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

3. What informed the Stroke Strategy
RCP Sentinel Audits ( )
NAO Report (Nov 2005)
Stroke strategy framework 2007
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
Slow admission to hospital, Difficult access to imaging, Insufficient specialist resources
Less than 1% of pts thrombolysed compared to 9% in Australia

5. Stroke is a Medical Emergency ’Time is Brain’
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)

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

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

8. Thrombolysis 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

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
Strict inclusion criteria
Licensed for IV use in under 80’s
Consultant decision: intra-arterial, 80+
Dramatic increase in post-stroke
quality of life

11. Cerebral infarct - onset
Ischaemic penumbra

12. Cerebral infarct – 6 hours
Ischaemic penumbra

13. Cerebral infarct – 24 hours
Ischaemic penumbra

14. Without thrombolysis
2hrs

15. Thrombolysis - The Evidence
NINDS trial 1995 (National Institute of Neurological Diseases & Stroke)
ECASS 1 and ECASS 2 (European Co-operative 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

16. RCP Audit 2006 - Thrombolysis
Only 10% admitted directly to unit with acute facilities
18% of hospitals do thrombolysis
30 hospitals thrombolysed 218 patients
But acute means diffferent things, not always that acute, staff not acutely trained

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
Frequently, dramatic lack of disability
Quicker recovery
Reduction in LOS

20. ‘Time is Brain’ - Stroke Pathway
Triage, FAST test
Speedy call to Stroke Team (whatever severity)
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
Breathing
Circulation

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

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

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

27. Thrombolysis Alteplase rTPA 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 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

29. Complications of Thrombolysis
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%

30. Angioedema

31. Patient Story 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”

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
Standardised stimuli
E1-E4
V1-V5
M1-M6

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

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

36. Physiological Monitoring
Hypoxia
Respirations
Saturations <92%
Associated with neurological deterioration
Temperature
>38C must be treated.
-associated with infarct volume
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
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

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

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

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

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

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

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

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

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

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

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

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

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