperacute Stroke Management
Discuss the impact of hyperacute stroke management on
patient outcomes
Identify your role in pre-hospital and ER stroke care
Review the Best Practice Recommendations related to
hyperacute stroke management
Identify how you can help to implement these at your institution
Identify your role in patient and caregiver education
Create a stroke care action plan for hyperacute stroke
management
Objectives
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Hyperacute Stroke Management
Introduction 15 min
Stroke 101(optional) 15 min
Pre-Hospital Stroke Care 45 min
In the Emergency Room 30 min
Break 15 min
Hyperacute Stroke Management BPRs 45 min
Patient and Family Education 15 min
Putting It All Together 30 min
Agenda
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Hyperacute Stroke Management
Prevention of strokePublic awareness & patient education
Hyperacute stroke
management
Acute inpatient stroke care
Stroke rehabilitation
& community reintegration
Continuum of Stroke Care
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Hyperacute Stroke Management
Prevention of strokePublic awareness & patient education
Hyperacute stroke management
Acute inpatient stroke care
Stroke rehabilitation
& community reintegration
Early
assessment
for stroke
rehabilitation
should start
here
Continuum of Stroke Care
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Acute stroke is a medical emergency
and optimizing out-of-hospital care
improves patient outcomes
EMS plays a critical role in assessment
and management
Acute interventions such as
thrombolysis are time sensitive
Hyperacute Stroke Management
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Redirecting
ambulances to
stroke centres
facilitates earlierassessment,
diagnosis and
treatment which
may result in
better outcomes.
Why Is This Important?
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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.caDecember 2, 2008
http://www.cmaj.ca/http://www.cmaj.ca/ -
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Intended onlyfor audiences
with no previous
knowledge of
stroke.
Stroke 101Hyperacute Stroke Management
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Hyperacute Stroke ManagementPre-Hospital Stroke Care45 min
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Hyperacute Stroke Management
Your Role in Pre-Hospital Stroke Care
1. At your tables, discuss best practices for effective
Pre-Hospital Stroke Care:
What information will you need EMS to gather about
the patient?
What you can do to help rapid assessment & triage
in hospital?
2. When done, we'll debrief the whole group to
arrive at some best practices
Pre-Hospital Stroke Care
3/28/2014 12TABLE ACTIVITY
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Hyperacute Stroke Management
Patient should be transported without delay to the
closest institution that provides emergency stroke
care (BPR 3.1)
Patient or other members of public must make
immediate contact with EMS
EMS dispatchers must triage as priority
Paramedics should use standardized screening tool
Direct transport protocols should be in place
Critical information/history should be obtained
Receiving facility must be notified
EMS Role in Hyperacute Stroke
3/28/2014 13DEBRIEF
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Hyperacute Stroke Management
From Recognition to Pre-Admission
Pre-Hospital Stroke Care
Detection Dispatch
Delivery
Door
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Hyperacute Stroke Management
Why is the time of onset of the stroke a
critical piece of information?
Stroke patients who arrive to ER within three andone half hours of symptom onset may be
candidates for thrombolytic therapy
Hospital destination decisions may be based on
time of onset of stroke symptoms
Care of Patient with Stroke
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Hyperacute Stroke Management
A 53-year-old man with a history of hypertension was broughtto the ED by paramedics after his employer noticed that he haddifficulty with speech, ambulation, and vision.
The employer reported that the patient usually left his house at
3:40 am and arrived at work by 4:00 am; however, no one sawhim arrive at work and no time clock is used.
Paramedics were called at about 5:00 am.
What was the time of onset of the stroke?
When he went to bed? 3:40 am?
4:00 am?
5:00 am?
Last Seen Normal-1
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Hyperacute Stroke Management
What do we know:
Patient successfully drove to work; it is unlikely that the stroke beganbefore he left the house.
Possible:
Symptoms MAY have been very mild at first, that he ignored them,and went to work anyway.
Decision:
Since we have no evidence for this yet, we TENTATIVELY assign anonset time of 3:40 am, subject to further history.
Needed:
Find someone at work who saw him and could testify that he wasnormal or obviously abnormal before the paramedics were called.
Last Seen Normal-2
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Hyperacute Stroke Management
Quick identification and screening by pre-
hospital providers in the field
Blood glucose measurement to excludehypoglycaemia as a cause of neurological
deficit
Notification of receiving hospital
Transport
Treatment to stabilize the patient
Pre-Hospital Important Steps
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Hyperacute Stroke Management
Consistently identifies patients with stroke
Evaluate three major findings:
Facial droop
Arm weakness
Speech abnormalities
Based on the Cincinnati Stroke Scale or Los Angeles Stroke Scale
Key Components of Paramedic Prompt Cards
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Hyperacute Stroke Management
Patients with 1 of these 3 findings
72% probability of an acute stroke if the symptomsare new
Patients with all 3 findings..
85% probability of an acute stroke if the symptomsare new
If the patient has a positive CPSS or one ormore of the findings, immediately activate localacute stroke protocol
Cincinnati Pre-Hospital Stroke Scale
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Hyperacute Stroke Management
Symptom Onset
Time
Trauma (history)
Seizure
Neurological Exam
LOC
Pre-Hospital Stroke
Scale
Basic DataAge and gender
Chief complaint
Other tPA exclusionsAs per tPA protocol
inclusion/exclusioncriteria
Information obtained and relayedby EMS provider is vital
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Pre-Hospital Stroke Care
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Hyperacute Stroke ManagementNIH Stroke Scale
Standard assessment tool formeasuring neurologic deficit
Measures level ofconsciousness, best gaze,visual, facial palsy, motorfunction, language, dysarthria,extinction and inattention
Can be used to quantifyneurologic function inspecified categories at varioustime points
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Hyperacute Stroke ManagementNIH Stroke Scale
3/28/2014 23Source: www.ninds.nih.govEXAMPLE
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Hyperacute Stroke ManagementNIH Stroke Scale
3/28/2014 24Source: www.ninds.nih.govEXAMPLE
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Hyperacute Stroke Management
Canadian Neurological Scale
was designed as a simple
clinical tool to evaluate theneurological status of acute-
stroke patients
Measures level of
consciousness, orientation,speech and motor functions
CNS Stroke Scale
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Hyperacute Stroke Management
Check Up Quiz
EXAMPLE
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Hyperacute Stroke ManagementCheck Up
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In hyperacute stroke
management, EMS should
transport a patient withoutdelay to what type of
institution?
To the nearest institution thatprovides emergency stroke care
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Hyperacute Stroke ManagementCheck Up
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What are the four steps in
pre-hospital stroke care fromrecognition to pre-
admission?
Detection, Dispatch,Delivery, Door
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Hyperacute Stroke ManagementCheck Up
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What are the four steps in
pre-hospital stroke care fromrecognition to pre-
admission?
Detection, Dispatch,Delivery, Door
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Hyperacute Stroke ManagementCheck Up
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Why is blood glucosemeasurement so important?To exclude hypoglycaemia as acause of neurological deficit
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Hyperacute Stroke ManagementCheck Up
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What is the probability of acute
stroke if a patient is abnormal on allthree of the Cincinnati measures
and symptoms are new?
85% probability
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Hyperacute Stroke ManagementCheck Up
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What does the CanadianNeurological Scale measure?
Level of consciousness, orientation,speech and motor functions
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In the Emergency Room30 min
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Hyperacute Stroke Management7-Step Stroke Chain of Survival
Detection
Dispatch Delivery
Door
DataDecision
Intervention
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Time is Brain
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Hyperacute Stroke Management
1. Treatment in the ER is only the start
2. Patients will have varying outcomes:
Lazarus effect (complete or almost recovery) Light to moderate disability
Moderate to severe disability
Where You Can Make a Difference!
HERE`S WHERE YOU CAN REALLY MAKE A DIFFERENCE!
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Diminishing Returns over TimeFavorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with
95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776)
Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I,
~4h 40min
Courtesy Brott T et al
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Hyperacute Stroke Management
Your Role in the Emergency Room
1.At your tables, discuss and flip chart key points about your
role in the ER:
What can you do to assess patients & triage rapidly?
What are the key activities of the stroke team?
What is your role in facilitating a smooth transfer from ER
to an inpatient unit?
2.When done, well debrief the whole group to arrive at some
best practices
In the Emergency Room
TABLE ACTIVITY
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Hyperacute Stroke Management
What is the single most important key to stroke care
success?
In the Emergency Room
Interprofessional
Communication!
so that everyone knowswhat to do and things can
be activated simultaneously!
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Hyperacute Stroke Management
What needs to get done?
In the Emergency Room
TABLE ACTIVITY
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Hyperacute Stroke Management
Include:
Maintaining or improving breathing,
CV function, nutrition, hydration and electrolyte balance
Evidenced based neurological assessment Limiting further neurological damage
Preventing complications
Treating or modifying reversible risk factors
Patient and family education
Treatment Objectives
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Hyperacute Stroke Management
Check airway, breathing, vitals (including
temperature)
Ensure adequate respiration, monitor BP and cardiac
rhythm Establish time of stroke symptom onset
Alert stroke team
Establish IV access-possibly 2 lines
Draw blood for CBC, blood glucose and other tests(INR)
Early ManagementInitial Steps
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Hyperacute Stroke Management
Perform neuro assessment
NIH Stroke Scale
Canadian Neurological Scale
Use of preprinted standard orders or protocols
Order a CT scan
Keep NPO until swallowing screen completed
Educate patient and family
Early ManagementInitial Steps
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Hyperacute Stroke Management
In the Emergency Room
Candidates for t-PA
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Hyperacute Stroke Management
Bypass and repatriation protocols to closest Regional Stroke
Centre
Established thrombolysis protocol
Triage: Rapid assessment using Acute Stroke protocol eligibilitycriteria / NIH Stroke Scale
t-PA target times: ensure you can meet the < 4.5 hr window
(ECASS III)
Access to CT scanning
Stroke team: (Stroke expert, emergency or family physician,
nursing staff, allied healthcare professionals, stroke survivor,
family, support network central to team)
Optimal Stroke Management with rt-PA
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Hyperacute Stroke Management
In the Emergency Room
Exclusions for t-PA
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Hyperacute Stroke Management
Exclusion criteria for intravenous t-PA
CT evidence of cerebral hemorrhage or an infarction that involves
>1/3 of the middle cerebral artery territory
Blood pressure >185/110 mmHg that cannot be reduced withappropriate intravenous bolus dose of labetalol (alpha blocker)
A prolonged PTT (Partial Thromboplastin Time), or an INR
(International Normalized Ratio) >1.7 (1.4), or platelet count
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Hyperacute Stroke Management
Exclusion criteria for intravenous t-PA, cont
Seizures at onset of stroke
Other major bleeding (e.g., gastrointestinal) within past 21 days
MI within past 14 days
Rapidly improving neurological signs or minimal deficit
Other illness that, in the physicians judgment, could limit
effectiveness of t-PA or increase risk of bleeding
Optimal Stroke Mgmt with t-PA: Triage
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Hyperacute Stroke Management
EMonitoring needs during t-PA treatment
Canadian Guidelines for Intravenous Thrombolytic Treatment in
Acute Stroke: (1998)
Vital signs should be taken every 15 minutes during the druginfusion, then 30 minutes for the next 2 hours, then hourly for 5
hours
Neurovital signs should be performed hourly for 6 hours, and then
according to the patient's condition
In the Emergency Room
Source: Can. J. Neurol. Sci. 1998; 25: 257
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Hyperacute Stroke Management
Check Up Quiz
QUIZ
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Hyperacute Stroke ManagementCheck Up
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What is the single most
important key to stroke caresuccess
Interprofessional Communication!
so that everyone knows what
to do and things can be activated
simultaneously
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Hyperacute Stroke ManagementCheck Up
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What is the t-PA target time?
Ensure you can meet the < 4.5 hr
window(ECASS III)
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Hyperacute Stroke ManagementCheck Up
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Who should be part of the Stroke
team?
Stroke expert, emergency or familyphysician, nursing staff, allied
healthcare professionals, strokesurvivor, family, support network
central to team
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Hyperacute Stroke ManagementCheck Up
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According to the CanadianGuidelines for Intravenous
Thrombolytic Treatment in AcuteStroke, when should vital signs be
taken?
Every 15 minutes during the drug
infusion, then 30 minutes for thenext 2 hours, then hourly for 5 hours
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Lets take a break15 min
Hyperacute Stroke Management
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Best Practice
Recommendations45 min
Hyperacute Stroke Management
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Hyperacute Stroke Management
3.1 EMS management of acute stroke patients
Patients who show signs and symptoms of hyperacute stroke,
usually defined as symptom onset within the previous 4.5
hours, must be treated as time-sensitive emergency cases and
should be transported without delay to the closest institution
that provides emergency stroke care
Patient or other members of public must make immediate contact
with EMS
EMS dispatchers must triage as priority
Paramedics should use diagnostic screening tool
Direct transport protocols should be in place
Critical information/history should be obtained
Receiving facility must be notified
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.2 Acute management of TIA and minor stroke
Patients who present with symptoms suggestive of minor
stroke or transient ischemic attack must:
Undergo a comprehensive evaluation to confirm the diagnosis
Begin treatment to reduce the risk of major stroke as soon as is
appropriate to the clinical situation
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.3 Neurovascular imaging
All patients with suspected acute stroke or transient ischemic
attack should undergo brain imaging immediately
In most cases, initial modality in a non-contrast CT scan
Vascular imaging should be done as soon as possible
If MRI is performed, it should include diffusion-weighted sequences
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.4 Blood glucose abnormalities
All patients with suspected acute stroke should have their blood
glucose concentration checked immediately.
Blood glucose measurement should be repeated if the first value is
abnormal or if the patient is known to have diabetes. Hypoglycemia
should be corrected immediately
Elevated blood glucose concentrations should be treated with
glucose-lowering agents
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.5 Acute thrombolytic therapy
All patients with disabling acute ischemic stroke who can be
treated within 4.5 hours after symptom onset should be
evaluated without delay to determine their eligibility for
treatment with intravenous tissue plasminogen activator
(alteplase)
All eligible patients should receive intravenous alteplase within 1
hour of arrival (door-to-needle time < 60 min)
Administration of alteplase should follow the ASA guidelines
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.6 Acute ASA therapy
All acute stroke patients should be given at least 160 mg of
ASA immediately as a one-time loading dose after brain
imaging has excluded intracranial hemorrhage
In patients treated with recombinant tissue plasminogen activator,
ASA should be delayed until after the 24-hour post-thrombolysis
scan has excluded intracranial hemorrhage
ASA (80325 mg daily) should then be continued indefinitely or until
an alternative antithrombotic regime is started
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
3.7 Management of subarachnoid and intracerebral
hemorrhage
Patients with suspected subarachnoid hemorrhage should have
an urgent neurosurgical consultation for diagnosis and
treatment
Patients with cerebellar hemorrhage should have an urgent
neurosurgical consultation for consideration of craniotomy and
evacuation of the hemorrhage
Patients with supratentorial intracerebral hemorrhage should be
cared for on a stroke unit
Best Practices Recommendations
OVERVIEW
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Hyperacute Stroke Management
1. Form two groups at your table and have
each select and prepare a briefing on
one of the sections in Hyperacute stroke
management
2. Use the worksheet in your PW to help
structure your briefing
3. Focus on the following topics:
Rationale for recommendation
System implications of it Performance measures
4. When done, each group will present its
briefing to the other and discuss
Recommendations Briefing
TABLE ACTIVITY
Imagine you have
been asked tobrief your
colleagues back
home on one of
the key sections
in Hyperacute
stroke
management.
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Hyperacute Stroke Management
1. Now switch sections with the other
group at your table and prepare to
answer the following:
How will this recommendation improve
stroke care at your institution?
What role can you play in implementing
it?
What barriers or enablers do you see?
2. When done, brief the other group on
these issues and discuss
3. Then, well debrief the whole group toarrive at some best practices
Recommendations Briefing
TABLE ACTIVITY
Imagine you have
been asked tobrief your
colleagues back
home on one of
the key sections
in Hyperacute
stroke
management.
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Patient and
Family Education15 min
Hyperacute Stroke Management
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From the Patient and Familys
Perspective:
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Hyperacute Stroke Management
1. At your tables, discuss
What would be your role in educating
and supporting patients and caregivers
about hyperacute stroke management?
2. When done, brief the other group onthese issues and discuss
3. When done, we'll debrief the wholegroup to identify some bestpractices
Where You Can Make a Difference!
Did you know that
skills training of
caregivers makesa huge difference
in patient
outcomes in areas
of functionality
and depression!
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Hyperacute Stroke Management
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 provisionand documentation of education
Patient and Family Education
REVIEW
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Hyperacute Stroke Management
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
Patient and Family Education
REVIEW
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Putting It All Together30 min
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Hyperacute Stroke Management
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. Well review when done to share some best practices and get
ready to create a Stroke Care Action Plan
Case Study
TABLE ACTIVITY
H S k M
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Hyperacute Stroke Management
Mrs. R is a 76 year old right handed woman who was shopping at
Canadian Tire at 1030am when she suddenly started to feel unwell.
She went to the clerk to ask for assistance but was unable to talk
and had a right sided weakness.
The clerk called 911 and she was taken to the local stroke centrewhere she was assessed at 1115am
Her past medical history includes: hypertension,
hypercholesteremia, osteoporosis and gastroesophageal reflux
Her current medications include: hydrochlorothiazide, coversyl,
simvastatin, didrocal and ranitidine She has no known allergies and does not smoke or drink alcohol
Case Study
H t St k M t
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Hyperacute Stroke Management
On admission to ER:
BP 162/72
Pulse 100 and irregular
Respirations 26
Temperature 37.0C
Heart sounds irregular but no murmurs heard
Lungs clear. No peripheral edema. Abdomen soft and non tender and
non-distended
Neurologically:
Mental status limited due to expressive aphasia but able to follow
simple commands Right visual field defect
Right facial weakness
Dense right flaccid hemiparesis
Blood work: Glucose: 6.8, WBC: 5.0, Platelets: 221, Hemoglobin: 122,
Sodium: 137, Potassium: 3.7, Troponin < 0.04, INR: 0.9
Case Study
H t St k M t
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Hyperacute Stroke Management
Did Mrs. C meet the criteria to activate the Code Stroke
Team?
Is Mrs. C a candidate for tPA? Why?
Case Study Questions
TABLE ACTIVITY
H t St k M t
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Hyperacute Stroke Management
If Mrs. C met the criteria for tPA, what possible complications
would you monitor for?
If Mrs. C receives tPA, when is the recommended time to
administer ASA 160mg?
What teaching would you give the patient/family in this phaseof care?
Case Study Questions
TABLE ACTIVITY
H t St k M t
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Hyperacute Stroke Management
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
2. Use the Stroke Care Action Plan worksheet in your PW to
record your plan
Creating a Stroke Care Action Plan
INDIVIDUAL ACTIVITY
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Best Practice Nursing CareAcross the Acute Stroke
ContinuumThank you for your participation!