Acute Stroke Nursing

365 Pages·5.06 MB·English

Acute stroke nursing
Edited by
Jane Williams
Portsmouth Hospitals NHS Trust, Portsmouth, Hampshire, UK
Lin Perry
University of Technology Sydney and the Northern Network Hospitals,
South Eastern Sydney and Illawarra Health, Australia
Caroline Watkins
Clinical Practice Research Unit, School of Nursing and Caring Sciences,
University of Central Lancashire, Preston, UK
A John Wiley & Sons, Ltd., Publication
Acute stroke nursing Edited by Jane Williams, Lin Perry and Caroline Watkins
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-16104-6
This edition fi rst published 2010
© 2010 by Blackwell Publishing Ltd
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Library of Congress Cataloging-in-Publication Data
Acute stroke nursing / edited by Jane Williams, Lin Perry, Caroline Watkins.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-6104-6 (pbk. : alk. paper) 1. Cerebrovascular disease–Nursing. 2. Evidence-
based nursing. I. Williams, Jane (Jane E.) II. Perry, Lin. III. Watkins, Caroline.
[DNLM: 1. Stroke–nursing. 2. Evidence-Based Nursing. WY 152.5 A1897 2010]
RC388.5.A288 2010
616.8′10231–dc22
2009029833
A catalogue record for this book is available from the British Library.
Set in 10/12.5pt Sabon by Toppan Best-set Premedia Limited
Printed in Malaysia
1 2010
Contents
Foreword vii
Editors and Contributors xiii
1 Setting the scene 1
Caroline Watkins and Michael Leathley
Introduction 1
Stroke epidemiology 2
Stroke policy 3
Stroke management strategies 8
Research and education 11
Conclusion 13
References 13
2 Developing stroke services: a key role for nursing and nurses 17
Christopher R. Burton
Introduction 17
Service development 17
The nursing contribution to stroke services 19
The political agenda shaping stroke service development 25
Conclusion 30
References 30
3 What is a stroke? 33
Anne W. Alexandrov
Introduction 33
Stroke development processes 34
Risk factors for stroke 37
Anatomy, physiology and related stroke clinical fi ndings 37
Standardised instruments for acute neurological assessment 57
Conclusion 60
References 64
iv Acute Stroke Nursing
4 Acute stroke nursing management 66
Anne W. Alexandrov
Introduction 67
Priorities in acute stroke management 67
Hyperacute stroke management 68
Acute stroke management 80
Conclusion 85
References 85
5 Nutritional aspects of stroke care 91
Lin Perry and Elizabeth Boaden
Introduction 92
Do stroke patients experience nutritional problems pre-stroke? 92
How does stroke affect dietary intake? 95
How can stroke patients be helped to maintain adequate
dietary intake? 104
Conclusion 115
References 117
6 Promoting continence 123
Kathryn Getliffe and Wendy Brooks
Introduction 124
Bladder problems and urinary incontinence 127
Bowel problems and bowel care 144
Conclusion 148
References 149
7 Management of physical impairments post-stroke 152
Cherry Kilbride and Rosie Kneafsey
Introduction 153
Movement 153
Moving and handling people with stroke 155
Therapeutic positioning and seating in the acute phase 157
Promoting early mobilisation 159
Falls prevention 163
Restoration and re-education of movement 164
Management of the upper limb 168
Further rehabilitation strategies and novel developments 171
Patients’ perspective on mobility rehabilitation 174
Conclusion 175
References 176
8 Communication 184
Jane Marshall, Katerina Hilari and Madeline Cruice
Introduction 185
Communication impairments caused by stroke 186
Language minorities 196
Contents v
The role of the speech and language therapist in acute
stroke care 197
Psychosocial issues and quality of life 199
Conclusion 201
References 201
9 Mood and behavioural changes 205
Peter Knapp
Introduction 205
Psychological reactions to the onset of stroke 206
Conclusion 218
References 219
10 Minimally responsive stroke patients 222
Elaine Pierce and Aeron Ginnelly
Introduction 222
Defi nitions and identifi cation 223
Minimally responsive state 224
‘Locked-in’ syndrome 232
Conclusion 237
References 238
11 Rehabilitation and recovery processes 241
Jane Williams and Julie Pryor
Introduction 241
Initiation of rehabilitation 244
Outcomes of rehabilitation 246
Recovery processes 249
Transfer to rehabilitation 250
Rehabilitation provision 252
Conclusion 256
References 256
12 Stroke and palliative care: a diffi cult combination? 263
Christopher R. Burton and Sheila Payne
Introduction 264
Palliative care 264
Relevance of palliative care to stroke 266
Organisational challenges 271
Conclusion 271
References 272
13 Reducing the risk of stroke 275
Peter Humphrey, Jo Gibson and Stephanie Jones
Introduction 275
Primary prevention 276
Secondary prevention: identifying those at risk of stroke 279
vi Acute Stroke Nursing
Public awareness and access to services 296
Secondary prevention of stroke in less common aetiologies
and patient groups 297
Conclusion 299
References 299
14 Longer-term support for survivors and supporters 309
Louise Brereton and Jill Manthorpe
Introduction 309
Leaving hospital 310
What is required longer term? 313
What do carers want? 316
Conclusion 322
References 323
15 Stroke resources for professionals, patients and carers 331
Graham Williamson
National associations 331
Resources for patients and carers 332
Other resources and organisations 333
Specialist international journals 336
Non-specialist journals’ stroke collections 336
Clinical practice guidelines 337
Finding current stroke research 338
Evidence-based practice resources 338
Chapter links 339
Index 343
Foreword
An A merican p erspective
Fifteen years ago, I was asked to assume responsibility for a clinically and
fi nancially ‘ failing ’ Stroke Service at a large academic medical centre in the
south - central United States, for the purpose of clinical quality improvement
and outcomes management. I accepted the job reluctantly; after all, there was
no treatment available for acute stroke other than tradition- bound methods
that focused on diagnosis, some degree of secondary prevention, and rehabili-
tation. Few resources existed at that time to support critical care and emergency
nurses in the management of acute stroke patients. There were no textbooks
that covered the full spectrum of stroke care, and papers authored by nurses
that addressed acute management of stroke were relatively unheard of. But,
within a year, things began to change with the onset of the NINDS’ (National
Institute of Neurological Disorders and Stroke) randomised controlled trial of
tissue plasminogen activator for treatment of acute ischaemic stroke (National
Institute of Neurological Disorders et al. 1 995 ).
Today, acute stroke management is following closely in the footsteps of
cardiology, supported by a growing arsenal of interventions that aim to reduce
neurological disability and death, as well as prevent a fi rst - ever or secondary
stroke event. What used to be a clinical practice area deemed highly undesir-
able and diffi cult to recruit nurses to, is now viewed as exciting and attractive
in centres that have adopted aggressive reperfusion therapies. Rehabilitative
strategies have also expanded dramatically and now include exciting technolo-
gies such as robotics and a variety of approaches to support return to functional
independence. Overall, evidence- based, cross - continuum strategies are being
implemented in centres once plagued by traditional and often unscientifi c prac-
tices, supporting improved interdisciplinary health care and ultimately, enhanced
patient and societal outcomes. In short, stroke nursing care has come of age.
This text provides a 360- degree orientation to stroke nursing. From the pre-
hospital environment, to hyperacute/acute management, complication avoid-
ance, secondary prevention, and neurological recovery, readers are provided
viii Acute Stroke Nursing
with an evidence- based, holistic approach to the management and prevention
of neurovascular disease. With the knowledge gained by reading this text, I
challenge my nursing colleagues to continue to push their local practice para-
digms to adopt an evidence- based approach to the interdisciplinary manage-
ment of stroke, and to commit to questioning and studying new and evolving
practices that aim to improve the lives of stroke survivors and their loved ones.
Nurses are the key drivers of health care quality throughout the world. As
the most numerous of the health professions employed within all of the practice
settings across the health continuum experienced by stroke patients, nurses
must commit themselves to ensuring ‘ safe passage’ of stroke survivors and their
family through an increasingly complex and fast paced health care environ-
ment. Mastering the knowledge contained within this text is an important
fi rst - step in a journey toward attainment of stroke nursing excellence; pledging
to continue that journey through formal education, knowledge generation and
dissemination, as well as ongoing self- refl ection are the next key steps to ensur-
ing best nursing practices for stroke patients. I congratulate the editors and
authors of this text for making this journey possible, and look forward to
watching stroke nursing knowledge ignite and expand among our readers.
Anne W. Alexandrov
An A ustralian p erspective
As elsewhere in the world, stroke is a leading cause of death and disability in
Australia (Senes 2 006 ); hence, optimal management is imperative. Results from
the Cochrane systematic review of randomised controlled trials of organised
stroke care provided compelling evidence for the effectiveness of stroke units
(Stroke Unit Trialists’ Collaboration 2003 ). In Chapter 1 , Professor Watkins
explains this evidence and the key features of stroke units. As a result, provision
of care for stroke patients in dedicated units by coordinated, multidisciplinary
teams is one of the pivotal strategies for improving patient outcomes interna-
tionally. This evidence has underpinned health reforms for hospitalised stroke
patients throughout the world, including Australia.
As in the UK, stroke is a national health priority area in Australia. In 2006,
a National Service Improvement Framework for Heart, Stroke and Vascular
Disease was developed which outlined ‘ critical intervention points ’ along the
continuum of stroke care where it was likely that health gains and improve-
ments to services could be made (National Health Priority Action Council
(NHPAC) 2006 ). The Framework recommended as a priority that stroke unit
care should be ‘ available to all Australians who suffer a stroke ’ . The National
Stroke Unit Program funded by the Commonwealth Government was
undertaken by the National Stroke Foundation (NSF), a not- for - profi t, non -
government organisation, to promote optimal treatment of stroke patients
(National Stroke Foundation 2 002 ). The Program included a review of stroke
service policy, development of acute stroke guidelines and performance indica-
tors. In addition, a Stroke Services Model was developed to classify hospitals
Foreword ix
according to categories A to D, based on the structure and processes of care
and the clinical profi le of patients (Cadilhac et al. 2006c ). Category A and B
hospitals have access to comprehensive stroke services such as on- site computed
tomography (CT) scanning and intensive care/high dependency beds with Cat-
egory A hospitals also having on- site neurosurgery. Category C hospitals have
access to CT scanning within 12 hours, usually off - site, whilst category D
hospitals have neither CT scan access nor availability of other structural crite-
ria. It is expected that all Category A and B hospitals have a stroke unit.
However, a survey conducted in 2004 indicated that only 83% of Category A
and 30% of Category B hospitals had such units (Cadilhac et al. 2006b ). In
total, only 19% of Australian public hospitals had a stroke unit. This fi gure
did not compare favourably internationally, particularly with data from Norway
and Sweden where 60% and 70% of hospitals respectively have stroke units
(Rudd & Matchar 2004 ). Hence, whilst equity of access to stroke unit care is
a health care policy issue for many countries, it is particularly so for Australia.
Provision of equitable stroke care within Australia remains a challenge. With
the majority of the nation’ s population located along the eastern coastline, this
is where most stroke services were initially established. Further, Australian
stroke units are primarily located in metropolitan hospitals and/or in hospitals
with 300 beds or more (Cadilhac et al. 2006b ). This potentially disadvantages
rural and non - metropolitan inhabitants. New South Wales (NSW) currently
has the highest number of stroke units in Australia, as a direct result of the
state government providing dedicated funding which increased their numbers
from 7 to 23 in metropolitan areas over fi ve years (Cadilhac et al. 2 006b ).
Subsequent initiatives have established seven stroke services in rural NSW.
Encouragingly, Australian hospitals with stroke units have been shown to
have greater adherence to important processes of clinical care when compared
with either a mobile stroke service or general medical ward (Cadilhac et al.
2004 ). Processes of care were chosen because of association with improved
outcomes, and included early CT- scanning, swallowing assessment, and regular
neurological observations. The importance of this was reinforced by clinical
audits, demonstrating signifi cant reduction in death and disability for patients
admitted to NSW metropolitan stroke units (Cadilhac et al. 2 006a ). As in other
countries, ‘ best practice’ guidance has been made available through develop-
ment and publication of Australian clinical practice guidelines for the manage-
ment of acute stroke, rehabilitation and recovery (National Stroke Foundation
2005, 2007 ).
To support practice and service development, a cohesive platform for train-
ing, education and implementation of collaborative, multidisciplinary stroke
services including research is provided by Stroke Services NSW. Similar mech-
anisms for fostering clinician and health service management partnerships have
been endorsed in the states of Victoria and Western Australia through state -
based stroke strategies (Department of Health Services, Victoria (DoHSV)
2007 ; Department of Health Western Australia 2 006 ). Other support initiatives
include the Towards A Safer Culture (TASC) Clinical Support Systems Program
and establishment of the Australian Stroke Clinical Registry (AuSCR). These
have been implemented in several Australian states and territories, and aim
x Acute Stroke Nursing
to embed evidence- based clinical practice with clinical quality improvement
activities by the use of online, web- based data acquisition and feedback systems
for minimum and extended data sets for stroke patients. Establishment of
formal liaison between acute stroke and ambulance services ensures that stroke
patients receive appropriate pre- hospital care and are transported to hospitals
with an acute stroke unit.
Professional networks such as the Stroke Society of Australasia and the Aus-
tralian Stroke Unit Network, comprised of multidisciplinary clinicians, policy
makers and researchers, work to improve delivery of evidence- based stroke
care. In addition, a number of research teams are undertaking leading- edge
stroke research from basic science through to public health research in col-
laboration with researchers around Australia and overseas. Further, many
stroke units throughout the country are involved in multicentre national and
international clinical trials and research aimed at improving stroke services. The
National Stroke Foundation provides information for stroke patients and their
carers and at state level, local stroke support associations play a vital role in
raising community awareness and supporting stroke patients and their families.
Although coverage is not comprehensive, Australia has well- developed
support for patients experiencing stroke. A proactive and growing stroke
health care professional community is a crucial element, and the important
contribution of nursing is recognised. Education and continuing professional
development are key to this. This book sets out in detail what excellence in
stroke nursing comprises, in an easy- to - read style. It makes a unique and essen-
tial contribution to dissemination of evidence- based practice and hence to
improvement and enhancement of stroke nursing care services at all levels and
internationally.
Sandy Middleton
References
Cadilhac , DA , Ibrahim , J , Pearce, DC , Ogden , KJ , McNeill , J et al. for the S COPES
Study Group , 2004 , Multicenter comparison of processes of care between Stroke
Units and conventional care wards in Australia , S troke , vol. 3 5 , no. 5 , pp. 1035 –
1040 .
Cadilhac , D , Pearce, D , Levi , C , & Donnan, G , 2006a , Preliminary audit results of a
clinician driven, government funded program to implement 19 networked stroke care
units (SCUs) in one Australian state , Cerebrovascular Diseases , vol. 21 , p. 134 .
Cadilhac , DA , Lalor , EE , Pearce, DC , Levi , CR , & Donnan, GA , 2006b , Access to
stroke care units in Australian public hospitals: facts and temporal progress, Internal
Medicine Journal , vol. 36 , no. 11 , pp. 700 – 704 .
Cadilhac , DA , Mooie , ML , Lalor , EE , Bilnet , LE , & Donnan , GA on behalf of the
National Stroke Foundation, 2006c , Improving access to evidence- based acute stroke
services: development and evaluation of a health systems model to address equity of
access issues , Australian Health Review , vol. 30 , no. 1 , pp. 109 – 118 .
Department of Health Services, Victoria (DoHSV), 2007 , A state - wide stroke care
strategy for acute and sub - acute stroke care , Department of Human Services, Mel-
bourne, Victoria .