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Stroke/TIA Care Guidelines
2014
Stroke/TIA Care Guidelines
2014
The Stroke care guidelines were created to help guide
nursing care based on best practice and evidence
intended to optimize patient care. The
rationale/evidence is provided that supports the care
elements for this population of patients.
These care guidelines should be initiated with rule out
stroke patients, patients that present with stroke like
symptoms, or confirmed stroke or TIA patients.
Stroke/TIA Care Guidelines
2014
When caring for the stroke patient the initial plan for
the nursing and medical management of an acute
stroke patient is to control vital signs, prevent any
deterioration of the patient, and prevent any medical
complications of the stroke. Medical complications
occurring in the acute stages of a stroke have shown
to worsen the patient’s neurological outcome. Nursing
management should focus on the prevention of
complications of stroke.
Assessment (expected care, not requiring physician order)
 Perform NIHSS on admission, with any acute neurological change,
transfers from the ICU (with ICU RN), and upon discharge.
 The NIHSS is a valid, efficient, and reliable measure of the patient’s status after
a stroke and in assessing outcome after treatment.
 Perform dysphagia screening before the patient eats, drinks, or
receives oral medications.
 Assessment of swallowing before the patient begins eating, drinking, or
receiving oral medications is recommended. (Nothing by mouth, including
medications if dysphagia screening failed.) Impairments of swallowing are
associated with a high risk of pneumonia.
 Neuro checks and vital signs Q 30 minutes x 4 then Q 4 hours
 After the airway, breathing, and circulation have been assessed and specific vital
signs determined, such as blood pressure, heart rate, oxygen saturation, and
temperature, a more deliberate and detailed physical examination is
performed. Frequent and consistent monitoring is important to help assess for
change in patient condition.
Stroke Education
 Stroke education is an essential element of the multidisciplinary care plan
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for post-stroke patients. Clinical practice guidelines include
recommendations for patient and family education during hospitalization.
Stroke education has been shown to be an effective tool in secondary
prevention of recurrent stroke and should be started as soon as possible.
Families and patients face many challenges after a stroke. Nurses play a
key role in providing education for patients and their families and should
ensure their understanding.
Every stroke survivor will have unique needs and will require
individualized education.
The type of stroke experienced and the resulting outcomes will play a
large role in determining not only the course of treatment but also what
education will be required. Patient education should include information
about the event (e.g., cause, treatment, and risk factors), the role of
various medications or strategies, as well as desirable lifestyle
modifications to reduce risk or improve outcomes.
Stroke Education
Stroke patients and/or their caregivers should be provided with
education and educational material addressing all of the
following:
 Patient specific information around personal risk factors related to
stroke (hyperlipidemia, diabetes, smoking, hypertension, diet,
sedentary lifestyle, alcohol, etc.)
 The need to call 911
 Signs and symptoms of stroke (Instruct on FAST- Face, arms,
speech, time)
 Medications prescribed at discharge and the importance of
compliance
 The need for physician follow up after discharge
 Willingness to change modifiable personal risk factors
Patient Management/ General Supportive Care
These are all key points to monitor that may lead to treatment in
order to prevent complications and/or poor outcomes. In these
instances collaborating with our physicians is necessary.
 Blood pressure; maintain systolic blood pressure to be <220 mm Hg or
the diastolic blood pressure is <120 mm Hg
 In patients with markedly elevated blood pressure who do not receive tPA,
a reasonable goal is to lower blood pressure by 15% during the first 24
hours after onset of stroke. The level of blood pressure that would mandate
such treatment is not known, but consensus exists that medications should
be withheld unless the systolic blood pressure is >220 mm Hg or the
diastolic blood pressure is >120 mm Hg. An elevated BP in stroke patients
is a compensatory mechanism to try to perfuse blood to the ischemia in the
brain.
Patient Management/ General Supportive Care
 Treat hyperglycemia to achieve blood glucose levels in a range of
140 to 180 mg/dL.
Evidence indicates that persistent in-hospital hyperglycemia during
the first 24 hours after stroke is associated with worse outcomes.
According to the American Diabetes Association inpatient glycemic
control guidelines, initiating therapy to achieve glucose targets of
140 to 180 mg/dL if fasting glucose is greater than 140 mg/dL or
random glucose is consistently higher than 180 mg/dL. Lower
glucose targets (<140 mg/dL) may be appropriate for patients
with well-controlled diabetes and those with stress hyperglycemia
who were not known to be diabetic before admission, but glucose
levels less than 80 mg/dL should be avoided.
Patient Management/ General Supportive Care
 Oxygen therapy: Supplemental oxygen should be provided to
maintain oxygen saturation >94%.
It is not apparent that routine supplemental oxygen is required
acutely in non-hypoxic patients with mild or moderate strokes.
 Cardiac monitoring for the first 24 hours
Cardiac monitoring is recommended to screen for atrial
fibrillation and other potentially serious cardiac arrhythmias that
would necessitate emergency cardiac interventions. Cardiac
monitoring should be performed for at least the first 24 hours
Patient Management/ General Supportive Care
 Infection prevention
Pneumonia and UTIs are frequently seen in the acute phase after
stroke. Indwelling catheters should be avoided if possible. If a
catheter is in place it should be removed as soon as the patient is
medically and neurologically stable. Screening for dysphagia and
early management of nausea and vomiting can help prevent
aspiration pneumonia.
 Head of the bed elevated at least 30° for patients at risk for
airway obstruction or aspiration and those with suspected
elevated ICP
Positioning of the head of the bed must be individualized for each
patient. When patient position is altered, close monitoring of the
airway, oxygenation, and neurological status is recommended, and
adjustment to changing clinical parameters may be required.
Patient Management/ General Supportive Care
 Maintenance of patient’s temperature less than 100°F during
the first 48 hours following stroke
In the setting of acute ischemic stroke, hyperthermia is associated
with poor neurological outcome, possibly secondary to increased
metabolic demands, enhanced release of neurotransmitters, and
increased free radical production.
 Nutrition and Hydration
Sustaining nutrition is important because dehydration or
malnutrition may slow recovery. Dehydration is a potential cause
of DVT after stroke.
Patient Management/ General Supportive Care
 Bowel management and bladder management
Early bowel and bladder care should be instituted to prevent
complications such as constipation and urinary retention or infection.
 Skin Care
Stroke patients are at risk for skin breakdown because of loss of
sensation and impaired circulation, older age, decreased level of
consciousness, and inability to move themselves because of paralysis.
Frequent turning should be instituted in bedridden patients to prevent
skin breakdown
 Fall Precautions
Fall precautions should be initiated, and the stroke patient should be
told not to ambulate without assistance. Use of a gait belt is important
when ambulating the patient.
Stroke Core Measures
 DVT prophylaxis
Subcutaneous administration of anticoagulants is recommended for
treatment of immobilized patients to prevent deep vein
thrombosis. The use of intermittent external compression devices
is reasonable for treatment of patients who cannot receive
anticoagulants. SCDs should be ordered, applied, and
documented if the patient cannot be on anti-coagulants.
 Anticoagulation therapy for atrial fibrillation/flutter
Ischemic stroke patients with atrial fibrillation/flutter should be
prescribed anticoagulation therapy at hospital discharge. If
anticoagulation therapy is not ordered at discharge a reason must
be documented by MD/APN/PA.
Stroke Core Measures
 Antithrombotic by the end of day 2 of hospitalization
Oral or rectal administration of aspirin (initial dose is 300mg-325
mg) within 24 to 48 hours after stroke onset is recommended for
treatment of most patients.
 Discharged on a statin
Among patients already taking statins at the time of onset of
ischemic stroke, continuation of statin therapy during the acute
period is reasonable. Ischemic stroke patients with LDL greater
than or equal to 100mg/dl, or LDL not measured, or who were
on a lipid lowering medication prior to hospital arrival are
prescribed statin medication at hospital discharge.
Stroke Core Measures
 Stroke education:
Patients with ischemic or hemorrhagic stroke or their
caregivers who were given education and educational
materials during the hospital stay addressing all of the
following: personal risk factors for stroke, warning signs
for stroke, activation of emergency medical system, need
for follow-up after discharge, and medications prescribed
at discharge.
 Patient assessed for rehab
Rehab therapy should start as early as possible once
medical stability is reached.
Depression Screening
 Nursing Department Patient Health Questionnaire
should be given to the patient on day 2 of their admission as
part of the Stroke protocol. Once completed, the front side
of this tool should be faxed to the Christian Hospital
Recovery Center. A Mental Health RN will follow up with
the patient within 24 hours or via phone interview if the
patient Completion of this tool may be on patient self-report
or with assistance of the assigned RN if needed. All responses
should be verified by the assigned RN to ensure
comprehension of the tool and accuracy of responses by the
patient.
Please Note
 These guidelines are recommended by Christian
Hospital/Northwest Healthcare for the clinical
management of stroke patients.These guidelines are not
intended as a substitute for clinical judgment. Clinical
circumstances may necessitate deviation from these
guidelines.
A Wise Person Once Said:
“Rule them in before you rule them out”
Don’t look for reasons why your patient might
not have had a stroke. It’s best for the patient if
we care for them as if they had a stroke until they
are ruled out.
References
 Baker L, Juneja R, Bruno A. Management of hyperglycemia in acute
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ischemic stroke. Current Treat Options Neurology. 2011;13:616–628.
Jauch, E., Sever, J., Abrams, H. & et. al. (2013). Guidelines for the
Early Management of Patients with Acute Ischemic Stroke. Stroke 44:
870-947.
Summers, D., et al. (2009). Comprehensive Overview of Nursing
and Interdisciplinary Care of the Acute
Ischemic Stroke Patient: A Scientific Statement from the American
Heart Association. Stroke 40, (8), pp.2911-2944.
The Joint Commission. (2013). Disease - Specific Care Certification
Manual 2013.