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Thrombolysis Nursing Competencies Objectives Nursing Care of a Thrombolysed patient Nursing Care of a Thrombolysed patient.

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Presentation on theme: "Thrombolysis Nursing Competencies Objectives Nursing Care of a Thrombolysed patient Nursing Care of a Thrombolysed patient."— Presentation transcript:

1 Thrombolysis Nursing Competencies Objectives Nursing Care of a Thrombolysed patient Nursing Care of a Thrombolysed patient

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3 What informed the Stroke Strategy RCP Sentinel Audits (2002-2006) RCP Sentinel Audits (2002-2006) NAO Report (Nov 2005) NAO Report (Nov 2005) Stroke strategy framework 2007 Stroke strategy framework 2007 Nice Nice

4 “There is a massive and regular failure to respond to the emergency of stroke” (NAO 2005) Low public awareness of symptoms, prevention & management Low public awareness of symptoms, prevention & management Slow admission to hospital, Difficult access to imaging, Insufficient specialist resources Slow admission to hospital, Difficult access to imaging, Insufficient specialist resources Less than 1% of pts thrombolysed compared to 9% in Australia Less than 1% of pts thrombolysed compared to 9% in Australia

5 Stroke is a Medical Emergency ’Time is Brain’ Speedy diagnosis Speedy diagnosis Rapid access to imaging Rapid access to imaging Thrombolysis Thrombolysis Rapid access to supportive therapy (HASU) Rapid access to supportive therapy (HASU) Rapid secondary prevention Rapid secondary prevention Rapid surgical/ radiological intervention in arterial disease (carotid / vertebral) Rapid surgical/ radiological intervention in arterial disease (carotid / vertebral)

6 80% of Strokes = Ischaemic 80% of Ischaemic stroke caused by embolism from 80% of Ischaemic stroke caused by embolism from Heart Heart Aortic arch Aortic arch Extracranial arteries to the brain Extracranial arteries to the brain

7 Thrombolysis Thrombus= clot Thrombus= clot Lysis = destruction of cells Lysis = destruction of cells Thrombolysis is achieved by using Thrombolysis is achieved by using rt-PA (alteplase) rt-PA (alteplase) rt-PA reverses underperfusion, allowing ischaemic penumbra to recover rt-PA reverses underperfusion, allowing ischaemic penumbra to recover

8 Thrombolysis rt-PA= recombinant tissue plasminogen activator rt-PA= recombinant tissue plasminogen activator Plasmin is the enzyme that degrades fibrin, the protein which is the main constituent of blood clots 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 rt-PA activates the release of plasmin as plasminogen

9 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

10 Thrombolysis Must be given within 4.5 hours of stroke Must be given within 4.5 hours of stroke Strict inclusion criteria Strict inclusion criteria Licensed for IV use in under 80’s Licensed for IV use in under 80’s Consultant decision: intra-arterial, 80+ Consultant decision: intra-arterial, 80+ Dramatic increase in post-stroke Dramatic increase in post-stroke quality of life quality of life

11 Cerebral infarct - onset Onset Infarct Ischaemic penumbra

12 Cerebral infarct – 6 hours 6 Hours Infarct Ischaemic penumbra

13 Cerebral infarct – 24 hours 24 Hours Infarct Ischaemic penumbra

14 Without thrombolysis 2hrs

15 Thrombolysis - The Evidence NINDS trial 1995 (National Institute of Neurological Diseases & Stroke) NINDS trial 1995 (National Institute of Neurological Diseases & Stroke) ECASS 1 and ECASS 2 (European Co- operative Stroke Study) up to 3 hours ECASS 1 and ECASS 2 (European Co- operative Stroke Study) up to 3 hours ECASS 3 showed benefit up to 4.5 hours ECASS 3 showed benefit up to 4.5 hours 2009 American stroke association widens use of rTPa to 4.5 hours 2009 American stroke association widens use of rTPa to 4.5 hours

16 RCP Audit 2006 - Thrombolysis Only 10% admitted directly to unit with acute facilities Only 10% admitted directly to unit with acute facilities 18% of hospitals do thrombolysis 18% of hospitals do thrombolysis 30 hospitals thrombolysed 218 patients 30 hospitals thrombolysed 218 patients

17 ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs of onset of stroke

18 Odds ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs of onset of stroke

19 Thrombolysis - The Evidence Fewer complications Fewer complications Frequently, dramatic lack of disability Frequently, dramatic lack of disability Quicker recovery Quicker recovery Reduction in LOS Reduction in LOS

20 ‘Time is Brain’ - Stroke Pathway Triage, FAST test Triage, FAST test Speedy call to Stroke Team (whatever severity) Speedy call to Stroke Team (whatever severity) Rapid admission to ASU Rapid admission to ASU

21 CAPACITY 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. Principles of the Act The Act sets out five principles which guide the legislation. These are: · ‘A person must be assumed to have capacity unless it is established that he lacks capacity. · (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. · (4) A person is not to be treated as unable to make a decision merely because he makes an unwise decision. · (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. · (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

22 Testing Capacity The Functional Test The person must be able to: understand the information relevant to the decision, retain that information, weigh that information as a part of the process of making a decision, communicate his/her decision (whether by talking, using sign language or any other means). This test must be complete and recorded; the documentation must demonstrate the above process

23 ABC Airway Airway Breathing Breathing Circulation Circulation

24 After ABC GCS GCS ECG ECG Blood glucose Blood glucose Fluid access Fluid access Hydration Hydration Bloods Bloods Nil by Mouth Nil by Mouth Transfer to CT-continue ABC Transfer to CT-continue ABC

25 Time is brain 1.9 million neurons are lost each minute after a stroke 1.9 million neurons are lost each minute after a stroke Protect ischaemic penumbra Protect ischaemic penumbra Stroke 2006 Stroke 2006

26 CT Known time of symptoms <4 hours Known time of symptoms <4 hours NIHSS score NIHSS score No haemorrhage No haemorrhage No contraindications No contraindications Consent Consent Age Age

27 Thrombolysis Alteplase rTPA 0.9mg /Kg 0.9mg /Kg 10% of total dose –Bolus 2-3 mins 90% of total dose –Infuse over 60 mins

28 rTPA Alteplase Do not mix t-PA with any other medications. Do not mix t-PA with any other medications. Do not use IV tubing with infusion filters. Do not use IV tubing with infusion filters. All patients must be on a cardiac monitor All patients must be on a cardiac monitor When infusion is complete, saline flush with Normal saline 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 t-PA must be used within 8 hours of mixing when stored at room temperature or within 24 hours if refrigerated

29 Complications of Thrombolysis Intra -cerebral haemorrhage-1.7% Intra -cerebral haemorrhage-1.7% (1 in 77 patients) 0.28% fatal (1 in 77 patients) 0.28% fatal SITS MOST 2007 SITS MOST 2007 Bleeding-minor bleeding is common (IV site) Bleeding-minor bleeding is common (IV site) Anaphylaxis- 1% Anaphylaxis- 1% Ace inhibitors Frontal & insular lesions Ace inhibitors Frontal & insular lesions Angiodoema 1.3% Canadian study 1,135 pts Angiodoema 1.3% Canadian study 1,135 pts Major Heamorrhage 0.4% Major Heamorrhage 0.4%

30 Angioedema

31 Patient Story Mr X 88 years of age Mr X 88 years of age Jet pilot in the war & last flew in 1986 Jet pilot in the war & last flew in 1986 Collapsed right sided weakness Collapsed right sided weakness Unable to talk. Couldn’t think clearly. Unable to talk. Couldn’t think clearly. 999 ambulance to A%E 999 ambulance to A%E “Clock work military precision like gun team at Earls court” “Clock work military precision like gun team at Earls court”

32 First 24 hours 30% of all stroke patients will deteriorate in the first 24hours Stroke 2009

33 Monitor GCS Ability to engage with immediate surroundings Ability to engage with immediate surroundings Standardised stimuli Standardised stimuli E1-E4 E1-E4 V1-V5 V1-V5 M1-M6 M1-M6

34 Best and Worst Score GCS 15- E4 V5 M6 GCS 15- E4 V5 M6 Awake, alert and fully responsive Awake, alert and fully responsive GCS 3-E1 V1 M1 GCS 3-E1 V1 M1 No cerebrally mediated response to stimulus No cerebrally mediated response to stimulus

35 NIHSS - A Research Tool Fifteen item impairment scale Fifteen item impairment scale Neurological outcome Neurological outcome Degree of recovery Degree of recovery

36 Physiological Monitoring 1. Hypoxia Respirations Saturations <92% Associated with neurological deterioration 2. Temperature >38C must be treated. >38C must be treated. -associated with infarct volume 3. Arrhythmias Continuous ECG Early detection and treatment of AF Right hemisphere /insular lesions

37 Physiological Monitoring contd 4.Blood pressure Non thrombolysed patients BP Not treated unless: Systolic >220mmHg or Systolic >220mmHg or Diastolic >120mmHg with 2 consecutive readings Diastolic >120mmHg with 2 consecutive readings Thrombolysed patients BP is treated if: Systolic >185mmHg or Systolic >185mmHg or Diastolic >110mmHg with 2 consecutive readings Diastolic >110mmHg with 2 consecutive readings Abrupt fall in BP may affect cerebral perfusion pressure

38 Physiological Monitoring contd 5.Blood Sugar 5.Blood Sugar Hyperglycaemia BM>10 treat & monitor Hyperglycaemia BM>10 treat & monitor Hypoglycaemia –immediate treatment with glucose Hypoglycaemia –immediate treatment with glucose Hyperglycaemia is associated with poor clinical outcome

39 Physiological Monitoring Contd 6. Hydration Glucose Glucose Cerebral perfusion Cerebral perfusion 7. Anuria Polyuria Polyuria Circulatory failure Circulatory failure

40 Complications of Stroke Aspiration Pneumonia Aspiration Pneumonia Urinary infection Urinary infection DVT DVT Pulmonary Embolus Pulmonary Embolus Shoulder subluxation Shoulder subluxation Depression Depression Malnourishment Malnourishment Pressure sores Pressure sores Falls Falls Seizures Seizures

41 Swallow Complications (Dysphagia) Chest Infection Chest Infection Aspiration Pneumonias Aspiration Pneumonias 50% are silent 50% are silent Swallow screen Swallow screen Nil by mouth first 24hours Nil by mouth first 24hours Guided eating & drinking regime Guided eating & drinking regime Encourage to cough Encourage to cough Sitting out of bed Sitting out of bed Mobilisation Mobilisation

42 Mouth Care Increased risk of infection Increased risk of infection Pain and discomfort Pain and discomfort Effects swallow Effects swallow Gentle mouth care Gentle mouth care Adequate hydration Adequate hydration Gentle tooth brushing Gentle tooth brushing

43 Head Position Controversial Controversial Head in a neutral position Head in a neutral position Flat if tolerated. Flat if tolerated. Or 30 –40 degrees Or 30 –40 degrees Aids venous drainage & improves cerebral perfusion Aids venous drainage & improves cerebral perfusion

44 Bladder &Bowels Urinary incontinence Urinary incontinence Urinary infection Urinary infection Avoid catheters Avoid catheters Early plan of care Early plan of care Adequate hydration Adequate hydration Bowels Bowels Privacy & dignity Privacy & dignity

45 Psychological Support Assess mood Assess mood Recognise grief/loss Recognise grief/loss Talk Talk Engage with family Engage with family Interests Interests Timely realistic goals Timely realistic goals Refer Refer

46 Pressure Sores Air mattress Air mattress Two hourly turns Two hourly turns Nutrition Nutrition Hydration Hydration Personal hygiene Personal hygiene

47 Deep Vein Thrombosis Early mobilisation Early mobilisation Low molecular weight heparin Low molecular weight heparin Compression devices Compression devices TED stockings not beneficial in stroke patients TED stockings not beneficial in stroke patients Clots Trial 2009 Clots Trial 2009

48 Positioning Loss of sensation Loss of sensation Loss of power Loss of power Subluxation Subluxation Supportive Supportive IV lines and BP cuffs avoided on affected limb IV lines and BP cuffs avoided on affected limb Assess moving and handling Assess moving and handling Good technique Good technique

49 Nutrition Malnourishment associated with poor outcome Malnourishment associated with poor outcome Weight Weight MUST assessment MUST assessment Naso gastric tube Naso gastric tube History of patients eating habits History of patients eating habits Controversial Controversial When to commence invasive feeding regime When to commence invasive feeding regime


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