Required Annual Nursing Education Primary Stroke Center For ICU, Step-Down and Floor

Transcription

1 Required Annual Nursing Education Primary Stroke Center For ICU, Step-Down and Floor Lori Massaro, RN, MSN, CRNP Bethanne McCabe, RN, MSN, CNRN Sue Underwood, RN, MSN, CNRN

2 Requirement RN s caring for stroke patients will demonstrate evidence of initial and ongoing training in the care of the Acute Stroke Patient New Hire Orientation Annually via a minimum of 8 hours continuing education with focus on Stroke/Stroke Care This educational requirement includes information on: Care of the Acute Ischemic Stroke patient Care of the Intracerebral Hemorrhage patient Care of the Subarachnoid Hemorrhage patient Nursing care priorities on Stroke by type Primary Stroke Center Performance Measures Post-test completion 2

3 Stroke Overview Stroke is the leading cause of Disability in the US Stroke is the 4 th leading cause of Death in the US The approach to acute stroke and urgent treatment has evolved over the past 15 years Primary stroke Centers are recognized by the State of PA & DOH EMS are instructed to bring patients to the closest stroke center A partnership with the UPMC Stroke Institute is in place for transfer of patients who require neurointerventional or neurosurgical vascular services beyond what is available at the Primary Stroke Center to UPMC PUH or UPMC Mercy 3

4 Acute Ischemic Stroke Risk factors Hypertension Hyperlipidemia Cardiac conditions Atrial fibrillation Cardiomyopathy with low EF (< 25%) Diabetes Smoking Large artery atherosclerosis Anterior circulation Carotid artery intracranial or extracranial Middle cerebral artery Posterior circulation Vertebral basilar arterial system 4

5 Acute Ischemic Stroke Symptoms usually occur suddenly May be accompanied by a headache Depending on area of brain affected/experiencing ischemia Anterior versus posterior Left versus right Cerebral dominance

6 Anterior circulation: ACA and MCA Posterior circulation: PCA and Cerebellar arteries 6

7 Symptoms by Location Anterior Circulation Unilateral hemiparesis (may range from mild weakness to complete paralysis) Unilateral sensory disturbance (numbness, tingling, loss of sensation) Speech abnormality (aphasia, dysarthria) Visual loss (quadrant loss, homonymous hemianopsia) Incoordination or arm, hand or leg Neglect syndromes, sensory or visual are most common in right hemisphere strokes 7

8 Symptoms by Location Posterior Circulation Balance or Gait changes (dizziness, spinning sensation, vertigo, lightheadedness) Ataxia Diplopia Dysarthria Hemiparesis Hemi sensory symptoms Alternating weakness or sensory symptoms Nausea and Vomiting 8

9 Cerebral Dominance Left Hemisphere is dominant in 90% of adults for motor function, 96% of adults for language functions Speech/language function Right body control for sensory/motor function Right visual field Left middle cerebral artery strokes result in right hemiplegia, aphasia and right visual field cut Right hemisphere is dominant in only 6-10% of adults Right hemisphere is considered non dominant hemisphere

10 Left Middle Cerebral Artery Functions Aphasia can range from expressive to receptive or global aphasia Intellectual impairment (difficulty reading, writing, or calculating) Right sided hemiparesis or hemiplegia Right sided sensory loss Right visual field defect

11 Right Middle Cerebral Artery Functions Motor and sensory control of left side of body Left visual field Visual and/or sensory neglect syndromes Much higher fall risk with right middle cerebral artery (MCA) stroke patient because they are unaware of deficits

12 Neurologic Assessment NIHSS is the standard quantitative assessment use for stroke patients Assessment should also include Cranial nerves Orientation Motor strength evaluation Sensory evaluation GCS Gait if able to assess 12

13 Imaging in Acute Ischemic Stroke: What are the Options? CT Scan CT angiography CT perfusion MRI Scan Diffusion Weight Imaging (DWI) for acute changes MR angiography MR perfusion

14 Imaging Priorities and Time Parameters < 3 hours hours Goal to exclude hemorrhage and assess for ischemic changes CT non contrast Performed in the ED initially to rule out evidence of hemorrhage or early ischemic changes Frank hypodensity in 1/3 or more of MCA territory is a strong contraindication for IV t-pa MRI obtained for same reason if doesn t cause a delay in treatment CTA/MRA may be obtained to determine large artery patency if it doesn t cause delay in treatment CT perfusion/mr perfusion may be obtained to determine if there is a mismatch between area infarcted versus what is at risk if doesn t cause a delay in treatment

15 Imaging Priorities and Time Parameters >4.5 hours is used when assessing for large artery occlusion/stenosis and need for intervention - CT with vessel study (CTA) - MRI with vessel study (MRA/P) Assessing for tissue viability - Perfusion diffusion mismatch

16 Left Posterior Parietal Lobe Hypodensity 16

17 Hyperdense Left Middle Cerebral Artery Sign 17

18 CT at 3 Hours - Hypodensity

19 Left Posterior Cerebral Artery (PCA) Occlusion

20 CT Perfusion Performed over 2 cuts of brain tissue 3 pieces of information can be obtain to develop quantitative maps of: Cerebral blood flow (CBF) Cerebral blood volume (CBV) Mean transit time (MTT) Measure of circulatory dysfunction

21 infarct core vessel occlusion Mismatch tissue at risk hypoperfused tissue

22 MRI Imaging in the Acute Phase Available 24/7 at PUH, SHY and Mercy for acute stroke evaluation Patient stability and cooperation are sometimes a factor More sensitive to detecting early ischemic changes Diffusion weighted imaging (DFI) sequence Also able to obtain vessel information MR angiography (MRA) and MR perfusion (MRP) information Contrast enhanced with gadolinium Newer and more accurate to determine if arterial and venous vessel patency

23 Gadolinium Enhanced MRA - Left MCA Branch Occlusion

24 MR Perfusion or Perfusion Weighted Imaging Used to evaluate infarcted tissue versus tissue at risk if perfusion is not restored Perfusion diffusion mismatch

25 infarct core vessel occlusion Mismatch tissue at risk hypoperfused tissue

26 Calculate Diffusion Perfusion Mismatch the higher the number - more likely to intervene with Intra-Arterial (IA) therapy Pink = area infarcted Green = area at risk

27 No mismatch: large core infarcted area compared to area at risk = Poor IA candidate

28 Large mismatch: small core infarction with large area at risk = Excellent IA candidate

29 Nursing Care Priorities across the Continuum Know how to perform a complete neurological examination Know the patients baseline Recognize and report changes ASAP Read the chart and understand the diagnosis, etiology of stroke/tia Understand potential complications for the neuroscience patient and intervene to prevent them

30 Nursing Care Priorities across the Continuum Perform NIHSS and neurologic assessment according to orderset/unit protocol to determine baseline exam Assess for neurologic changes and communicate to medical team Implement secondary stroke prevention measures Antithrombotic, anticoagulant and statin Implement measures to prevent complications related to stroke Dysphagia screening and speech evaluation DVT prophylaxis and early mobilization Rehabilitation evaluation Education for patients and families 30

31 Stroke Mimics Seizure Todds paralysis or post ictal focal neurologic symptoms Hypoglycemia Low circulating glucose = lack of glucose getting to brain cells causing cellular dysfunction Metabolic disturbance Elevated ammonia in liver disease, elevated Cr in renal failure Narcotics/sedatives

32 ED RN Care Priorities Establish last known normal time Prioritize diagnostics CT imaging and lab testing Perform and monitor NIHSS/neurologic exam Obtain IV access, obtain 2 peripheral IV s Continuous cardiac monitoring, identify rhythm BP and SaO2 monitoring Administer weight based thrombolytic therapy if indicated Monitor the post tpa patient every 15 min with vital signs and NIHSS Observe for bleeding complications, neurologic changes Report and hand-off to ICU nursing team 32

33 ED Priorities Minimize door to CT time Target is 25 minutes or less Minimize time to results Target order to CT results and Lab results < 45 minutes Minimize door to treatment times (IV tpa) Target is 60 minutes or less Earlier treatment with thrombolytics goal is to restore blood flow and improve patient outcomes

34 Review Inclusion/Exclusion Criteria for Thrombolysis Inclusion Criteria Check blood sugar and treat if abnormal Present w/in 3 hours symptom onset (witnessed onset) CT of head to rule out hemorrhage Review patient history for contraindications Treatment of patients with rapidly improving symptoms NOT RECOMMENDED Normal coagulation profile Exclusion Criteria Evidence of hemorrhage Recent trauma, stroke or MI Brain or spine surgery with in last 3 months BP>185/110 Ok to start IV infusion to lower BP prior to IV t-pa and continue during and after infusion for optimal BP control Seizure at onset of stroke Intracranial neoplasm INR < 1.7 if on warfarin, use of dabigatran (pradaxa) within 48 hours 34

35 Additional Inclusion/Exclusion Criteria for tpa Administration hours History of prior stroke and diabetes Age greater than 85 History of previous stroke NIHSS greater than 25 Age > 80 Any anticoagulant use prior to admission (even if INR <1.7) CT findings involving more than 1/3 of the MCA territory 35

36 IV Thrombolytics Tissue Plasminogen Activase (tpa) IV tpa is dosed based on weight 0.9 mg kg total dose Not to exceed 90 mg 10% given as bolus over 1 minute Remainder given by infusion pump over 1hour Excess should always be removed from bottle cc NSS bag to flush line after infusion complete

37 Nursing Care During Thrombolytics No vena punctures or invasive procedures Insert Foley catheter prior to IV tpa or wait 1 hour after completion NIHSS/neuro checks and vital signs every 15 minutes for 2 hours, then every 30 minutes X 6 hours then every 1hour for remaining of 24 hour time period Watch for potential adverse reactions such as: Bleeding Angioedema, Neurologic decline New onset headache

38 ICU Nursing Care Types of Patient who need ICU care Patients who may need more aggressive monitoring or who are unstable hemodynamically Post IV tpa After Intra-arterial intervention Mechanical clot removal Manual aspiration Intra-arterial tpa 38

39 ICU Care Priorities Perform NIHSS and complete neurologic exam Follow Post tpa orders when appropriate Recognize and communicate Changes in neurologic status Hemodynamic parameters to maintain cerebral blood flow Neurologic or hemodynamic changes associated with increased intracranial pressure Prevention of complications DVT Pneumonia Recurrent stroke Skin breakdown Initiate patient and family education for stroke 39

40 BP Management in the Acute Phase - Ischemic If treated with thrombolytics you must aggressively control BP for first 24 hours to reduce risk of hemorrhagic conversion Agents to consider Beta Blockers such as IV Labetalol Calcium Channel Blockers such as IV Nicardipine Avoid Nipride if possible

41 BP Management in the Acute Phase - Ischemic If no thrombolytics, in general, may let BP run a little higher until vessel patency established In the setting of large artery occlusion or stenosis, higher blood pressure may be needed to perfuse brain May allow SBP to rise to 220 mmhg temporarily

42 Stroke Unit Priorities Perform NIHSS and complete neurologic exam Recognize and communicate changes in neurologic status Prevention of complications from stroke/immobility DVT Pneumonia Recurrent stroke Skin breakdown Assessment and facilitate transition post hospital Rehabilitation or home Family or caregiver support/capacity Safety Education for patients and family/caregiver 42

43 Patient and Family Education Education should be ongoing from entry to discharge Organized system of providing information to patients/family SKAT documentation form located in ERecord Document that education is personalized Education must include Signs and symptoms of stroke The need to activate 911 Education on risk factors and strategies for modification Education on medications Need for follow up appointment

44 Dysphagia Screening Bedside dysphagia screen (BSD) must be performed on all ischemic, hemorrhagic and TIA stroke patients and documented prior to giving oral meds/fluids Presence or absence of gag is not enough If patient fails BSD, repeat test in 12 hours and keep NPO Include speech therapy consultation in admission order Bedside evaluation is not intended to replace speech therapy evaluation Ensure results of BSD are communicated during hand off Form located in adhoc Bedside Dysphagia Screen All stroke nurses are required to complete dysphagia ULearn

45 Hyperglycemia and Stroke Hyperglycemia at the time of stroke and post stroke worsens prognosis for recovery Treat hyperglycemia aggressively Insulin infusion protocols widely used to maintain therapeutic glucose range

46 Fevers and Stroke Efforts to diagnose fever and treat aggressively are important in stroke prognosis and outcome Fever increases the brain s oxygen demands 6-10% for every degree above normal Treat fevers aggressively with external cooling measures, Acetaminophen, and Ibuprofen Do not rely on axillary temperatures, rectal or core temperatures preferred

47 Neurologic Decline after Stroke May be due to increased intracranial pressure Edema due to stroke Extension of stroke Hemorrhagic transformation Other potential causes Seizures Fever/Infection

48 Diagnostic Work-up for Source of Stroke To examine arterial patency and/or rule out large artery stenosis/occlusion Non-invasive carotid duplex CT angiography (CTA) MR angiogram (MRA) Cerebral angiogram

49 Diagnostic Work-up for Source of Stroke To rule out cardioembolic source TTE transthoracic echocardiogram with bubble study TEE transesophageal echo with bubble study 24 hour holter monitor Fasting lipid profile Hgb A1C Hypercoagulable profile is limited to patients without detected etiology and higher degree of suspicion

50 Intracerebral Hemorrhage Responsible for 20% of all stroke types Symptoms often mimic those of an ischemic stroke presentation May also present with headache and elevated BP Urgent neuroimaging is needed to determine if hemorrhage is present 50

51 Intracerebral Hemorrhagic Patient with intracerebral hemorrhage may present similar to ischemic stroke Lateralized weakness, sensory symptoms, aphasia, visual field cuts Headache is often present also Vomiting Elevated Systolic Blood Pressure Coma and/or decreases LOC Progressive decline in LOC

52 Right parietal Intracerebral Hemorrhage

53 Right Occipital Intracerebral Hemorrhage 53

54 Intracerebral Hemorrhage Care Medical Priorities are to prevent hematoma expansion Reverse anticoagulants Vitamin K, FFP, Factor VIIa Blood pressure management If SBP > 200 mm HG or MAP > 150 mm Hg consider infusion If SBP > 180 mm Hg or MAP > 130 mm HG with suspected increase in ICP consider intermittent or continuous agents Maintain cerebral perfusion pressure> 60 mm Hg if monitoring ICP If concern for high ICP, consider ICP monitoring and target BP 160/90 and MAP 110 while maintaining CPP 60

55 Intracerebral Hemorrhage Care BP management continued If SPB > 180 or MAP > 130 and no evidence if elevated ICP Modest BP reduction using intermittent or Infusions Clinically re-examine patient every 15 minutes Toxicology screen in young or middle age patients Cocaine Sympathomimetic drugs 55

56 ICH Care Frequent neurologic exams and hemodynamic monitoring ICP monitoring CPP monitoring Fever prevention maintain normothermia Maintain therapeutic glucose levels Seizures treat if clinically present Prevention of complications Aspiration DVT 56

57 ICH Surgical Clot Evacuation Cerebellar hemorrhage Larger than 3 cm in diameter Neurologic deterioration Brainstem compression with or without hydrocephalus Hemispheric hemorrhage Lobar clots > 30cc that are more superficial Minimally invasive clot removal techniques Endoscopic aspiration 57

58 Cause and Location of ICH Hypertensive vasculopathy Basal ganglia, thalamus, brainstem Cerebral amyloid angiopathy Seen in older patient with history of dementia Lobar location of ICH Anticoagulation associated Lobar and/or intraventricular 58

59 Hypertensive ICH 52 yo male with HTN, Smokes 2 PPD. Not seen For 2 days. Found down by sister SBP 230 mmhg DBP 110 mmhg 59

60 Cerebral Amyloid Angiopathy Hemorrhage 60

61 Aneurysmal Subarachnoid Hemorrhage Incidence of aneurysmal SAH ranges depending on ethnicity 9.7 per 100,000 adults in the US Increased incidence in women Risk factors Hypertension Smoking Alcohol abuse Use of sympathomimetic drugs (cocaine) History of familial aneurysms Autosomal dominant polycystic kidney disease Type IV Ehlers-Danlos Syndrome 61

62 Subarachnoid Hemorrhage Patient presentation is classic Sudden severe headache worst headache of life or thunderclap headache May have loss of consciousness, brief or sustained Nuchal rigidity or stiff neck Focal neurologic deficits or cranial nerve palsies Photophobic, photophonic Nausea/vomiting 12% of patients die before receiving medical attention

63 SAH Diagnostic Evaluation Non contrast CT scan of Brain If non diagnostic consider LP Lumbar puncture Analysis of spinal fluid to identify Xanthochromia (red blood cell breakdown) MRI more sensitive than previously Use fluid attenuated inversion recovery, proton density, DWI, and gradient echo sequences CTA to detect aneurysm Cerebral angiography is the gold standard for aneurysm detection 63

64 Aneurysmal Subarachnoid Hemorrhage 64

65 Subarachnoid Hemorrhage 65

66 Nursing Care of the SAH Patient If hydrocephalus present may require EVD insertion Blood pressure monitoring and management To prevent re-bleeding Prevent vasospasm Balance risk of stroke Maintain cerebral perfusion Frequent neurologic assessment and monitoring Anticonvulsants to prevent seizures in the early post bleed period Transport to center where ICU care and treatment is available 66

67 Complications of SAH Cerebral Vasospasm Occurs 4-14 days post SAH in 40-70% patients Prevention: Triple H Hypertention /Hypervoemia /Hemodilution Nimodopine : Calcium Channel Blocker to relax vessels Neurointervention to open vessels if spasm present Fluid and Electrolyte disturbances Hydrocephalus Caused by blood in the subarachnoid blocking re-absorption of CSF EVD to drain CSF tpa may be injected into EVD by MD to clear blood Increased Intracranial Pressure Monitor with EVD in place 67

68 Medical Management of Aneurysmal SAH GOAL is complete obliteration of aneurysm Endovascular coiling is accomplished in the interventional suite Surgical clipping in the OR with open craniotomy 68

69 6 mm R PCA aneurysm 69

70 R PCA aneurysm post coil with EV3 platinum coils 70

71 Open Surgical Aneurysm Clipping 71

72 Patient and Family Education Organized system of providing information to patients/family SKAT documentation form ERecord Document that education is personalized Education must include Signs and symptoms of stroke The need to activate 911 Education on risk factors and strategies for modification Education on medications Need for follow up appointment

73 Post Hospital Care Assessment of family/caregiver capacity Care giver and stroke survivor support group information Options for respite care Post hospital care services Home health SNIF Rehabilitation PT/OT/Speech language therapy 73

74 Patient and Family support Important to us as nurses and health care providers to look at the family needs and develop a plan to meet the needs of the patient/family unit Families respond to the stress of illness and unexpected nature of stroke differently

75 Performance Measures for Primary Stroke Centers Venous Thromboembolism Prophylaxis for ischemic or hemorrhagic stroke, DVT prophylaxis initiated and documented by day 2 Discharged on Antithrombotic Therapy for ischemic stroke or TIA Anticoagulation Therapy for Atrial fibrillation/flutter on ischemic stroke or TIA Thrombolytic Therapy for ischemic stroke for patients who present within 2 hours of symptom onset tpa is provided. If not eligible/excluded document reason why 75

76 Performance Measures for Primary Stroke Centers Antithrombotic Therapy is initiated by the end of hospital day 2 for ischemic stroke Discharged on a Statin Medication for ischemic stroke and TIA patients if LDL > 99 Stroke Education provided for all patients and must include 5 components Assessed for Rehabilitation prior to discharge for ischemic and hemorrhage patients Dysphagia screening prior to PO medications on all patients with persistent neurologic symptoms 76

77 Additional Measures to Review and Report Door to CT times Door to tpa times Outcomes after tpa Symptomatic intracranial hemorrhages 90 day modified Rankin scores (disability scores) 77

78 References Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient: A Scientific Statement from the AHA - Stroke 2009;40; Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the AHA/ASA Stroke 2010;41; Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from AHA/ASA Stroke 2012;43;