What do the new nursing guidelines mean for nurses. Caroline Smith Consultant Nurse for Acute Stroke Yeovil District Hospital

Transcription

1 What do the new nursing guidelines mean for nurses Caroline Smith Consultant Nurse for Acute Stroke Yeovil District Hospital

2 SSNAP publications 2016 specific guides produced for: Psychology Nutrition & dietetics Speech & Language Orthoptics OT PT Pre-hospital Nursing Commissioners

3 Key areas for nursing Education / R&D Staffing Assessments Feeding / hydration / oral care Positioning VTE Continence Falls Mood Pain Sex EoL Carers Rehab approach

4 Key areas for nursing Education / R&D Staffing Assessments Feeding / hydration / oral care Positioning VTE Continence Falls Mood Pain Sex EoL Carers Rehab approach

5 Clinical monitoring Level of consciousness Blood glucose Blood pressure Oxygen saturation Hydration and nutrition Temperature Cardiac rhythm and rate

6 Neuro -obs 50 % early neurological deterioration with no clear mechanism 30% of all strokes deteriorate <24 hrs with ICH and LVO being earlier AHA (2009) NICE/ RCP rtpa every 15 mins, non rt-pa hourly no recommendations GCS 56% incorrectly state no neuro deficit (n=172) Nye et al 2012

7 Preventing complications key is spotting in a timely manner Monitor conscious level Peter Langhorne (2017) END modifiable dehydration, BMs, temp, <BP, <P Mgmt: monitor & manage physiology in acute phase Early treatment results in improved outcomes

8 Early warning of complications Langhorne Complication Neuro scale Function (ADL) Temperature Heart rate Oxygen saturation (resp rate) BP Blood Glucose Raised ICP *** *** Neurological deterioration/recur *** *** ** Chest infection ** ** *** ** *** * Urinary tract infection ** ** *** ** * Cardiac arrhythmia * * *** ** ** Cardiac failure * * ** *** * Myocardial infarction * * ** ** * * Pulmonary embolism ** ** ** *** Deep vein thrombosis * ** * ***definite value **some value *occasional value

9 Interventional Neuroradiology

10 Mgmt of oedema Death due to herniation 80% mortality when space occupying oedema 2-10% 70-80% have normal ICP No effect: Steroids/ < temp / barbiturates / > vent Rx decompression with craniectomy > 12cm Poor prognostic predictors - DWI vol > 145cm3 - > BM - < GCS

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12 Blood Sugars 45% raised in 1 st 48 hrs If > 8 then poor prognostic indicator Raised in non diabetic 3 x more likely to die If BM > 8 then HbA1c tended to be +ve Middleton 2015

13 BP mgmt Raised post stroke for 7-10 days Very high or low poor prognostic indicator

14 Labetalol protocol

15 Oxygen saturations NIHSS > 15 results in 26% risk of pneumonia Age & dysphagia also raised risk 25% pneumonias are apyrexial CRP raised in both IS & ICH SLT Ax delays in 1 st 24 hrs - > pneum risk MAPS- 2 trial metaclopramide & oral decontamination reduce risk Craig Smith 2017 Only give O2 supplements of sats > 95%

16 Hydration & Nutrition Up to ¼ of stroke patients will become malnourished in the first few weeks of hospitalisation and risk increases with LOS and lasts for many months likely if swallow probs, cannot self feed, cognitive issues, anxiety or depression, fatigue & unfamiliar foods NG feeding bridles are helpful (Beavan 2010), less evidence on mittens in reducing displacement of the tube

17 Mouth Care Increased risk of infection Pain and discomfort Effects swallow Gentle mouth care Adequate hydration Gentle tooth brushing

18 BMI / MUST score

19 Fever ¼ - 1/3 rd have temp > 37.5 in 1 st few days +ve association with poor outcome M & M 1 st 24 hrs 2 x odds of short term mortality Raised temp 9 x more likely to have early neurological deterioration Artificial cooling no effect

20 Cardiac monitoring MI / CCF / BRADY / AF (Aflutter) Reperfusion arrthymias don t occur with rt-pa AF Often diagnosed post stroke Monitor HR. NOAC don t control rate/ rhythm

21 Often focal initially, hemiparetic side Seizures more common if large cortical stroke (TACS/ PACS) or ICH Look for odd behaviour / mvmt Careful observation Absence seizures no-one at home, tiredness following

22 DVT / PE In Europe each year >540,000 die from VTE. (86,000 from breast cancer) PE accounts for 10% of all deaths in hospital (2004) Key aim = prevention Patients with immobility after acute stroke should be offered intermittent pneumatic compression within 3 days of admission to hospital for the prevention of deep vein thrombosis. Treatment should be continuous for 30 days or until the patient is mobile or discharged, whichever is sooner.

23 Stroke specific data Of those patients who cannot walk. 20% will have a DVT on ultrasound 10% will have a PE on MRI / CTPA 5% clinical DVT (40% calf / 60% pop +/- femoral) 5% clinical PE Greatest risk in the 1 st week -? Due to dehydration Predictors previous clot / > stroke severity / less evidence but also dehydration/ infection/ active cancer M Dennis ESOC 2017

24 IPC Reduce DVT & moderate evidence that reduce risk of death by approx 1/6 th 5 per 100 patients saved DVTs LMWH consider BUT increased ICH risk and no effect on mortality Anticoagulation & IPC together Martin Dennis 2017

25 Incontinence post stroke Initial 32-79%. On discharge 25-28% 10 years post stroke 12-19% Faecal 5% (1.5% normal pop) More likely with immobility, diabetes, dehydration. Mgmt: prevent catheterisation, mobilise patient and manage temperature, have protocol & plan If continues > 2/52

26 Enuresis alarms the way forward??

27 Constipation Advice on diet, fluid intake and exercise A regulated routine of toileting A drug review to use of constipating drugs Oral laxatives A structured bowel management programme which includes nurse-led bowel care interventions Education and information for the person with stroke and their family/carers Rectal laxatives if severe problems persist.

28 Mood Motivational interviewing or problem solving therapy (adapted for those with altered cognition or aphasia) Given information on increased social interactions, increased exercise, other interventions eg psychosocial education group Risk prediction: PMH; physical disability; stroke severity; cognitive impairment

29 Assess mood Recognise grief/loss Talk / use ex-patients Engage with family Interests Timely realistic goals Refer Psychological Support

30 Sex People with stroke should be asked, soon after discharge and at their 6-month and annual reviews, whether they have any concerns about sex. Partners should also have an opportunity to raise any problems. People with sexual dysfunction after stroke who help should be: assessed for treatable causes including a medicine review; reassured that sexual activity is not contraindicated and is extremely unlikely to precipitate a further stroke; assessed for erectile dysfunction and the use of a phosphodiesterase type 5 inhibitor (e.g. sildenafil); advised against the use of a phosphodiesterase type 5 inhibitor for 3/12 after stroke and/or until BP controlled; referred to a professional with expertise in psychosexual problems if sexual dysfunction persists.

31 Sex Montorsi et al 2006: 93% of pts with ED and CAD the ED came before the CAD symptoms in an average timescale of 2 years MMSA 2005 n= year study with no previous history of Stroke ED 3 x more likely to have a stroke than those without

32 Monga et al 1986 n= 113 Diminished / reduced libido 79% men 66% women Disorders of erection 62% Ejaculation 78% Vaginal lubrication 61% Female orgasm ability 77% No sexual activity post stroke 64% m 54% f

33 Answers wanted: Safety of having sex on early home visits Alternate physical positions Side effects of medication for sexual dysfunction Effects of stroke on sexual function Aging and sexuality Coping with depression in context of sexuality

34 End of life Recognise the patient is approaching end of their life Decisions to withhold or withdraw life-prolonging treatments after stroke including artificial nutrition and hydration should be taken in the best interests of the person and whenever possible should take their prior expressed wishes into account. End-of-life (palliative) care for people with stroke should include an explicit decision not to impose burdensome restrictions that may exacerbate suffering. In particular, this may involve a decision, taken together with the person with stroke, those close to them and/or a palliative care specialist, to allow oral food and/or fluids despite a risk of aspiration. TEP form

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36 Other considerations In-pt stroke 5% - rtpa reversal of dabigatran consider for thrombectomy Malignant MCA consider for decompression 48hrs no age cut off

37 Summary Role of the nurse in stroke recovery is becoming clearer- Early detection & treatment saves lives Things to make a difference to outcome: Paracetamol at 1 st fever Finger prick BM within 72hr If Bm > 11mmol/l start insulin Early swallow Ax (Middleton 2015) Always consider malignant MCA / thrombectomy in deteriorating patient Quality of life is essential smile, empathise and reassure

38 Boundaries moving all the time essential to keep up Role of the nurse is to observe, monitor and pick up problems early If in doubt Holler!!!