Discussion

ATTACHED FILE(S)
24 February 2016 •Nursing Management www.nursingmanagement.com
Staff development special
A
ccording to the American Heart Association (AHA), someone
has a stroke every 40 seconds in the United States; a person dies
of one approximately every 4 minutes.1 This translates into 1 in
every 20 deaths in the United States resulting from stroke, making it the
fifth leading cause of death for Americans.2-4 Stroke has also remained
the leading cause of disability for the last decade. Currently, there are
3.8 million women and 3 million men living with disabilities as a direct
result of stroke.1,4 Research has shown that early evaluation and treat-
ment are directly linked to reduced motor and cognitive deficits, as well
as lower mortality. (See Introduction to The Joint Commission stroke core
measures and stroke center certification.)
Two types to know
There are two types of stroke: ischemic and hemorrhagic. Both result in
vital oxygen-rich blood depletion to areas of the brain. Emergent diagno-
sis and treatment must be implemented quickly to prevent brain tissue
hypoxia and death. Although both types may cause similar clinical pre-
sentation, each requires a different approach to treatment.
By Charlotte Davis, BSN, RN, CCRN,
and Lisa Lockhart, MHA, MSN, RN, NE-BC
2.5
CONTACT HOURS
By Charlotte Davis, BSN, RN, CCRN,
d Li L kh t MHA MSN RN NE BC
5
RS Stroke
Update:
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www.nursingmanagement.comNursing Management •February 2016 25
guidelines
www.nursingmanagement.comNursing Management •February 2016 25
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
26 February 2016 •Nursing Management www.nursingmanagement.com
Update: Stroke guidelines
Ischemic stroke
An ischemic stroke is caused by a
thrombus that blocks blood supply
to a cerebral artery, which supplies
oxygen-rich blood to brain tissue.
The thrombus causes both glucose
and oxygen deprivation, with sub-
sequent mitochondrial cell death.
According to the AHA, 45% of all
ischemic strokes are caused by a
small or large arterial thrombus,
20% are venous emboli that migrate,
and the remaining 35% are of
unknown origin.1 Microembolic
showers as a result of untreated
atrial fibrillation, arteritis, patent
foramen ovale, left ventricular
dysfunction, and refractory septic
shock can also cause an ischemic
stroke. Other less common causes of
ischemic stroke are carotid dissec-
tion, the acute phase of traumatic
brain injuries, and coagulopathy
states such as disseminated intra-
vascular coagulation.
An ischemic stroke may initially
present as a transient ischemic
attack (TIA), which is commonly
referred to as a “mini-stroke” or
a precursor to a future ischemic
stroke. A TIA occurs when there’s a
temporary occlusion or blockage of
blood flow to a portion of the brain.
This transient occlusion can cause
symptoms that mimic a stroke,
such as slurred speech; visual dis-
turbances; weakness in an extremity;
or brief changes in level of con-
sciousness (LOC), lasting between
1 and 30 minutes and disappearing
without any long-term effects. With
a stroke, the symptoms last longer
than 30 minutes.
It’s imperative that any symp-
toms of a TIA or stroke be evalu-
ated immediately so that diagnostic
and treatment interventions can be
initiated to minimize the likelihood
of long-term cognitive, sensory, and
physical impairment. According to
the AHA, approximately one-third
of patients who experience a TIA
will have an ischemic stroke within
1 year.2,4
Hemorrhagic stroke
A hemorrhagic stroke occurs when
areas of the cerebral arterial system
become weakened or thin due to
long-term or acute episodes of
hypertension. This weakened or
thin area of the vessel wall can
either result in an outpouching of
the arterial blood vessels (aneu-
rysm) or it can rupture as the arte-
rial pressure rises, exerting pressure
on the thinned fragile wall during
periods of acute hypertension.
Both the aneurysm and thin arterial
vessel areas are prone to rupture.
Intracerebral hemorrhages are typi-
cally caused by rupture of vessels
due to long-term atherosclerotic
damage and arterial hypertension.
Risk factors
Common risk factors include:
• age older than 45
• smoking5
• atrial fibrillation
• female sex (current AHA research
reveals that women ages 55 to
75 have a 20% risk of having a
stroke compared with 17% for
men)2,4,6
• sleep apnea
• hypertension
• heredity
• Black, Hispanic, or Asian ethnicity7
• history of TIA, previous stroke, or
myocardial infarction
• substance abuse or alcoholism
(some illicit drugs, such as cocaine,
can cause profound vasoconstric-
tion to the cerebral arteries, dramat-
ically reducing or occluding blood
supply to the brain tissue, which
can result in impaired blood flow,
clot formation, and an evolving
ischemic stroke).5,8
Symptoms watch
Despite the AHA’s public educa-
tion campaign on stroke warning
signs, many patients postpone
medical treatment after they begin
to experience stroke symptoms.
It’s vital that symptoms be recog-
nized early and time-sensitive
interventions be performed within
the recommended guidelines to
improve clinicaloutcomes, mini-
mize neurologic dysfunction, and
reduce mortality.
Currently, the AHA and the
National Institute of Neurologi-
cal Disorders and Stroke (NINDS)
recommend that healthcare facili-
ties strategically place community
education posters in heavily traf-
ficked areas displaying the FAST
mnemonic:
• facial drooping
• arm weakness
• speech slurred
• time to call 911.
According to the AHA,
approximately one-third of
patients who experience a
TIA will have an ischemic
stroke within 1 year.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.nursingmanagement.comNursing Management •February 2016 27
Assessment stat
The NINDS recommends utilizing
a specific stroke assessment tool to
evaluate patients suspected of hav-
ing a stroke. Two common stroke
assessments are the Cincinnati Pre-
hospital Stroke Scale (CPSS) and
the National Institutes of Health
Stroke Scale (NIHSS).
The CPSS is commonly utilized
by emergency medical services
personnel and paramedics.9 It con-
sists of performing the following
assessment:
• facial droop
—normal: both sides of the face
move equally
—abnormal: one side of the face
doesn’t move at all
• arm drift
—normal: both arms move equally
or not at all
—abnormal: one arm drifts com-
pared with the other
• speech
—normal: the patient uses correct
words with no slurring
—abnormal: the patient uses
slurred or inappropriate words or
is mute.
The NIHSS was developed
to help nurses and physicians
objectively identify the severity
of ischemic strokes by assessing
15 specific areas for abnormali-
ties or disabilities. The modified
version only assesses 11 specific
physical areas.
An elevated NIHSS score corre-
lates with the size of the infarction
on both a computed tomography
(CT) scan and magnetic resonance
imaging (MRI).2,6 Scores should be
assessed initially when a stroke is
suspected, 24 hours after fibrino-
lytic therapy, 7 days post stroke,
and 30 days post stroke. Scores
assessed at 48 hours following a
stroke have been directly corre-
lated with clinical outcomes at the
3-month and 1-year mark.
According to the NINDS,
patients with a NIHSS score of 4 or
less have been linked to a high like-
lihood of functional independence
regardless of treatment. Patients
with a high score (greater than 22)
may experience severe debilitation
and be dependent on assistance
from others to perform basic activi-
ties of daily living.
The Miami Emergency Neu-
rologic Deficit, or MEND, exam
is another stroke scoring tool
that healthcare facilities may uti-
lize, which incorporates all three
components of the CPSS (speech,
droop, drift) and eight additional
components from the NIHSS, such
as LOC, eye gaze, orientation, com-
mands, visual fields, leg motor
strength, ataxia, and sensation.10
A noncontrast CT scan should
be performed within 25 minutes of
time zero (arrival to the ED), with
diagnostic results made available to
the stroke team within 45 minutes
so that a decision can be made on
the most appropriate treatment
plan. Contrast isn’t used if a stroke
is suspected because it will mask
blood in the cranial vault, making
it difficult to differentiate between
ischemic and hemorrhagic stroke.
The most common type of
stroke is nonhemorrhagic-ischemic
(approximately 87%), which may
not be readily visualized on the
CT scan.1,2 MRI may be needed in
addition to a CT scan to diagnose
ischemic stroke and confirm the
presence of the thrombus or embo-
lism occluding specific vessels within
the brain. Magnetic resonance angi-
ography and cerebral angiography
are useful if the stroke team suspects
that the thrombus is in a location
where a thrombectomy may be a fea-
sible treatment option. For example,
if the patient is experiencing hemi-
anopsia (decreased vision or blind-
ness in half of the visual field), the
stroke team may suspect a posterior
cerebral artery occlusion/ clot that
may be resolved with thrombectomy.
Time-sensitive interventions
Early intervention when a stroke
is suspected is vital to optimize
neurologic outcomes. According to
recent research, the ischemic brain
ages 3.6 years each hour that treat-
ment is delayed.4 When a large
vessel ischemic stroke occurs, 1.9
million neurons, 14 billion syn-
apses, and 12 km (7.5 miles) of
myelinated fibers are destroyed
every minute.11
After the patient enters the ED,
the 1-hour clock should be started
so that all staff members are aware
of when each time-sensitive inter-
vention should be performed. The
AHA recommends that all EDs
have a clock or stopwatch that the
healthcare team activates at time
zero. This is the time from which all
further ED interventions will start.
The team member in charge of time
should remind each staff member
of how many minutes have passed
since each intervention has been
performed.
The AHA and the American
Stroke Association (ASA) devel-
oped the 60 minute or less stroke
protocol that all healthcare facili-
ties should follow, with specific
time-sensitive interventions that
must be performed at 10 minutes,
15 minutes, 25 minutes, 45 minutes,
and 60 minutes after the patient
enters the ED. These protocol-
directed interventions are designed
to improve neurologic outcomes
based on clinical research findings.
The AHA/ASA stroke proto-
col recommends the following
sequence of events during the first
hour after the patient’s arrival:
• 10 minutes—patient seen by
the ED physician for an initial
assessment
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
A
s nursing leaders, we’re
responsible for ensuring
that our staff members par-
ticipate in evidence-based practice
and maintain compliance with
widely established national guide-
lines that govern care standards.
With the prevalence of ischemic
stroke occurrence increasing within
all healthcare settings, a key focus
is The Joint Commission stroke
core measure set and stroke center
certification.
When caring for patients expe-
riencing stroke, we must create a
culture of early recognition and
intervention. In this environment,
the nurse manager ’s role in clini-
cal collaboration, development
of multidisciplinary teams, and
communication across service
lines is critical. As we look to The
Joint Commission, the American
Heart Association (AHA), and
the American Stroke Association
(ASA) for guidance, we clearly
understand that nurses at the
point of care are vital to positive
patient outcomes.
Stroke core measures
The Joint Commission stroke core
measures were developed collabor-
atively with the AHA, the ASA,
and the Brain Attack Coalition. The
eight core measures are as follows:
• STK-1: venous thromboembolism
prophylaxis
• STK-2: discharged on antithrom-
botic therapy
• STK-3: anticoagulation therapy
for atrial fibrillation/flutter
• STK-4: thrombolytic therapy
• STK-5: antithrombotic therapy by
the end of hospital day 2
• STK-6: discharged on statin
medication
• STK-8: stroke education
• STK-10: assessed for
rehabilitation.1
STK-1
All patients diagnosed with either
hemorrhagic or nonhemorrhagic
stroke should have deep vein
thrombosis (DVT) prophylaxis
implemented or documentation
as to why it’s contraindicated.
This is required due to the high
risk of DVT in stroke patients.
Note that aspirin therapy isn’t
considered adequate to meet this
standard.
STK-2
Patients diagnosed with ischemic
stroke need to be discharged with
some form of antithrombotic ther-
apy. Research has shown that
antithrombotic therapy helps
decrease the high risk of stroke
reoccurrence, as well as morbidity
and mortality. This is especially
important with patients whose
stroke is attributed to a cardioem-
bolic event.
Introduction to The Joint Commission stroke core
28 February 2016 •Nursing Management www.nursingmanagement.com
Update: Stroke guidelines
• 15 minutes—patient seen by the
stroke team
• 25 minutes—noncontrast CT scan
performed
• 45 minutes—CT scan results
available to the stroke team and
decision made for treatment
• 60 minutes—initiation of fibrino-
lytic therapy within 3 hours of stroke
symptoms unlesscontraindicated.
Medications
According to the AHA, tissue
plasminogen activator (tPA) is the
gold standard for treating isch-
emic stroke. It’s contraindicated
inhemorrhagic stroke because
it can dramatically expand the
area of intracranial bleeding and
worsen the stroke. It’s the only
FDA-approved drug for adminis-
tration in the acute care of isch-
emic stroke when systolic BP is
below 185 or diastolic BP is below
100.12 tPA is a fibrinolytic medica-
tion that works by stimulating the
production of the enzyme plas-
min, which digests fibrin strands
and restores oxygen-rich blood
flow to the brain. However, tPA
puts the patient at risk for bleed-
ing.13 In a 2014 research study,
22.8% of all ischemic stroke
patients treated with tPA experi-
encedbleeding complications,
including intracranial bleeding.12
Getting a history as complete
as possible from the patient or
caregiver, including the time last
known well, and verification of
ischemic stroke are required before
administration of tPA. Door-to-
admission time of 3 hours is the
widely accepted timeline for tPA
administration. However, it can
be administered in well-screened
patients who are at low risk for
bleeding for up to 4.5 hours.14
tPA is contraindicated in patients
with an international normalized
ratio of greater than 2, those with
a recent history of a traumatic
brain injury (less than 90 days),
and those with a history of hemor-
rhagic stroke.15
Other medications that may be
administered include:
• furosemide—a loop diuretic uti-
lized to reduce intracranial volume
in hemorrhagic stroke, resulting in
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
measures and stroke center certification
www.nursingmanagement.comNursing Management •February 2016 29
a decreased incidence of transtento-
rial or uncal herniation
• mannitol—an osmotic diuretic
used to decrease cerebral edema
and tissue damage, and reduce
the risk of transtentorial or uncal
herniation2
• fosphenytoin—a water-soluble
prodrug of phenytoin utilized to
stabilize neuronal membranes and
decrease seizure activity
• phenytoin—an antiepileptic drug
used to inhibit the spread of seizure
activity in the cerebral motor cortex,
as well as in the brainstem centers
that are responsible for the tonic
phase of grand mal seizures
• benzodiazepine—a psychoactive
drug utilized to reduce skeletal
muscle spasms.16
Surgical procedures
Endovascular thrombectomy is an
option to remove the thrombus and
reestablish blood flow for the isch-
emic stroke patient. The benefit of
endovascular thrombectomy over
tPA is that it can mechanically
remove a thrombus in a matter of
minutes, whereas tPA can take up
to 2 hours to dissolve it.12 Innova-
tive endovascular catheter devices
have shown to be the most effective
at restoring blood flow and remov-
ing thrombi. However, an endovas-
cular catheter has limitations, such
as it can only remove thrombi from
Nursing interventions are
centered on the support
of airway, breathing, and
circulation as a primary goal.
STK-3
Patients with atrial fibrillation/flutter
must be discharged with some
form of anticoagulation therapy.
The risk of stroke in patients with
atrial fibrillation/flutter increases
with age. Note that studies have
shown a decrease in stroke occur-
rence by as much as 68% in patients
treated with warfarin.2
STK-4
The use of specific thrombolytic
agents has proven to be highly effec-
tive in patients who are carefully
screened and meet specific criteria
related to medical history, time of
stroke onset, and current cause of
presentation. The recommended
medication is I.V. tissue plasmino-
gen activator (tPA). Maintaining
tPA administration compliance
within the time requirements is vital
for achieving and sustaining stroke
center certification. Nursing man-
agement team members should be
aware that a younger age, milder
stroke, shorter door-to-needle time,
normoglycemia, and absence of
comorbidities are all linked to
improved clinical outcomes, shorter
length of stay, and reduced mortality.3
To minimize ischemic stroke
mortality and disability complica-
tions, a growing trend in tertiary
hospitals is the “drip-and-ship”
method—transfer of the acute
stroke patient to another facility
after administration of I.V. tPA.4 If
utilizing the drip-and-ship method,
management team members should
closely monitor the clinical inter-
ventions performed before the
patient is transferred and follow the
clinical outcomes of those patients
to monitor for positive results.
STK-5
Antithrombotic therapy must be
started within 2 days of acute
stroke in patient who meet the
screening criteria. One of the limit-
ing factors in stroke care is the time
of onset, which is a major influence
on treatment choices and known
success rates (recovery). Note that
DVT prophylaxis therapy is consid-
ered inadequate for this purpose.
STK-6
Increased serum lipid levels have
proven to be a risk factor for both
stroke and cardiac events. Patients
with a low-density lipoprotein
cholesterol level equal to or greater
than 100 mg/dL should be started
on and discharged with statin
therapy.
STK-8
The patient must receive stroke
education. Preventive health edu-
cation on the control of risk factors
is vital to recovery and prevention
continued on page 30
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
30 February 2016 •Nursing Management www.nursingmanagement.com
Update: Stroke guidelines
large cerebral vessels and,therefore,
isn’t an appropriate treatment
option if the thrombus is lodged in
a smaller arterial cerebral vessel.
Recent clinical research outcomes
from the SWIFT-PRIME study
released in February 2015 revealed
that endovascular thrombectomy
patients had better clinical out-
comes and functional independence
in 60.2% of cases of large vessel
thrombi compared with 35.5%
of tPA patients. In 4.3% of cases,
the clinical outcomes remained
unchanged.1
Surgical procedures that may be
considered to treat hemorrhagic
stroke include:
• superficial temporal artery to mid-
dle cerebral artery bypass graft—a
small, superficial temporal artery
can be grafted to bypass the cerebral
vessel that has the thrombus or an
unruptured aneurysm (can also be
used to treat ischemic stroke)
• Guglielmi detachable coils—
small, platinum coils are used to
occlude an inoperable, ruptured, or
unruptured aneurysm
• aneurysm clipping—surgical
clips may be placed to seal bleeding
from a fusiform aneurysm (ruptured
or unruptured) or multiple small
vessel aneurysms
• decompressive craniotomy—a
cranial bone flap window is
removed to allow for visualization
of the aneurysm during surgical
clip placement (a controversial and
aggressive approach to managing
a hemorrhagic stroke).
With all surgical interventions,
the nurse needs to assess the
of reoccurrence. In addition, educa-
tion about how to recognize stroke
symptom onset and the importance
of immediate response to the warn-
ing signs is needed.
STK-10
The process of recovery is immedi-
ate and ongoing. After the patient
is stabilized, he or she should be
assessed for rehabilitation needs,
such as physical, speech, or occupa-
tional therapy. This should include
a safe discharge plan and aftercare
if needed. Rehabilitation should
start as soon as the patient is able.
This approach is associated with an
increase in return to function and
improved quality of life.
In addition to having compre-
hensive knowledge of these core
measures, staff members should
understand the AHA/ASA stroke
protocol, which outlines time-
sensitive interventions for the first
hour of care after the patient enters
the ED (time zero).5 If you visit the
AHA website at www.heart.org,
there are numerous resources avail-
able, including the Get with the
Guidelines stroke program. These
are strong tools to facilitate your
journey to stroke center certifica-
tion and excellence.
Stroke center certification
The Joint Commission offers three
levels of stroke program certification:
• acute stroke ready hospital
• primary stroke center
• comprehensive stroke center.6
Acute stroke ready hospital
To qualify as an acute stroke ready
hospital, your facility must:
• have a dedicated stroke program
• be staffed with qualified health-
care professionals trained in stroke
care
• have a qualified practitioner
available to assess a patient sus-
pected of experiencing a stroke
within 15 minutes of arrival
• be able to quickly perform diag-
nostic imaging and lab testing to
facilitate I.V. thrombolytic medica-
tion administration in eligible
patients
• utilize AHA/ASA guidelines
• have transfer agreements with
primary or comprehensive stroke
centers.6,7
The goal is that acute stroke
ready hospitals are prepared to
treat, stabilize, and transport
stroke patients to a primary or
comprehensive stroke center in a
timely fashion.
Primary stroke center
To be designated as a primary
stroke center, your facility needs to:
• have a designated stroke unit
• utilize a standard care delivery
method
• provide individualized treatments
and interventions
• promote the flow of patient
information across settings and
providers
• promote patient self-management
activities
• utilize AHA/ASA guidelines
As the clock begins at time zero
when a new stroke patient arrives
at your facility, the nursing staff
must be profi cient in assessment
and implementation of time-
sensitive interventions.
continued from page 29
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.nursingmanagement.comNursing Management •February 2016 31
surgical site at the beginning of
each shift and frequently thereafter
for either a puncture site hematoma
formation or localized edema and
erythema that may indicate infec-
tion. Changes in vital signs, such as
tachycardia, hypo- or hypertension,
and an elevated body temperature,
may signal infection or unmet pain
needs. If a hematoma or signs of
localized infection are noted, the
healthcare team should be imme-
diately notified so that emergent
evaluation, diagnostics, and treat-
ments can be initiated.
A full neurologic assessment
should be performed at least once
an hour for the first 3 days after the
procedure and thereafter if neuro-
logic changes, such as a decreased
LOC, new visual changes, and
new-onset weakness, are noted. If
changes are present, the healthcare
team should be alerted immedi-
ately because this may signal an
extension of the stroke area, cerebral
vasospasm, or evolving cerebral
brainstem herniation.
Minimizing complications
Aspiration is a potential complica-
tion of stroke. The nurse must
ensure that the patient remains
N.P.O. because he or she is at high
risk for aspiration. The patient
should successfully pass a bedside
swallowing assessment before eat-
ing, drinking, or consuming as
needed medications. A fluoroscopic
swallowing exam should be per-
formed to assess for prominent or
silent aspiration—the aspiration of
gastric or orogastric contents into
the lung fields without causing
immediate symptoms such as
coughing. The nurse needs to
ensure that the head of the bed
remains elevated at a minimum of
30 degrees unless contraindicated
to decrease the risk of aspiration
and reduce cerebral edema.
Other complications include:
• cerebral edema
• pneumonia
• urinary tract infection and/or loss
of bladder control
• seizures
• depression
• pressure ulcers
• limb contractures
• shoulder pain
• deep vein thrombosis
• ischemic stroke conversion to
hemorrhagic stroke
• cerebral vasospasm
• hypotension or hypertension.
• analyze standardized perfor-
mance measure data (eight required
measures).6
Comprehensive stroke center
To become a comprehensive stroke
center, your facility is required to:
• have significant resources to pro-
vide state-of-the-art care to all
stroke patients
• have a dedicated neuro ICU that
provides around-the-clock critical
care for complex stroke patients
• have advanced imaging
capabilities
• meet the minimum requirements
for caring for patients diagnosed
with subarachnoid hemorrhage
• coordinate posthospital care
• utilize a peer review process to
evaluate the care provided
• analyze standardized perfor-
mance measure data (16 required
measures)
• participate in stroke research.6
The following three require-
ments must be met to apply for
certification:
• standards: the program must
meet the standards outlined in the
Disease-Specific Care manual
• clinical practice guidelines: the
program must demonstrate compli-
ance with evidence-based clinical
care guidelines outlined in the
Disease-Specific Care manual
• performance measures: the pro-
gram must meet specific perfor-
mance measure requirements that
address urgent care assessment,
acute care hospitalization/treatment,
risk factor modification, secondary
prevention, education, and rehabili-
tation, with monthly data collection
demonstrating compliance and
improvement.8
The Joint Commission utilizes
ORYX to analyze the data col-
lected.9 This method enables
The Joint Commission and the
applicant to gauge the facility’s
performance based on individual
observed performance versus the
standard norm, which is derived
from analysis of similar organiza-
tions. The facility’s norm is deter-
mined through the use of compara-
tive historical data. This facilitates
assessment of the facility’s overall
performance improvement process
and its effectiveness. The result
is a strong look at the facility’s
accountability and quality regard-
ing research, proximity, accuracy,
and adverse reactions.
On your radar
Preparation for certification starts a
year or more in advance. The sur-
vey process requires a site visit in
addition to a detailed application
packet and data collected on core
measure requirements (historical
and current data, along with pro-
cess improvements). Stroke certifi-
cation is valid for 2 years and then
must be renewed.
Regardless of the level of certifi-
cation, the benefits not only extend
to your patients, but also your
organization’s community standing
and draw when recruiting qualified
professional staff. According to The
continued on page 32
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
32 February 2016 •Nursing Management www.nursingmanagement.com
The nurse should monitor vital
signs at least every 15 minutes.
It’s critical that patients who expe-
rienced an ischemic stroke avoid
hypotension because they already
have reduced oxygen-rich blood
flow to the brain. If tPA is initi-
ated, vital signs should be moni-
tored before initiation and every
5 minutes for the first 15 minutes
after administration, then every
15 minutes thereafter.13 Nurses
managing a patient with a diagno-
sis of hemorrhagic stroke should
avoid hypertensive states because
this can result in an expansion
of intracranial bleeding, which
will result in increased intracra-
nial hypertension and predispose
the patient to further neurologic
injury.15
Nursing interventions are cen-
tered on the support of airway,
breathing, and circulation as a pri-
mary goal. These patients may need
ventilator support for respiratory
depression or respiratory fatigue
secondary to the neurologic injury.
Neurologic assessments should
be performed hourly or as needed
to closely monitor for neurologic
decline. An increased frequency may
be needed if hemodynamic decline
is present or signs of imminent brain
stem herniation are noted (increased
intracranial pressure, decreasing
strength in extremities, focal or
global seizure activity, or pupils
becoming grossly asymmetrical).17
Patients should be closely monitored
for seizure activity, with seizure pre-
cautions in place at all times.
The earlier, the better
As the clock begins at time zero
when a new stroke patient arrives at
your facility, the nursing staff must
be proficient in assessment and
implementation of time-sensitive
interventions. Adhering to the 2015
AHA/ASA stroke guidelines can
improve patients’ chain of survival.17
As nurses continue to utilize these
guidelines, lives are saved. NM
REFERENCES
1.Sidney S, Rosamond WD, Howard VJ, Luepker
RV; National Forum for Heart Disease and
Stroke Prevention. The “heart disease and
stroke statistics—2013 update” and the need
for a national cardiovascular surveil lance
system. Circulation. 2013;127(1):21-23.
2.American Heart Association, American
Stroke Association. Stroke webinar 7: acute
stroke therapy. https://learn.heart.org/Activ-
ity/2699791/Detail.aspx#lnk2699791.
Joint Commission, the benefits of
stroke certification include:
• improving patient care quality
through the reduction of clinical
process variation
• providing structure for a disease
management program
• facilitating opportunities for team
members to hone their knowledge
and skills within a framework of
common goals
• promoting an organizational cul-
ture of excellence.10
Certification may be a prerequisite
for insurance reimbursement eligibil-
ity, and it may also meet certain regu-
latory requirements in some states.10
Deep impact
Early recognition, timely interven-
tion, and utilization of The Joint
Commission stroke core measures
and AHA/ASA guidelines save
lives. Engaging in a journey to obtain
stroke center certification can have a
tremendous impact on your organi-
zation and the community that uti-
lizes its care. Ensuring that your staff
members receive initial and ongoing
stroke education isn’t only vital for
accreditation compliance, but also to
achieve positive patient outcomes.
REFERENCES
1.The Joint Commission. Stroke. www.
jointcommission.org/stroke.
2.January CT, Wann LS, Alpert JS, et al.
2014 AHA/ACC/HRS guideline for the
management of patients with atrial fibril-
lation: a report of the American College
of Cardiology/American Heart Association
Task Force on practice guidelines and
the Heart Rhythm Society. Circulation.
2014;13(23):e199.
3.König IR, Ziegler A, Bluhmki E, et al.
Predicting long-term outcome after acute
ischemic stroke: a simple index works
in patients from controlled clinical trials.
Stroke. 2008;39(6):1821-1826.
4.Sheth KN, Smith EE, Grau-Sepulveda MV,
Kleindorfer D, Fonarow GC, Schwamm
LH. Drip and ship thrombolytic therapy
for acute ischemic stroke: use, tem-
poral trends, and outcomes. Stroke.
2015;46(3):732-739.
5.American Stroke Association. Target: stroke.
www.strokeassociation.org/idc/groups/
heart-public/@wcm/@hcm/@gwtg/docu-
ments/downloadable/ucm_308277.pdf.
6.The Joint Commission. Facts about
Joint Commission stroke certification. www.
jointcommission.org/facts_about_joint_
commission_stroke_certification/.
7.The Joint Commission. Acute stroke ready
hospital certification example standards.
www.jointcommission.org/assets/1/18/
asrh_flyer.pdf.
8.The Joint Commission. 2015 compre-
hensive certification manual for disease-
specific care including advanced programs
for disease-specific care certification.
www.jcrinc.com/2015-certification-
manuals/2015-comprehensive-certifi-
cation-manual-for-disease-specific-care-
including-advanced-programs-for-disease-
specific-care-certification/.
9.The Joint Commission. Facts about ORYX
for hospitals (national hospital quality
measures). www.jointcommission.org/
facts_about_oryx_for_hospitals/.
10.The Joint Commission. Benefits of
Joint Commission certification. www.
jointcommission.org/certification/primary_
stroke_centers.aspx.
continued from page 31
Update: Stroke guidelines
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.nursingmanagement.comNursing Management •February 2016 33
INSTRUCTIONS
Update: Stroke guidelines
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3.Mozaffarian D, Benjamin EJ, Go AS,
et al. Heart disease and stroke statis-
tics—2015 update: a report from the
American Heart Association. Circulation.
2015;131(4):e29-e322.
4.Vaartjes I, O’Flaherty M, Capewell S,
Kappelle J, Bots M. Remarkable decline
in ischemic stroke mortality is not
matched by changes in incidence. Stroke.
2013;44(3):591-597.
5.Towfighi A, Markovic D, Ovbiagele B. Impact
of a healthy lifestyle on all-cause and
cardiovascular mortality after stroke in
the USA. J Neurol Neurosurg Psychiatry.
2012;83(2):146-151.
6.Rauch U. Gender differences in anticoagu-
lation and antithrombotic therapy. Handb
Exp Pharmacol. 2012;(214):523-542.
7.Qian F, Fonarow GC, Smith EE, et al.
Racial and ethnic differences in outcomes
in older patients with acute ischemic
stroke. Circ Cardiovasc Qual Outcomes.
2013;6(3):284-292.
8.Randel A. AHA and ASA release guideline
for prevention of future stroke in patients
with stroke or TIA. Am Fam Physician.
2015;91(2):136-137.
9.Ekundayo OJ, Saver JL, Fonarow GC.
Patterns of emergency medical services
use and its association with timely stroke
treatment: findings from Get With the
Guidelines-Stroke. Circ Cardiovasc Qual
Outcomes. 2013;6(3):262-269.
10.Brotons A, Motola I, Rivera HF, Soto RE,
Schwemmer S, Issenberg B. Correlation of
the Miami Emergency Neurological Deficit
(MEND) Exam performed in the field by
paramedics with an abnormal NIHSS and
final diagnosis of stroke airlifted from the
scene. http://asls.net/pdf/MEND%20
Poster%202012.1.23%20Final.pdf.
11.Sheth KN, Smith EE, Grau-Sepulveda MV,
Kleindorfer D, Fonarow GC, Schwamm
LH. Drip and ship thrombolytic therapy
for acute ischemic stroke: use, temporal
trends, and outcomes. Stroke. 2015;
46(3):732-739.
12.Fonarow GC, Zhao X, Smith EE, et al.
Door-to-needle times for tissue plasmino-
gen activator administration and clinical
outcomes in acute ischemic stroke before
and after a quality improvement initiative.
JAMA. 2014;311(16):1632-1640.
13.American Heart Association, American
Stroke Association. Stroke treatments.
www.strokeassociation.org/STROKEORG/
AboutStroke/Treatment/Stroke-Treatments.
14.Cronin CA, Sheth KN, Zhao X, et al. Adher-
ence to Third European Cooperative Acute
Stroke Study 3- to 4.5-hour exclusions
and association with outcome: data from
Get With The Guidelines-Stroke. Stroke.
2014;45(9):2745-2749.
15.Lee VH, Conners JJ, Cutting S, Song SY,
Bernstein RA, Prabhakaran S. Elevated
international normalized ratio as a
manifestation of post-thrombolytic coagu-
lopathy in acute ischemic stroke. J Stroke
Cerebrovasc Dis. 2014;23(8):2139-2144.
16.Frank B, Fulton RL, Lees KR, Sanders RD;
VISTA Collaborators. Impact of benzodiaz-
epines on functional outcome and occur-
rence of pneumonia in stroke: evidence
from VISTA. Int J Stroke. 2014;9(7):
890-894.
17.Prvu Bettger J, McCoy L, Smith EE, Fonarow
GC, Schwamm LH, Peterson ED. Contem-
porary trends and predictors of postacute
service use and routine discharge home
after stroke. J Am Heart Assoc. 2015;4(2).
pii: e001038.
Charlotte Davis is a clinical critical care nurse
educator at Piedmont Healthcare System,
Henry Division, in Stockbridge, Ga., and a
nursing clinical faculty member at Marian
University. Lisa Lockhart is a nurse manager,
Specialty Clinics, at Alvin C. York VA Medical
Center in Murfreesboro, Tenn.
The authors and planners have disclosed
no potential conflicts of interest, financial or
otherwise.
This article originally appeared as: Davis C,
Lockhart L. Seconds count! Stroke guide-
lines update. Nursing made Incredibly Easy!
2016;14(1):26-35.
DOI-10.1097/01.NUMA.0000479442.68020.46
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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