ICU Nursing Intervention Clinical Case by Slidesgo.pptx

Stroke

1. Stroke Program Orientation for Medical Staff

2. Learning Objectives Complete a focused assessment on the patient presenting with signs and symptoms of a stroke Initiate facility specific protocol for the patient presenting with an ischemic stroke Communicate effectively when managing the care of the patient experiencing a stroke

3. STROKE FACTS Each year about 1,250 ,000 people experience a new or recurrent stroke About  1,85,000 stroke cases are reported every year in India   with nearly one stroke every 40 seconds and one stroke death every 4 minutes. Increase in cases: A 51% rise in stroke cases was observed in India over the last 30 years. Prevalence surge: The prevalence of stroke in India has also increased by 47%, from 4.4 million in 1990 to 9.4 million in 2021. Global burden: India now accounts for approximately 10% of the global stroke burden. 87% of the stroke risk could be attributed to modifiable risk factors such as HTN, obesity, DM, HLD, and renal dysfunction; 47% could be attributed to behavioral risk factors such as smoking, a sedentary lifestyle, and an unhealthy diet. Sci Rep   14 , 22640 (2024) Int J Stroke. 2021 Jul 2;17(2):132–140

4. Short-term and long-term solutions in stroke care in India. Stroke, Vol 51, No. 7, June, 2020

5. STROKE - ACUTE CARE PATHWAY DEFINITIONS 1.WHO A NEUROLOGICAL DEFICIT OF Sudden onset With focal rather than global dysfunction In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin and last for >24 hours 2. NINDS 2005 When the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts 3.TIA-neurological deficit of vascular origin lasts from few minutes to hours and resolves within 24 hours

6. Joint Commission Standardized Performance Measures for Stroke Venous Thromboembolism(VTE) Prophylaxis by Day 2 (Ischemic and Hemorrhagic) Discharged on Antithrombotic Therapy Anticoagulation Therapy for At Fib/Flutter Thrombolytic Therapy Antithrombotic Therapy by end of Hospital Day 2 Discharged on Statin Medication Dysphagia Screening Smoking Cessation Stroke Education (Ischemic and Hemorrhagic) Assessed for Rehab (Ischemic and Hemorrhagic)

7. TIME IS BRAIN

8. TYPES OF STROKE ISCHEMIC 85% HEMORRHAGIC 15% Stroke Atherosclerotic (20%) Cryptogenic (30%) Unusual causes Prothrombotic Dissections Arteritis Migraine Drug abuse (5%) Haemorrhage Intraparenchymal Subarachnoid (15%) Cardioembolic (20%) Penetating artery Disease ( lacunar) (25%)

9. Risk Factors Conditions Behaviors Previous stroke or transient ischemic attack (TIA) Unhealthy diet Hypertension Physical inactivity Hyperlipidemia Obesity Cardiac disease Tobacco abuse Atrial fibrillation (A fib) Alcohol abuse Diabetes Sickle Cell disease Other Risk Factors Age, gender, heredity, race or prior stroke Stroke

10. Stroke Care What’s the best way to care for stroke patients? Are there guidelines for care of a stroke patients?

11. STROKE ACUTE CARE PATHWAY CHANGING TRENDS…. Stroke is a preventable and treatable disease More effective evidence based primary and secondary prevention strategies Evidence of interventions that are effective soon after the onset of symptoms Understanding of the care processes that contribute to a better outcome has improved

12. STROKE CONTINUUM PRIMARY PREVENTION ACUTE CARE REHABILITATION COMMUNITY RE-INTEGRATION SECONDARY PREVENTION OUTPATIENT ER

13. The recommendations focus on 11 aspects of Stroke Care: 1. Acute stroke team: includes a doctor experienced in diagnosing and treating cerebrovascular disease, along with other specialists, available 24 hours a day, seven days a week to evaluate within 15 minutes any patient who may have suffered a stroke Beth Wiese, RN Stroke Coordinator, Dr. Steve Goins, Stroke Director 2. Written care protocols: written procedures to help streamline and speed up the diagnosis of stroke and treatment of stroke patients 3. Emergency medical services : in-the-field diagnosis and treatment, and rapid transport of patients to the emergency department 4. Emergency department : ED staff trained in diagnosing stroke and treating patients with stroke; maintaining strong lines of communication with EMS and the stroke care team 5. Stroke care team : a unit of hospital-based specialists called together to provide monitoring and care of stroke patients 6. Neurosurgical services : a specialty that focuses on the surgery that treats diseases of the brain, spinal cord and nervous system 7. Support of medical organization : the commitment of administration and professional and nonprofessional staff to provide high-quality care to stroke patients 8. Neuroimaging : imaging of the brain, spinal cord and nervous system, with the capability of performing an imaging study within 25 minutes of the doctor's order, and evaluating the image by a doctor within 20 minutes of its completion 9. Laboratory services : around-the-clock standard laboratory services, including chest x-rays and measurements of heart activity, with results delivered rapidly and accurately 10. Quality improvement: includes written or electronic recordkeeping for tracking the number and types of stroke patients seen, their treatments, and some measurement of patient outcomes 11. Educational programs : continuing medical training for the professional staff of a primary stroke center, and at least two programs a year to educate the public about stroke prevention and the availability of emergency treatment

14. STROKE FLOW Acute Care Pathway MODIFICATIONS 5 COMPONENTS: TIA PATHWAY STROKE – THROMBOLYSIS- ER TO ICU PATHWAY STROKE UNIT CARE NEUROINTERVENTION IN STROKE PATHWAY STROKE SURGERY PATHWAY

15. 8 Ds of stroke care D etection D ispatch D elivery D oor D ata D ecision D rug/Device D isposition

16. Important Time Goals Notify the emergency response immediately FAST assessment/**Cincinnati Pre-Hospital Stroke Scale (ACLS Suspected Stroke Algorithm) Establish last known well (LKW) Immediate general assessment and stabilization within 10 minutes Neurologic assessment within 25 minutes Interpret CT Scan or MRI within 45 minutes Determine treatment pathway within 60 minutes - Hemorrhagic or Ischemic Stroke?

17. Target Response Times: EMS recognition of stroke in the field → hospital pre-notification that a stroke patient is en route MD Evaluation : <10 minutes Stroke Team : < 15 minutes CT Initiation Time : <15 minutes Lab result : <45 minutes ; only the assessment of blood glucose level must precede the administration of IV alteplase or IV tenecteplase unless there is a suspicion of abnormal hematologic or coagulation test. IV thrombolytic administration : <45 minutes Mechanical Thrombectomy: First Pass : < 60 minutes for Transfers and Mobile Stroke Unit; < 90 minutes for patients presenting directly to the Hospital ACUTE STROKE MANAGEMENT

18. Within 10 Minutes Immediate General Assessment ABCs Oxygen Vital signs Intravenous access and blood samples Blood glucose Neurologic assessment Activate the stroke team Order CT Scan/MRI per policy Obtain 12 Lead ECG Other Head of bed at 30 o Head midline Suction NPO

19. Within 25 Minutes Neurologic assessment National Institutes of Health (NIH) Stroke Scale or Canadian Stroke Scale depending on policy By a stroke team member Help determine the appropriate treatment Also used to monitor worsening or improvement and as predictors of outcome

20. Within 45 Minutes Stroke is confirmed but hemorrhage confirmed The patient is not a candidate for fibrinolytics Administer aspirin orally if the patient is able to swallow

21. Within 60 minutes Ischemic Stroke pathway Consider transfer to another facility for appropriate care if not a stroke center Consult a neurologist Admit the patient to the stroke unit or intensive care Prepare for thrombolytics

22. Post rtPA Therapy Begin post- rtPA stroke pathway Within 3 hours Monitor the patient aggressively per protocol Blood pressure Blood glucose Neurological deterioration Emergent admission to a monitored bed

23. Points to Consider Other options Anticipate transfer Current medications The patient’s weight in kilograms Communication ISBAR Who to notify What number to dial Keep the patient and family informed Pertinent documentation

24. Required documentation for education Personal modifiable risk factors for stroke Stroke Warning Signs and Symptoms How to Activate EMS for Stroke Need for Follow up after Discharge Medication information Provide and review Red Stroke Education Folder and Document in Discharge Assessment. The DC assessment can be opened upon admission, Education should be provided day 1. Stroke Education

25. Assessment must be completed by any one member of the Rehab team including: Physiatrist Physical Therapist Occupational Therapist Speech Therapist Assessed for Rehab

26. Summary Reviewed a focused assessment for the patient presenting with signs and symptoms of a stroke per facility protocol Discussed facility-specific protocol to manage the care of the patient presenting with signs and symptoms of a stroke Discussed effective communication when managing the care of the patient experiencing a stroke

27. Thank You