Practice Guideline: Inpatient Care for Patients Following an Acute Stroke. December 2013

Transcription

1 December f 12 PURPOSE AND INTENT T enhance the quality f care prvided t persns with strke and their families within the WRHA, the fllwing guidelines have been adpted frm the Canadian Strke Strategy/ Canadian Best Practice Recmmendatins fr Strke Care (2012) and incrprated t prvide evidence infrmed clinical practice and directin fr the interprfessinal team(s) with perfrming assessments and managing the care f the persn with strke admitted t the acute care setting. 1. OUTCOME 1.1. The clinical practice guideline prmtes assessment and care management based n best available evidence and is intended t reduce practice variatins and clse the gaps between evidence and practice The use f these clinical practice guidelines will imprve patient care utcmes and prmte the efficient use f resurces in the WRHA. 2. BACKGROUND In Canada, strke and ther cerebrvascular diseases are the 3rd leading cause f death and the leading cause f adult disability resulting in admissin t lng term care facilities (Canadian Best Strke Practice Recmmendatins, 2010). The fcus f care fr persns with strke changes thrughut the inpatient stay. Screening and/r assessments in the first 48 hurs are cnducted t assess and prevent strke prgressin, recurrent strke and the develpment f cmmn pst-strke issues, while at the same time ensuring early mbilizatin and rehabilitatin. Initial assessments are cmpleted and management plans develped by the interprfessinal team including transitin (discharge) planning. Transitin planning needs t begin early. A smth transitin frm inpatient t cmmunity and utpatient care is a critical element t ensure strke survivrs and their families are well supprted nce they leave hspital. Transitin plans shall be cmprehensive and invlve the patient and family, any infrmal caregivers, primary health care prviders and ther cmmunity prviders in their develpment. The patient and family shuld be prvided with any educatin, training, emtinal supprt and cmmunity services specific t the transitin they are underging. 3. S The fllwing guidelines incrprate best practice recmmendatin statements frm the Canadian Strke Strategy/ Canadian Best Practice Recmmendatins fr Strke Care (2012). Each recmmendatin in the Canadian Best Practice Recmmendatins fr Strke Care (2012) was evaluated against several criteria: the strength f the available research evidence t supprt the recmmendatin, the degree t which the recmmendatin drives system change r prcesses f care delivery, and the verall validity and relevance as a cre recmmendatin fr strke care acrss the cntinuum. The definitins f levels f evidence used in these guidelines are described belw: Level f Evidence A- Strng recmmendatin. Data derived frm multiple randmized cntrl trials r meta-analyses f randmized cntrlled trials. Desirable effects clearly utweigh undesirable effects, r vice versa.

2 2 f 12 Level f Evidence B- Data derived frm a single randmized cntrlled trial r well-designed bservatinal study with strng evidence: r well designed chrt r case-cntrl analytic study; r multiple time series r dramatic results f uncntrlled experiment. Desirable effects clsely balanced with undesirable effects. Level f Evidence C- At least ne well- designed, nnexperimental descriptive study (e.g. cmparative studies, crrelatin studies, case studies) r expert cmmittee reprts, pinins and/ r experience f respected authrities, including cnsensus frm develpment and/ r reviewer grups. 4. COMPONENTS OF ACUTE INPATIENT CARE. Assessment and Management Venus thrmbemblism risk, temperature, mbilizatin, cgnitin, pain, depressin, cntinence, swallwing, nutritin, and ral care shuld be addressed in all hspitalized persns with strke. Hspitalized persns with strke are als at high risk fr falls and the develpment f pressure ulcers. Apprpriate management strategies shuld be implemented fr areas f cncern identified during screening and assessments. Transitin planning shuld be included as part f the initial assessment and nging care f patients with acute strke. Educatin abut strke including available supprts, and an assessment f patient/ families readiness t learn shuld als be part f the nging care received. 4.1 Patients admitted t an inpatient unit with acute strke shuld have an initial assessment by rehabilitatin prfessinals (Physitherapy, Occupatinal Therapy, Speech Language Pathlgy) as sn as pssible after admissin (Evidence Level A), preferably within the first 24 t 48 hurs (Evidence Level C). The initial assessment shuld include assessment f patient functin; safety and risk; physical readiness and ability t learn and participate; and transitin planning. Unit teams shuld cnduct at least ne frmal interprfessinal meeting per week t discuss prgress and prblems, rehabilitatin gals and discharge arrangements (Evidence Level B). Clinicians shuld use standardized, valid assessment tls t evaluate the patient s strkerelated impairments and functinal status (Evidence Level B). Patients shuld receive the intensity and duratin f clinically relevant therapy defined in their individualized rehabilitatin plan and apprpriate t their needs and tlerance levels (Evidence Level A). Sectin 5 fr details n the prvisin f strke rehabilitatin thrughut the cntinuum f care The team shuld prmte the practice f skills gained in therapy int the patient s daily rutine in a cnsistent manner (Evidence Level A). Refer t the Canadian Best Practice Recmmendatins fr Strke Care (2012) Sectin 5 fr details n the prvisin f strke rehabilitatin thrughut the cntinuum f care

3 3 f Neurlgical Assessment A neurlgical assessment shuld be cnducted n admissin, and when there is a change in patient status, using a validated tl that measures strke impairments (such as the Canadian Neurlgical Scale, Natinal Institute f Health Strke Scale, etc).the patient s neurlgical status shuld be mnitred and assessed n an nging basis and shuld include at minimum: Level f cnsciusness; Orientatin; Pupillary respnse; Mtr respnse (strength, mvement, prnatr drift, balance and crdinatin); Speech and cmprehensin; Vital signs (T,HR, RR, BP, Sp02); Glucse; Pain assessment. Please refer t WRHA Pain Assessment and Management Clinical Practice Guideline Temperature, Bld Pressure and Bld Glucse Management Temperature- Shuld be mnitred as part f rutine vital sign assessments (every 4 hurs fr first 48 hurs and then as per unit rutine r based n clinical judgment) (Evidence Level C). Fr temperatures mre than 37.5 C, increase mnitring frequency, initiate temperature reducing measures, investigate pssible infectin such as pneumnia r urinary tract infectin (Evidence Level C), initiate antipyretic and an antimicrbial therapy as required (Evidence Level B). Bld Pressure- Shuld be mnitred as part f rutine vital signs assessment. Hypertensin is a cmmn ccurrence with strke and is ften transient. Pharmaclgical agents and rutes f administratin shuld be chsen t avid precipitus falls in bld pressure. The fllwing recmmendatin reflect current evidence: The treatment f hypertensin in the acute ischemic strke patient nt eligible fr thrmblytic therapy shuld nt be rutinely undertaken Extreme bld pressure elevatin (Systlic Bld Pressure (SBP) > 220 and Diastlic Bld Pressure (DBP) > 120) shuld be treated and nly reduce by %; Ischemic strke patients that are eligible r have received thrmblytic therapy shuld aim t have a bld pressure f SBP < 185 and DBP < 110 in rder t reduce the risk fr secndary intracranial hemrrhage In the setting f hemrrhagic strke bld pressure shuld be treated t achieve < 140/ 90 r in diabetic patients < 130/ 90 Glucse Management- All patients with strke shuld have their bld glucse checked n arrival.

4 4 f 12 If first randm glucse is elevated > 10 mml/ L repeat and if elevated, the use f antihyperglycemic agents shuld be cnsidered by the team. 4.4 Acute Aspirin (Antiplatelet) Therapy After brain imaging has excluded intracranial hemrrhage all acute strke patients shuld be given at least 160 mg f acetylsalicylic acid (ASA) immediately as a ne time lading dse (Evidence Level A). In patients treated with rt-pa, ASA shuld be delayed until after the 24-hur pst-thrmblysis scan has excluded intracranial hemrrhage. (Evidence Level B). ASA ( mg daily) shuld then be cntinued indefinitely r until an alternative antithrmbtic regime is started (Evidence Level A). In patients with dysphagia, ASA may be given by enteral tube r by rectal suppsitry. (Evidence Level A). In patients already n ASA prir t ischemic strke r transient ischemic attack, clpidigrel may be cnsidered as an alternative (Evidence Level B). If rapid actin is required then a lading dse f 300 mg f clpidigrel culd be cnsidered, fllwed by a maintenance dse f 75mg nce a day Refer t Canadian Best Practice Guidelines (2012) Sectin 2.5 and 2.6 fr additinal infrmatin and details n antiplatelet therapy at Venus thrmbemblism (VTE) prphylaxis All persns with strke shuld be assessed fr their risk f develping venus thrmbemblism. High risk patients include patients with inability t mve ne r bth lwer limbs and thse patients unable t mbilize independently; a previus histry f venus thrmbemblisim; dehydratin; and cmrbidities such as malignant disease. Early mbilizatin and adequate hydratin shuld be encuraged fr all persns with acute strke t help prevent venus thrmbemblism (Evidence Level C). Patients wh are identified as high risk fr venus thrmbemblism shuld be started n venus thrmbemblism prphylaxis immediately (Evidence Level A): Lw mlecular weight heparin (with apprpriate prphylactic dses per agent) shuld be cnsidered fr patients with acute ischemic strke at high risk f VTE r unfractinated heparin fr patients with renal failure (Evidence Level A); The use f anti-emblic stckings alne fr pst-strke venus thrmb-emblism prphylaxis is nt recmmended (Evidence Level A). There is insufficient evidence n the safety and efficacy f anticagulatin deep vein thrmbsis prphylaxis after intracerebral hemrrhage. Antithrmbtic and anticagulant use shuld be avided fr at least 48 hurs after nset (Evidence Level C). In additin t secndary strke preventin, antiplatelet therapy shuld be used fr peple with ischemic strke t prevent VTE (Evidence Level A). Refer t Refer t Canadian Best Practice Guidelines (2012) Sectin 2.5 and 2.6 fr additinal infrmatin and details n antiplatelet therapy at Language and Cgnitin

5 5 f 12 All patients admitted t acute care with strke are cnsidered at high risk fr cgnitive and perceptual impairment and shuld be screened fr impairment using a validated screening tl (Evidence Level B) Screening shuld ccur at varius transitin pints alng the cntinuum f care, including upn admissin t acute care, particularly if any evidence f delirium is nted, and befre discharge t the cmmunity r prir t transfer t alternate setting f care. Refer t WRHA Delirium Prtcl- Screening t investigate a persn s cgnitive status shuld address arusal, alertness, attentin, rientatin, memry, language, agnsia, visual-spatial/perceptual functin, praxis, executive functins such as insight, judgment, scial cgnitin, prblem-slving, abstract reasning, initiatin, planning and rganizatin (Evidence Level C) Additinal assessment by a Speech Language Pathlgist will be required when cmmunicatin and language is impaired t investigate language mdalities The Mntreal Cgnitive Assessment is cnsidered mre sensitive t cgnitive impairment than the Mini Mental Status Exam in patients with vascular cgnitive impairment. Its use is recmmended when vascular cgnitive impairment is suspected (Evidence Level B) Pst-strke patients wh demnstrate cgnitive impairments in the screening prcess shuld be referred and fllwed by a healthcare prfessinal with specific expertise in this area, such as ccupatinal therapist fr additinal cgnitive, perceptual and functinal assessments, and a speech-language pathlgist fr cgnitive-cmmunicatin assessments; and where necessary, t a neurpsychlgist fr neurpsychlgical assessments t further guide management (Evidence Level B) Additinal assessments shuld be undertaken t determine the severity f impairment and impact f deficits n functin and safety f activities f daily living and instrumental activities f daily living, and t implement apprpriate remedial, cmpensatry and/r adaptive interventin strategies (Evidence Level B) A team apprach is recmmended and health care prfessinals may include and ccupatinal therapist, speech-language pathlgist, neurpsychlgist, psychiatrist, neurlgist, geriatrician and scial wrker ( Evidence Level C) Patients with evidence f vascular cgnitive impairment shuld be referred t a physician with expertise in vascular cgnitive impairment fr further assessment and recmmendatins regarding pharmactherapy (Evidence Level C) 4.7 Mbilizatin Patients with acute strke shuld be mbilized as early and as frequently as pssible (Evidence Level B), and preferably within 24 hurs f strke symptm nset, unless cntraindicated (Evidence Level C). Mbilizatin is defined as the prcess f getting a patient t mve in the bed, sit up, stand and eventually walk. Onging assessments include: Ability in activities f daily living, level f independence and safety. This assessment shuld be cmpleted and reassessed regularly; Falls Risk. Based n the risk assessment findings, an individualized falls preventin plan shuld be implemented fr each patient (Evidence Level B). Please refer t WHRA Falls Preventin and Management Guidelines fr Acute Care Facilitieshttp://hme.wrha.mb.ca/ebpt/tls_falls.php

6 6 f 12 Mbility, Transfers, Repsitining and Handling: Assessment f the apprpriate mving, handling and psitining f the patient with strke with respect t the patient s abilities and need fr assistance. Please refer t WRHA Safe Patient Handling & Mvement prcedures - Depending n patient cnditin, BP, 02 saturatin and heart rate shuld be mnitred as apprpriate befre and during mbilizatin. NB- Precautins t Mbilizatin Medical Instability; Dcumented decisin that the patient is palliative (e.g. thse with devastating strke); Persns wh have received rt-pa until cleared by the physician t mbilize. NB- Shulder Pain (Assessment and Preventin): Incidence f shulder pain fllwing strke is high, with as many as 72% f adult strke patients reprting at least ne episde f shulder pain within the first year after strke. Careful psitining and handling f affected upper extremity (ties) must be incrprated in mbilizatin. The presence f pain and any exacerbating factrs shuld be indentified early and treated apprpriately (Evidence Level C) Jint prtectin strategies include: Psitining and supprting the limb t minimize pain (Evidence Level B); Prtectin and supprt fr the limb t minimize pain during functinal mbility tasks using slings, pcket, r by therapist and during wheelchair use by using hemitry r are trughs (Evidence Level C); Teaching patient t respect the pain (Evidence Level C); The shulder shuld nt be passively mved beynd 90 degrees f flexin and abductin unless the scapula is upwardly rtated and the humerus is laterally rtated (Evidence Level A); Educate staff and caregivers abut crrect handing f hemiplegic arm (Evidence Level A). Refer t Canadian Best Practice Guidelines Sectin fr additinal infrmatin regarding assessment, preventin and management f shulder pain Cntinence All patients with strke shuld be assessed fr urinary incntinence and retentin (with r withut verflw), fecal incntinence and cnstipatin (time and frequency) (Evidence Level C). The use f prtable ultrasund is recmmended as the preferred nninvasive painless methd fr assessing pst-vid residual and eliminates the risk f intrducing urinary infectin r causing urethral trauma by catheterizatin (Evidence Level C). Pssible cntributing factrs surrunding cntinence management shuld be assessed, including medicatin, nutritin, diet, mbility, activity, cgnitin, envirnment and cmmunicatin (Evidence Level C). This shuld include assessing the strke patient fr urinary tract infectins t determine a pssible transient cause f urinary retentin (Evidence Level C). Apprpriate intermittent catherizatin schedules shuld be established based n amunt f pst vid residual (Evidence Level B).

7 7 f 12 The use f indwelling catheters shuld be avided due t the risk f urinary tract infectin. If used, indwelling catheters shuld be assessed daily and remved as sn as pssible. (Evidence Level A). Excellent pericare and infectin preventin strategies shuld be implemented t minimize risk f infectins (Evidence Level C). Patients with strke with urinary incntinence shuld be assessed by trained persnnel using a structured functinal assessment (Evidence Level B). A bladder training prgram shuld be implemented in patients wh are incntinent f urine (Evidence Level C), including timed and prmpted tileting n a cnsistent schedule (Evidence Level B). A bwel management prgram shuld be implemented in patients with strke with persistent cnstipatin r bwel incntinence (Evidence Level A). 4.9 Dysphagia Screen and Assessment Patients with strke shuld have their swallwing ability screened using a simple, valid, reliable bedside testing prtcl as part f their initial assessment, and befre initiating ral intake f medicatins, fluids r fd (Evidence Level B). Patients wh are nt alert within the first 24 hurs shuld be mnitred clsely and dysphagia screening perfrmed when clinically apprpriate (Evidence Level C). Patients with strke presenting with features indicating dysphagia r pulmnary aspiratin shuld receive a full clinical assessment f their swallwing ability by a speech language pathlgist r apprpriately trained specialist wh shuld advise n safety f swallwing ability and cnsistency f diet and fluids (Evidence Level A). Patients wh are at risk f malnutritin, including thse with dysphagia shuld be referred t a dietitian fr assessment and nging management. Assessment f nutritinal status shuld include the use f validated nutritin assessment tls r measures (Evidence Level C) Nutritin The nutritinal and hydratin status f strke patients shuld be screened within the first 48 hurs f admissin using a valid screening tl (Evidence Level B). Results frm the screening prcess shuld guide apprpriate referral t a dietitian fr further assessment and the need fr nging management f nutritinal and hydratin status (Evidence Level C). Patients with strke with suspected nutritinal and/r hydratin deficits, including dysphagia shuld be referred t a dietitian fr: 4.11 Oral Care Recmmendatins t meet nutrient and fluid needs rally while supprting alteratins in fd texture and fluid cnsistency based n the assessment by a clinical dietician and/ r speech language pathlgist and /r ther trained prfessinal (Evidence Level C); Cnsideratin f enteral nutritin supprt (tube feeding) within 7 days f admissin fr patients wh are unable t meet their nutrient and fluid requirements rally. This decisin shuld be made cllabratively with the interprfessinal team, the patient, and their caregivers and families (Evidence Level B).

8 8 f 12 All patients with strke shuld have an ral/dental assessment, which includes screening fr bvius signs f dental disease, level f ral care and appliances, upn r sn after admissin (Evidence Level C) Fr patients wearing a full r partial denture it must be determined if they have the neurmtr skills t safely wear and use the appliance(s) (Evidence Level C) An ral care prtcl shuld be established and include: Frequency (twice per day r mre minimum); Types f ral care prducts; Strategies fr patients with dysphagia; Cnsultatin with dentistry, dental hygienist, ccupatinal therapy, and/r speech language pathlgy shuld there be cncerns implementing the prtcl (Evidence Level C); Cnsultatin with dentistry shuld there be cncerns with ral health and/ r appliances (Evidence Level B) Skin and Wund Care All strke patients shuld have an assessment f skin integrity and risk assessment fr develping pressure ulcers/wunds n admissin and when a change is nted Based n the risk assessment/ findings, an individual care plan shuld be implemented fr each patient. Please refer t WRHA Wund Care Recmmendatins ( ) 4.13 Identificatin and Management f Pst-Strke Depressin All patients with strke shuld be cnsidered t be at risk fr depressin. During the first assessment, the clinical team shuld determine whether the patient has a histry f depressin r risk factrs fr depressin (Evidence Level B). All patients with strke shuld be screened at all transitin pints alng the cntinuum f care. Transitin pints in acute care may include upn admissin t acute care, particularly if any evidence f depressin r md change is nted, and befre discharge t the cmmunity r prir t transfer t alternate setting f care. Patients shuld be screened fr depressin fllwing a strke event using a standardized tl (e.g. Hspital Anxiety Depressin Scale, Beck Depressin Inventry r the Geriatric Depressin Scale). Screening shuld be cmpleted by trained prfessinals such as Nursing, Occupatinal Therapy and Scial Wrk. Patients shuld be given infrmatin and advice abut the impact f strke, and the pprtunity t talk abut the impact n their lives (Evidence Level B). Patients and their caregivers shuld have their psychscial and supprt needs reviewed n a regular basis as part f lng-term strke management (Evidence Level A) including as part f the discharge plan frm acute care. Patients identified at risk fr depressin shuld be referred t the health care prfessinal with expertise in diagnsis and management f depressin (Evidence Level B). 5. TRANSITION PLANNING

9 9 f 12 Transitin planning shuld be initiated as sn as pssible after patient admissin t hspital. A prcess shuld be established t ensure invlvement f patients and caregivers in the develpment f the care plan, management and transitin (discharge) planning. Transitin planning discussins shuld be nging thrughut hspitalizatin t supprt a smth transitin frm acute care. Infrmatin abut discharge issues and pssible patient needs fllwing discharge shuld be prvided t patients and caregivers sn after admissin. Discharge activities shuld include patient, family and team meetings, care plans, cnsults t ther services, pre-discharge assessment, caregiver training, pst discharge fllw-up. Any discharge infrmatin shuld be clearly dcumented in the apprpriate frmat (e.g. Discharge Infrmatin Sheet, WRHA Transfer frm, etc) ensuring transfer f infrmatin t the next service prvider( e.g. Primary Health Care Prvider) in rder t prmte smth transitin f care thrughut the cntinuum f care The transitin plan shuld include fllw-up in the cmmunity by the mst apprpriate cmmunity healthcare prvider accrding t client s needs, prgress and current gals(e.g.: Primary Health Care Prvider, Hme Care Prgram Early Supprted Discharge Services, Day Hspital and/ r Outpatient physitherapy, ccupatinal therapy, speech language pathlgy services, and/r Hme Care Prgram supprt services, etc.) whenever indicated. Refer t Canadian Best Practice Recmmendatins fr Strke Care (2010) Sectin 5.6, 6.5, fr mre details n managing transitins f care fllwing a strke. 6. ADVANCE CARE PLANNING Patients surviving a strke and their families shuld be apprached by the health care team t participate in advance care planning (ACP). Please refer t WRHA Plicy n Advance Care Planning ( ACP) Gals f Care 7. PALLIATIVE AND END-OF-LIFE CARE The palliative apprach shuld be used with thse experiencing significant mrbidity r t ptimize endf-life care fr dying strke patients and their families. Cmmunicatin with patients and their families shuld prvide, n an nging basis, infrmatin and cunseling regarding diagnsis, prgnsis, and symptm management Palliative care specialists shuld be invlved in the care f patients with difficult t cntrl symptms, cmplex r cnflicted end-f- life decisin making, r cmplex psych-scial family issues (Evidence Level C). Patients and the interprfessinal team shuld have access t palliative care specialists fr cnsultatin n palliative patients. Please refer t WRHA Palliative Care Prgram r cntact SUPPORTING PATIENTS, FAMILIES AND CAREGIVERS Health care practitiners in all practice settings shuld assess the patient and their caregivers learning needs, abilities, learning preferences and readiness t learn. This assessment shuld be nging as the patient mves thrugh the cntinuum f care t determine their needs and as educatin is prvided

10 10 f 12 Dcumentatin f educatin shuld be timely, interactive, up t date and prvided in a variety f frmats, languages including aphasia friendly. Refer t Canadian Best Practice Recmmendatins fr Strke Care (2010), Sectins 6.1, 6.2 and DOCUMENTATION Health care prfessinals shuld dcument cmprehensive infrmatin regarding screening and/r assessment at the time f assessment and reassessment f strke clients, and avid duplicating infrmatin previusly dcumented. 10. RESOURCES A. Manitba Strke Strategy Website Infrmative link available t healthcare prviders and the public that highlights what Manitba is ding t advance strke care. The site prvides strke infrmatin fr the public, resurces t reduce risk f strke, resurces t help after strke, infrmatin fr healthcare prviders, links t ther prvincial strategies, and upcming strke cnferences and wrkshps. *** B. Links t Evidence-Based Clinical Resurces Canadian Best Practice Recmmendatins fr Strke Care, StrkEngine fr Clinicians and Families StrkEngine Assess (evidence related t utcme measures) Evidence Based Review f Strke Rehabilitatin (EBRSR) View different sectins identified n tp right crner f hme page including evidence reviews, appendices, educatinal mdules, and resurces C. Educatinal Materials fr Clinicians t use with Clients and Caregivers Tips and Tls fr Everyday Living: A Guide fr Strke Caregivers Published by Heart and Strke Fundatin f Ontari, D85B2D02EE71%7D/TipsandTls_ENG.cmplete.pdf Let s Talk Abut Strke Lets_ Talk_abut_Strke.htm Living with Strke, Educatinal Supprt Grup

11 11 f 12 Cntact HSFM at r tll free at Strke Recvery Assciatin f Manitba Phne: (204) StrkEngine fr Families A Patient s Guide t Canadian Best Practice Recmmendatins fr Strke Care Facts n Sdium Reductin WRHA Intranet: Falls Preventin and Management Reginal Clinical Practice Guidelines: Advance Care Planning: Delirium: Wund Care Plicy : Wund Care Recmmendatins: Palliative Care: Pain Clinical REFERENCES: (1) Alberta Prvincial Strke Strategy. Admissins (2) Heart and Strke Fundatin f Canada. Canadian Strke Strategy Best Practices and Standards, Canadian Best Practice Recmmendatins fr Strke Care (3) ) Heart and Strke Fundatin f Canada. Canadian Strke Strategy Best Practices and Standards, Canadian Best Practice Recmmendatins fr Strke Care

12 12 f 12 (4) Lindsay M, Gubitz G, Bayley M, Hill MD, Davies-Schinkel C, Singh S, et al. Canadian Best Practice Recmmendatins fr Strke Care (Update 2010, 2012). On behalf f the Canadian Strke Strategy Best Practice and Standards Writing Grup, Ottawa, Ontari: Canada: Canadian Strke Netwrk.; (5) RNAO Nursing Best Practice Guidelines Prgram. Strke Assessment Acrss the Cntinuum f Care Guideline Supplement PRIMARY AUTHOR (S) Mary Anne Lynch Krista Williams Marlene Stern Susan Alcck Luise Nichl Reviewed by Dr. Allan Jacksn Kathleen Klaasen