Top Things to Know: Care of the Patient With Acute Ischemic Stroke

Prehospital and Acute Phase of Care, Endovascular/Intensive Care Unit-Postinterventional Therapy, and Posthyperacute and Prehospital Discharge

Published: marzo 11, 2021

  1. 2020 was the year of the nurse, which celebrated nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy.
  2. Nurses are critical in supporting and providing educational opportunities to prehospital providers, dispatchers, and community members supporting the “Ds of Stroke Care”:
    • Detection – rapid recognition of stroke symptoms
    • Dispatch- early activation and dispatch of EMS by calling 911
    • Delivery – rapid EMS identification, management and transport
    • Door – appropriate triage to a stroke center
    • Data – rapid triage, evaluation, and management within the Emergency Department
    • Decision- stroke expertise and therapy selection
    • Drug/Device – fibrinolytic therapy or intra-arterial strategies
    • Disposition- rapid admission to stroke unit or critical care unit
  3. Nurses are key drivers in quality improvement programs, improving statewide stroke systems of care in local, state, and regional health care platforms that target initiatives to address economic, racial, and sex disparities affecting access to emergency stroke care.
  4. In the era of interventional stroke treatment, nurses are responsible for:
    • Preprocedural care – includes documentation of history and physical exam, assessment of airway prior to endotracheal intubation, assessment of mental status, posterior circulation involvement, higher NIHSS score, and other comorbid cardiopulmonary disease; all are more likely to require extra support and intubation.
    • Periprocedural care – using Universal protocol, or time-out, monitoring and assessment of vital signs, ECG rhythms, pulse, blood pressure, respiratory rate, blood oxygen (Spo2) by pulse oximetry, end-tidal carbon dioxide by capnography, pain level, anxiety level, and level of consciousness while in the procedure room.
    • Post procedural care – monitoring during this phase starts at completion of the mechanical thrombectomy (MT) procedure and sheath removal once hemostasis is achieved and includes monitoring for access complications (arterial spasm, pain swelling, bruising, erythema, bleeding, hematoma, pulsatile mass, and drainage from the puncture site)
  5. Complications from interventional procedures may include those from
    • Mechanical thrombectomy itself ischemic or hemorrhagic, and may be symptomatic or asymptomatic,
    • Device-related intraprocedural complications such as vasospasm, arterial perforation or dissection, device detachment or misplacement during the procedure.)
    • Postprocedural complications may relate to post intravenous thrombolytic intervention, intracranial hemorrhage, Systemic hemorrhage, and orolingual angioedema.
  6. When the patient with acute ischemic stroke (AIS) is treated with IV thrombolysis with or without MT, they are vulnerable to developing complications leading to secondary brain injury; because of this these patients usually require intensive monitoring in an intensive care unit (ICU).
  7. The ICU allows frequent nursing care assessment and monitoring. Initial nursing assessments and monitoring after admission to the acute inpatient care unit includes vital signs, fever, hyperglycemia, and swallowing dysfunction.
  8. Key nursing assessments for potential complications: hemorrhagic transformation; cerebral edema/elevated intracerebral pressure/herniation; recurrent stroke with clinical worsening; dysphagia and pneumonia; urinary and gastrointestinal issues (urinary retention, constipation, gastrointestinal bleeding); psychological and neuropsychological complications; mobility complications, such as falls, pressure injury (skin integrity); poststroke pain; and venous thromboembolism.
  9. Secondary stroke prevention requires collaboration from all members of the health care team, which includes treatment of the stroke mechanism and reduction of modifiable stroke risk factors (e.g., hypertension, diabetes, dyslipidemia) and promotion of a healthy lifestyle through diet and exercise, smoking cessation, and addressing any social concerns.
  10. Nurses are the key drivers of stroke care throughout all phases of hospitalization in the acute phase of stroke. Continued nursing research remains a cornerstone for building and expanding nursing knowledge, practice, and evidence-based care for patients and families living with stroke.

Citation


Ashcraft S, Wilson SE, Nystrӧm KV, Dusenbury W, Wira CR, Burrus TM; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. Care of the patient with acute ischemic stroke (prehospital and acute phase of care): update to the 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association [published online ahead of print March 11, 2021]. Stroke. doi: 10.1161/STR.0000000000000356

Rodgers ML, Fox E, Abdelhak T, Franker LM, Johnson BJ, Kirchner-Sullivan C, Livesay SL, Marden FA; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. Care of the patient with acute ischemic stroke (endovascular/intensive care unit-postinterventional therapy): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association [published online ahead of print March 11, 2021]. Stroke. doi: 10.1161/STR.0000000000000358

Green TL, McNair ND, Hinkle JL, Middleton S, Miller ET, Perrin S, Power M, Southerland AM, Summers DV; on behalf of the American Heart Association Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association [published online ahead of print March 11, 2021]. Stroke. doi: 10.1161/STR.0000000000000357