Post Stroke Complications - The Stroke Network of Southeastern ...

Post Stroke ComplicationsLaura MacIsaacStroke Specialist Case ManagerStroke Strategy of Southeastern Ontario

Learning Objectives• Identify complications of stroke acrossthe continuum• Examine key prevention strategies• Identify early identification

Why is it important?• LOS• mortality• morbidity• outcomes

Neurological Complications“Nurses in all settings should recognizethat signs of neuro status may berelated to neuro OR medicalcomplications.”

NeurologicalComplicationsMedicalComplications• Hemorrhagictransformation• Infarct extension• Cerebral edema, ICP• Second stroke• Seizures• Hypoglycemia• Hyponatremia• Infection• MI

Hemorrhagic Transformation• Presents in first couple weeks• Risk dependent on size, location, etiologyInfarct ExtensionCerebral Edema with ICP• Peak time 3-5 days• At risk patients include those with majorintracranial artery occlusion with multilobarinfarcts OR obstructive hydrocephalus

Prevention• Blood pressure, temperature control,euglycemicIdentification – Signs & Symptoms• Change in LOC – confusion, restlessness,combativeness, lethargy• Headache• motor strength• coordination• Speech/language changes

Additional Stroke• est risk immediately poststroke• Risk 33% within 2 yearsPrevention• Secondary meds; life stylechangesIdentification• The 5 warning signs of strokeHEADACHE

Seizures• 85% occur in the 1 st 72 hours• Affects ~ 10% of stroke survivorsTreatment• Rule out metabolic causes• Initiate anticonvulsants as required

Skin breakdown“Nurses in all setting should assess forpressure ulcer development, which isdetermined by the combination of clinicaljudgment and the use of a reliable riskassessment tool.”

When?•At any time during hospitalizationWho?• est risk are those who are incontinent; thosewith: vascular disease, sensory loss, neglect,bilateral motor deficits, elderly, nutrition status•Incidence is 14.5%Resource – BPG: Risk Assessment & Prevention of Pressure Ulcers

Prevention• pressure and shearing; positioning;seating; mattress selection, adequate dietand hydration, early mobilization

Falls“Nurses in all practice settings shouldassess stroke clients’ fall risk onadmission and after a fall using avalidated tool.”

When?• Anytime during hospitalizationWho?• risk with cognitive impairments, visual orsensory loss, incontinence, neglect, impairedpostural stability, bilateral motor impairmentPrevention• Fall risk assessment on admission and withchanges in status, low bed, bed alarm, frequenttoileting, frequent bed checks, etc.

STRATIFYScore 1 point for each ofthe following thatapplies:1. Fall is presenting c/o2. Unstable gait3. Agitation present4. Frequent toileting5. Visual disturbanceScore of > 2 indicateshigh risk of fallTIMED UP AND GOMeasurees physicalmobility in ambulatoryfrail elderlyPatient is timed gettingup from chair, walking3 meters, turning,walking back to chair,and sitting down againMay use aids (cane,walker) but no staffassist.Resource – BPG: Prevention of Falls & Injury in the Older Adult

“Nurses in all practice settings shouldassess for the following strokecomplications:•Painful hemiparetic shoulder•Spasticity/contractures•Deep vein thrombosis…”

Shoulder and Joint InjuryWhen?• Most common 2-3 weeksWho?• Most common withhemparetic shoulderPrevention• Positioning, limb supporthttp://www.msjensen.gen.umn.edu/webanatomy/Images/Bones

Spasticity and ContracturesWhen?• Incidence is 19-38% at 3 months – 1 yearPrevention?• Proper positioning•ROM• Splinting• Medications

DVT / PEInformation provided by the Society of Interventional Radiology,www.SIRweb.org © 2005

• DVT 20 – 70% PE 10% mortalityPrevention• Heparin prophylaxis ’s DVT risk by 50%• Antiembolic stockings• Early mobilization• Adequate hydrationIdentification• Asymmetrical pain, tenderness, swelling,discolouration• Ultrasound is gold standard

PainCauses• Spasticity• Joint injury, shoulder subluxation• Pre-existing arthritis/neuropathies• NeurogenicPrevention• Positioning, ROM, splints, assistive devicesAssessment

Dysphagia“Nurses should maintain all paclients withstroke NPO (including oral medications)until a swallowing screen is administeredand interpreted, within 24 hours of theclient being awake and alert.”

When?• For those at risk, anytime but increases withfatigueWho?• 50% of all stroke patients• Mortality rate is 20% within the 1 st year d/taspiration pneumonia• 50% of all aspirations are SILENT• ’s risks of malnutrition, dehydration,aspiration pneumonia

Prevention of Complications• NPO until swallowing assessmentcompleted• Oral hygience before & after feeding• Promote self-feeding• Position HOB at 90 degrees for 30 minutespost feeding• Neck positioning (not extended)

Identification of DysphagiaScreening is needed to identify those at riskPotential Swallowing Deficit – S&S•Pocketing food•Excessive throatswallowing•Copious PO and/orpulmonary secretions•Drooling•Slow effortful eating•Difficulties swallowing•Coughing whileswallowing•Wet sounding voice•Weak cough voiceGag reflex = Safe swallowing

Nutrition“Nurses in all practice settings shouldcomplete a nutrition and hydration screenwithin 48 hours of admission, after apositive dysphagia screen & with changesin neurological or medical status.”

• Incidence as high as 50% in rehab patients 2 weekspost stroke (higher in the 16% malnourished prior totheir stroke)Prevention• Assess intake & ability to feed. Advocate. DietitianconsultIdentification• Physical – thin, weak, cachetic, dry mucousmembranes/hair• Recent weight loss > 10 lbs• Recent intake• Comorbid Conditions – diabetes, CRF, Ca, AIDs• At risk – depressed, cognitive deficits, visual/sensorydeficits

Urinary Tract complications•UTI occurs in ~ 40% of patients•Urinary incontinence affects 32-79%Interventions•Early assessment for retention orincontinence•Avoid use of indwelling catheters•Regular toileting

OthersDepressionCognitive and perceptual deficitsNeglectAphasiaApraxia

Take home message1. Primary goal is prevention2. Early identification and treatment3. Be aware of available resourcesThe staff RN can positively impact theoutcomes of stroke patients inthroughout the entire continuum of care.

References1. Best Practice Guidelines for Stroke Care, Heart& Stroke Foundation of Ontario, 2003.2. Management of Acute Stroke, Heart & StrokeFoundation of Ontario, 20043. Stroke Assessment Across the Continuum ofCare, Heart & Stroke Foundation of Ontario andthe Registered Nurses’ Foundation of Ontario,June 2005