Transcript Management of the Acute Stroke Patient

Thrombolysis Nursing
Competencies
Objectives
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Nursing Care of a Thrombolysed patient
What informed the Stroke Strategy
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RCP Sentinel Audits (2002-2006)
NAO Report (Nov 2005)
Stroke strategy framework 2007
Nice
“There is a massive and regular
failure to respond to the
emergency of stroke” (NAO 2005)
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Low public awareness of symptoms,
prevention & management
Slow admission to hospital, Difficult access
to imaging, Insufficient specialist
resources
Less than 1% of pts thrombolysed
compared to 9% in Australia
Stroke is a Medical Emergency
’Time is Brain’
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Speedy diagnosis
Rapid access to imaging
Thrombolysis
Rapid access to supportive therapy
(HASU)
Rapid secondary prevention
Rapid surgical/ radiological intervention in
arterial disease (carotid / vertebral)
80% of Strokes = Ischaemic
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80% of Ischaemic stroke caused by
embolism from
Heart
Aortic arch
Extracranial arteries to the brain
Thrombolysis
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Thrombus= clot
Lysis = destruction of cells
Thrombolysis is achieved by using
rt-PA (alteplase)
rt-PA reverses underperfusion, allowing
ischaemic penumbra to recover
Thrombolysis
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rt-PA= recombinant tissue plasminogen
activator
Plasmin is the enzyme that degrades
fibrin, the protein which is the main
constituent of blood clots
rt-PA activates the release of plasmin as
plasminogen
Rational for giving Thrombolysis
Reduces the size of Ischaemic damage
( infarct) by restoring blood flow
Cells in the brain ie. Neurons die over time
.Prompt treatment with a thrombolytic
agent ( rTPa –Alteplase) may promote
reperfusion & improve functional outcomes
Thrombolysis
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Must be given within 4.5 hours of stroke
Strict inclusion criteria
Licensed for IV use in under 80’s
Consultant decision: intra-arterial, 80+
Dramatic increase in post-stroke
quality of life
Cerebral infarct - onset
Onset
Infarct
Ischaemic
penumbra
Cerebral infarct – 6 hours
6 Hours
Infarct
Ischaemic
penumbra
Cerebral infarct – 24 hours
24 Hours
Infarct
Ischaemic
penumbra
Without thrombolysis
2hrs
Thrombolysis - The Evidence
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NINDS trial 1995 (National Institute of
Neurological Diseases & Stroke)
ECASS 1 and ECASS 2 (European Cooperative Stroke Study) up to 3 hours
ECASS 3 showed benefit up to 4.5 hours
2009 American stroke association widens
use of rTPa to 4.5 hours
RCP Audit 2006 - Thrombolysis
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Only 10% admitted directly to unit with
acute facilities
18% of hospitals do thrombolysis
30 hospitals thrombolysed 218 patients
ratios (with 95% CIs) of an unfavourable outcome with
tPA given within 3 hrs of onset of stroke
Odds ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs of
onset of stroke
Odds ratios (with 95% CIs) of an unfavourable outcome
with tPA given within 3 hrs of onset of stroke
Thrombolysis - The Evidence
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Fewer complications
Frequently, dramatic lack of disability
Quicker recovery
Reduction in LOS
‘Time is Brain’ - Stroke Pathway
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Triage, FAST test
Speedy call to Stroke Team (whatever
severity)
Rapid admission to ASU
CAPACITY
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The Mental Capacity Act 2005, which came fully into force in October 2007, provides the legal
framework for acting and making decisions on behalf of individuals who lack the capacity to make
specific decisions for themselves in relation to personal welfare, healthcare and financial
matters. It applies to persons age 16 and over.
The Mental Capacity Act (MCA) applies to England and Wales.
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Principles of the Act
The Act sets out five principles which guide the legislation. These are:
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‘A person must be assumed to have capacity unless it is established that he lacks
capacity.
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(3) A person is not to be treated as unable to make a decision unless all practicable steps
to help him to do so have been taken without success.
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(4) A person is not to be treated as unable to make a decision merely because he makes
an unwise decision.
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(5) An act done, or decision made, under this Act for or on behalf of a person who lacks
capacity must be done, or made, in his best interests.
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(6) Before the act is done, or the decision is made, regard must be had to whether the
purpose for which it is needed can be as effectively achieved in a way that is less restrictive of
the person’s rights and freedom of action
Testing Capacity
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The Functional Test
The person must be able to:
understand the information relevant to the decision,
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retain that information,
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weigh that information as a part of the process of making a decision,
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communicate his/her decision (whether by talking, using sign language or
any other means)
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This test must be complete and recorded; the documentation must
demonstrate the above process
ABC
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Airway
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Breathing
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Circulation
After ABC
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GCS
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ECG
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Blood glucose
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Fluid access
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Hydration
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Bloods
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Nil by Mouth
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Transfer to CT-continue ABC
Time is brain
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1.9 million neurons are lost
each minute after a stroke
Protect ischaemic penumbra
Stroke 2006
CT
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Known time of
symptoms <4 hours
NIHSS score
No haemorrhage
No contraindications
Consent
Age
Thrombolysis
Alteplase rTPA
0.9mg /Kg
10% of total dose –Bolus 2-3
mins
90% of total dose –Infuse over 60
mins
rTPA Alteplase
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Do not mix t-PA with any other medications.
Do not use IV tubing with infusion filters.
All patients must be on a cardiac monitor
When infusion is complete, saline flush with
Normal saline
t-PA must be used within 8 hours of mixing
when stored at room temperature or within 24
hours if refrigerated
Complications of Thrombolysis
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Intra -cerebral haemorrhage-1.7%
(1 in 77 patients) 0.28% fatal
SITS MOST 2007
Bleeding-minor bleeding is common
(IV site)
Anaphylaxis- 1%
Ace inhibitors Frontal & insular lesions
Angiodoema 1.3% Canadian study
1,135 pts
Major Heamorrhage 0.4%
Angioedema
Patient Story
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Mr X 88 years of age
Jet pilot in the war & last flew
in 1986
Collapsed right sided weakness
Unable to talk . Couldn’t think
clearly.
999 ambulance to A%E
“Clock work military precision
like gun team at Earls court”
First 24 hours
30% of all stroke patients will deteriorate in
the first 24hours
Stroke 2009
Monitor GCS
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Ability to engage with
immediate surroundings
Standardised stimuli
E1-E4
V1-V5
M1-M6
Best and Worst Score
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GCS 15- E4 V5 M6
Awake, alert and fully
responsive
GCS 3-E1 V1 M1
No cerebrally mediated
response to stimulus
NIHSS - A Research Tool
Fifteen item impairment
scale
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Neurological outcome
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Degree of recovery
Physiological Monitoring
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Hypoxia
Respirations
Saturations <92%
Associated with neurological
deterioration
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Temperature
>38C must be treated.
-associated with infarct volume
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Arrhythmias
Continuous ECG
Early detection and treatment of AF
Right hemisphere /insular lesions
Physiological Monitoring contd
4.Blood pressure
Non thrombolysed patients
BP Not treated unless:
Systolic >220mmHg or
Diastolic >120mmHg with 2
consecutive readings
Thrombolysed patients
BP is treated if:
Systolic >185mmHg or
Diastolic >110mmHg with 2
consecutive readings
Abrupt fall in BP may affect cerebral
perfusion pressure
Physiological Monitoring contd
5.Blood Sugar
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Hyperglycaemia BM>10 treat &
monitor
Hypoglycaemia –immediate
treatment with glucose
Hyperglycaemia is associated with
poor clinical outcome
Physiological Monitoring Contd
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6.
Hydration
Glucose
Anuria
Polyuria
Circulatory failure
Cerebral perfusion
Complications of Stroke
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Aspiration Pneumonia
Urinary infection
DVT
Pulmonary Embolus
Shoulder subluxation
Depression
Malnourishment
Pressure sores
Falls
Seizures
Swallow Complications
(Dysphagia)
Chest Infection
Aspiration Pneumonias
50% are silent
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Swallow screen
Nil by mouth first 24hours
Guided eating & drinking regime
Encourage to cough
Sitting out of bed
Mobilisation
Mouth Care
Increased risk of infection
Pain and discomfort
Effects swallow
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Gentle mouth care
Adequate hydration
Gentle tooth brushing
Head Position
Controversial
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Head in a neutral position
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Flat if tolerated.
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Or 30 –40 degrees
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Aids venous drainage &
improves cerebral perfusion
Bladder &Bowels
Urinary incontinence
Urinary infection
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Avoid catheters
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Early plan of care
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Adequate hydration
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Bowels
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Privacy & dignity
Psychological Support
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Assess mood
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Recognise grief/loss
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Talk
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Engage with family
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Interests
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Timely realistic goals
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Refer
Pressure Sores
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Air mattress
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Two hourly turns
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Nutrition
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Hydration
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Personal hygiene
Deep Vein Thrombosis
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Early mobilisation
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Low molecular weight heparin
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Compression devices
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TED stockings not beneficial in
stroke patients
Clots Trial 2009
Positioning
Loss of sensation
Loss of power
Subluxation
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Supportive
IV lines and BP cuffs avoided
on affected limb
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Assess moving and handling
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Good technique
Nutrition
Malnourishment associated
with poor outcome
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Weight
MUST assessment
Naso gastric tube
History of patients eating
habits
Controversial
When to commence invasive
feeding regime