national-clinical-guidelines-for-stroke-fourth-edition

Nursing concise guide for stroke 2012
National clinical guideline for stroke
B All staff caring for people dying with a stroke
should be trained in the principles and practice
of palliative care.
Initial diagnosis of acute transient event
(TIA) (4.2.1)
B People with a suspected TIA, that is, they have
no neurological symptoms at the time of
assessment (within 24 hours), should be
assessed as soon as possible for their risk of
subsequent stroke by using a validated scoring
system such as ABCD 2 .
Immediate management of nonhaemorrhagic
stroke (4.6.1)
D Alteplase should only be administered within a
well-organised stroke service with:
● staff trained in the delivery of thrombolysis
and monitoring for post-thrombolysis
complications
● nurse staffing levels equivalent to those
required in level 1 or level 2 nursing care
with staff trained in acute stroke and
thrombolysis
● immediate access to imaging and reimaging,
and staff appropriately trained to
interpret the images
● processes throughout the emergency care
pathway for the minimisation of in-hospital
delays to treatment, to ensure that
thrombolysis is administered as soon as
possible after stroke onset
● protocols in place for the management of
post-thrombolysis complications.
Immediate diagnosis and management of
subarachnoid haemorrhage (4.8.1)
D After any immediate treatment, all patients
should be observed for the development of
treatable complications, especially
hydrocephalus and delayed cerebral
ischaemia.
Early phase medical care of stroke –
physiological monitoring and
maintenance of homeostasis (4.12.1)
C People who have had a stroke should receive
supplemental oxygen only if their oxygen
saturation drops below 95% and there is no
contraindication. The routine use of
supplemental oxygen is not recommended in
people with acute stroke who are not hypoxic.
D People with acute stroke should be treated to
maintain a blood glucose concentration
between 4 and 11 mmol/L.
Initial, early rehabilitation assessment
(4.13.1)
A All patients should be assessed within a
maximum of 4 hours of admission for their:
● ability to swallow, using a validated swallow
screening test (eg 50 ml water swallow)
administered by an appropriately trained
person
● immediate needs in relation to positioning,
mobilisation, moving and handling
● bladder control
● risk of developing skin pressure ulcers
● capacity to understand and follow
instructions
● capacity to communicate their needs and
wishes
● nutritional status and hydration
● ability to hear, and need for hearing aids
● ability to see, and need for glasses.
Early mobilisation (4.15.1)
A Every patient with reduced mobility following
stroke should be regularly assessed by an
appropriately trained healthcare professional to
determine the most appropriate and safe
methods of transfer and mobilisation.
B People with acute stroke should be mobilised
within 24 hours of stroke onset, unless
medically unstable, by an appropriately trained
healthcare professional with access to
appropriate equipment.
134 © Royal College of Physicians 2012