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Administration of t-PA: Preventing Complications ACUTE ISCHEMIC STROKE Carolyn Walker RN, BN January 2011.

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Presentation on theme: "Administration of t-PA: Preventing Complications ACUTE ISCHEMIC STROKE Carolyn Walker RN, BN January 2011."— Presentation transcript:

1 Administration of t-PA: Preventing Complications ACUTE ISCHEMIC STROKE Carolyn Walker RN, BN January 2011

2 t-PA Administration/ Preventing Complications of Stroke Learning Objectives: Upon completion of this session, participants will be able to: Describe the action of t-PA in relation to acute ischemic stroke Describe the action of t-PA in relation to acute ischemic stroke Identify criteria necessary for the administration of t-PA Identify criteria necessary for the administration of t-PA Explain recommended preparation, administration, assessment and on-going care of t-PA infusion Explain recommended preparation, administration, assessment and on-going care of t-PA infusion Identify possible adverse effects of t-PA administration Identify possible adverse effects of t-PA administration Identify signs and symptoms of 10 common stroke complications Identify signs and symptoms of 10 common stroke complications Describe the appropriate management of common stroke complications Describe the appropriate management of common stroke complications

3 Thrombolysis in Acute Stroke Rationale: Limit size of infarct by dissolving clot & restoring blood flow to ischemic brain Limit size of infarct by dissolving clot & restoring blood flow to ischemic brain Neuronal death & infarction evolve in a time dependent manner Neuronal death & infarction evolve in a time dependent manner Prompt treatment with a thrombolytic agent may promote reperfusion & improve functional outcomes Prompt treatment with a thrombolytic agent may promote reperfusion & improve functional outcomes

4 t-PA (Activase) in Acute Ischemic Stroke NINDS Study (1995) – Thrombolytic (t-PA) given IV within 3 hours of stroke symptom onset for treatment for acute ischemic stroke: Approved in US in 1996 Approved in US in 1996 Approval in Canada in 1999 Approval in Canada in 1999

5 Diminishing Returns over Time Favorable Outcome (mRS 0-1, BI , NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776) Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-II Courtesy Brott T et al NNT 5 NNT 20

6 Canadian Stroke Strategy: Best Practice Recommendations 2010 All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with t-PA. All patients with disabling acute ischemic stroke who can be treated within 4.5 hours after symptom onset should be evaluated without delay to determine their eligibility for treatment with t-PA. All eligible patients should receive intravenous alteplase (t-PA) within one hour of hospital arrival All eligible patients should receive intravenous alteplase (t-PA) within one hour of hospital arrival door-to-needle time < 60 minutes door-to-needle time < 60 minutes

7 Pre-Hospital Care: What’s New? WHEN CAN YOU TREAT WITH T-PA? WHEN CAN YOU TREAT WITH T-PA?

8 The Art of t-PA Decision Making Treat Enthusiastically Treat EnthusiasticallyEarlyYoung Glucose, BP normal On Protocol Moderate-Severe Strokes Good CT – higher ASPECTS Treat nervously and selectively (if at all) Late Old ↑↑Glucose, ↑↑BP Off Protocol Minor Stroke Bad CT – ASPECTS < 3 Dual antiplatelet therapy

9 Canadian Stroke Strategy: Best Practice Recommendations 2010 There is limited clinical trial data to support use of t-PA in the following circumstances: There is limited clinical trial data to support use of t-PA in the following circumstances: pediatric stroke pediatric stroke stroke patients > 80 years old with diabetes stroke patients > 80 years old with diabetes adults who do not meet current criteria for t- PA treatment adults who do not meet current criteria for t- PA treatment intra-arterial thrombolysis. intra-arterial thrombolysis. Obtain emergency consultation with a comprehensive stroke center

10 BRAIN ATTACK TIME IS BRAIN! Get drug in fast! 1.9 million neurons are destroyed each minute treatment is delayed Goal - door to drug < 30 min

11 Pathophysiology and t-PA Thrombus is formed during ischemic stroke. Thrombus is formed during ischemic stroke. Alteplase binds to fibrin in a thrombus: Alteplase binds to fibrin in a thrombus: converts plasminogen to plasmin converts plasminogen to plasmin initiates local fibrinolysis with minimal systemic effects. initiates local fibrinolysis with minimal systemic effects. Alteplase is cleared rapidly from circulating plasma by the liver. Alteplase is cleared rapidly from circulating plasma by the liver. >50% cleared within 5 min after infusion >50% cleared within 5 min after infusion 80% cleared within 10 min 80% cleared within 10 min

12 Onset Time Onset Time = Time when patient was last seen well Onset Time = Time when patient was last seen well Requires detective skills Requires detective skills

13 Inclusion Criteria Acute ischemic stroke with disabling neurological deficits Acute ischemic stroke with disabling neurological deficits Acute ischemic stroke presenting within 4.5 hours of stroke symptom onset. Acute ischemic stroke presenting within 4.5 hours of stroke symptom onset. No hemorrhage on CT scan No hemorrhage on CT scan

14 Exclusion Criteria: Absolute Contraindications : Intracranial hemorrhage Intracranial hemorrhage Active internal bleeding Active internal bleeding Endocarditis or acute pericarditis Endocarditis or acute pericarditis

15 Exclusion Criteria: Relative Contraindications: Consult Stroke Specialist

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17 Prior to Infusion of t-PA: EMS / Bypass, ER protocols EMS / Bypass, ER protocols Early arrival to ER Early arrival to ER Rapid Assessment - ABC’s, LOC Rapid Assessment - ABC’s, LOC Ensure is drawn: Ensure Bloodwork is drawn: CBC, lytes, Cr, urea, glucose, INR, PTT, TSH*, fasting lipids, CK* and troponin CBC, lytes, Cr, urea, glucose, INR, PTT, TSH*, fasting lipids, CK* and troponin Determine eligibility for t-PA based on the inclusion/exclusion criteria. Determine eligibility for t-PA based on the inclusion/exclusion criteria. TIME of ONSET is CRITICAL! TIME of ONSET is CRITICAL! STAT CT of head STAT CT of head

18 Prior to Infusion of t-PA: : IV Access: start 2 IV’s #1: used only for t-PA #1: used only for t-PA Saline lock post infusion, and use for blood drawing only Saline lock post infusion, and use for blood drawing only #2: ‘life line’ #2: ‘life line’ for IV drug access/fluid administration for IV drug access/fluid administration Patient / family education Patient / family education Purpose of therapy Purpose of therapy Potential side effects Potential side effects

19 Prior to Infusion of t-PA: Blood pressure management Blood pressure management Maintain SBP < 185mmHg and DBP < 110mmHg BP Treatment: Labetalol 10-20mg IV push over 1-2 min, Labetalol 10-20mg IV push over 1-2 min, repeat q10-20 min prn (max 300mg). repeat q10-20 min prn (max 300mg). Do NOT use ß-blockers if HR < 60bpm Do NOT use ß-blockers if HR < 60bpm Hydralazine 10-20mg IV push over 1 min q20 min prn Hydralazine 10-20mg IV push over 1 min q20 min prn IF PROBLEMS OCCUR CONTACT STROKE SPECIALIST COMPREHENSIVE STROKE CENTER!

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21 Preparing t-PA: 100mg Vial Holding Activase vial upside down, insert other end of transfer device into center of the stopper - Invert vials Holding Activase vial upside down, insert other end of transfer device into center of the stopper - Invert vials Allow vials to sit undisturbed till foam subsides (takes only seconds) Allow vials to sit undisturbed till foam subsides (takes only seconds) DO NOT SHAKE THE VIAL AS IT WILL DENATURE THE PROTEIN STRANDS DO NOT SHAKE THE VIAL AS IT WILL DENATURE THE PROTEIN STRANDS TIME IS BRAIN!

22 Preparing t-PA (continued) Infusion Chart: Look up patient’s weight to determine bolus amount Infusion Chart: Look up patient’s weight to determine bolus amount Withdraw bolus and give over seconds Withdraw bolus and give over seconds Spike reconstituted vial of t-PA with infusion tubing, and prime line Spike reconstituted vial of t-PA with infusion tubing, and prime line Set infusion pump at rate listed for patient’s weight Set infusion pump at rate listed for patient’s weight t-PA Must be given with an INFUSION PUMP!! 0.9 mg/kg (less 10% bolus) x 60 minutes 0.9 mg/kg (less 10% bolus) x 60 minutes

23 Precautions!! 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 lock IV and flush with N/S When infusion is complete, saline lock IV and flush with N/S 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

24 Assessment during and after t-PA: Vital Signs Assess NVS, BP and Pulse Assess NVS, BP and Pulse q15min x 2 hrs then q30 min x 6 hrs, q1hr x 16 hrs and q4 hrs x 48 hrs q15min x 2 hrs then q30 min x 6 hrs, q1hr x 16 hrs and q4 hrs x 48 hrs Assess NIHSS Assess NIHSS Immediately after t-PA bolus, repeat at 30min, 60min, 3hr, 6hr and 24hr post t-PA initiation Immediately after t-PA bolus, repeat at 30min, 60min, 3hr, 6hr and 24hr post t-PA initiation If evidence of bleeding, neurological deterioration (change of 2+ points on NIHSS), new headache or nausea: - notify physician; arrange CT scan Treat Blood Pressure: Treat Blood Pressure: If SBP > 180 mmHg and/or DBP >105 mmHg If SBP > 180 mmHg and/or DBP >105 mmHg

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26 Nursing Care during t-PA Avoid taking BP in arm with IV’s or venipunctures. Avoid taking BP in arm with IV’s or venipunctures. BP should be taken manually BP should be taken manually NIBP will cause petechiae NIBP will cause petechiae Avoid unnecessary handling of the patient. Avoid unnecessary handling of the patient. Bed rest for 12 – 24 hours post t-PA administration then reassess Bed rest for 12 – 24 hours post t-PA administration then reassess

27 Nursing Care during t-PA No unnecessary venous or arterial punctures No unnecessary venous or arterial punctures Blood is drawn from IV saline lock if possible Blood is drawn from IV saline lock if possible Avoid invasive procedures Avoid invasive procedures NG tubes, suction, or urinary catheterization NG tubes, suction, or urinary catheterization Apply pressure dressing to potential sources of bleeding Apply pressure dressing to potential sources of bleeding Assess all secretions and excretions for blood Assess all secretions and excretions for blood

28 APSS Recommended t-PA Protocol Diet NPO for 6 hours post t-PA, pending swallow screen NPO for 6 hours post t-PA, pending swallow screen Complete swallow screen prior to any oral intake Complete swallow screen prior to any oral intake If fails, keep NPO then reassess If fails, keep NPO then reassessGlucose Monitor capillary glucose as follows: Monitor capillary glucose as follows: If diabetic or lab glucose > 10 mmol/L If diabetic or lab glucose > 10 mmol/L q4h x 24hr then reassess q4h x 24hr then reassess If non-diabetic or lab glucose < 10 mmol/L If non-diabetic or lab glucose < 10 mmol/L qid x 48 hr then reassess qid x 48 hr then reassess Notify physician if glucose > 8 mmol/L Recommend insulin by sliding scale (sc or IV)

29 APSS Recommended t-PA Protocol Antiplatelet/Anticoagulant Therapy No ASA, Clopidogrel, Aggrenox, Ticlopidine or other antiplatelet agents for 24 hours from start of t-PA No ASA, Clopidogrel, Aggrenox, Ticlopidine or other antiplatelet agents for 24 hours from start of t-PA No heparin, heparinoid or warfarin for 24 hours from start of t-PA No heparin, heparinoid or warfarin for 24 hours from start of t-PA CT or MRI must be completed and reviewed by physician to exclude intracranial hemorrhage prior to above therapy

30 APSS Recommended t-PA Protocol Venous Thromboembolism Prophylaxis (DVT & PE) Assess patient daily for deep vein thrombosis Assess patient daily for deep vein thrombosis Intermittent pneumonic compression stockings while on bed rest, then reassess Intermittent pneumonic compression stockings while on bed rest, then reassess After 24h, if CT/MR is negative for hemorrhage, consider the following when patient remains on bed rest due to significant lower limb hemiparesis/plegia: After 24h, if CT/MR is negative for hemorrhage, consider the following when patient remains on bed rest due to significant lower limb hemiparesis/plegia: Unfractionated heparin sc 5000u q12 h OR Unfractionated heparin sc 5000u q12 h OR Enoxaparin 40mg sc q24h Enoxaparin 40mg sc q24h

31 APSS Recommended t-PA Protocol Bladder Management If possible, catheterize before t-PA admin If possible, catheterize before t-PA admin DO NOT DELAY t-PA for this DO NOT DELAY t-PA for this Avoid catheterization 5-7 hrs post t-PA infusion Avoid catheterization 5-7 hrs post t-PA infusion If unable to void - bladder scan and in/out catheterization q4-6hrs If unable to void - bladder scan and in/out catheterization q4-6hrs If voiding – do residuals daily until < 100 ml If voiding – do residuals daily until < 100 ml

32 CSS 2010 Recommendations: Continence Screen all stroke pts for urinary & fecal incontinence and constipation Screen all stroke pts for urinary & fecal incontinence and constipation Use of portable ultrasound is recommended Use of portable ultrasound is recommended Assess contributing factors Assess contributing factors Meds, nutrition, diet, mobility, cognition, environment and communication Meds, nutrition, diet, mobility, cognition, environment and communication Avoid indwelling catheters due to risk of infection Avoid indwelling catheters due to risk of infection Bladder training program Bladder training program Bowel management program Bowel management program

33 Adverse Effects of t-PA Bleeding due to lysis of fibrin in the hemostatic plug Superficial: due to lysis of fibrin in the hemostatic plug observe potential bleeding sites: venous & arterial puncture, lacerations, etc. observe potential bleeding sites: venous & arterial puncture, lacerations, etc. Internal: GI tract, GU tract, respiratory, retroperitoneal or intracerebral GI tract, GU tract, respiratory, retroperitoneal or intracerebral : If clinically significant bleeding or deterioration of neuro status: t-PA and notify physician. ACTIONS: If clinically significant bleeding or deterioration of neuro status: STOP t-PA and notify physician.

34 Adverse Effects of t-PA Angioedema Assess patient for signs of Assess patient for signs of of the tongue: Angioedema of the tongue: Swelling of tongue/lips Swelling of tongue/lips notify Physician immediately if swelling seen 1.3% of population Assess at 30, 45, 60, 75 minutes after tPA bolus. Once the t-PA infusion has finished the risk of angioedema falls off Patients on ACE inhibitors are at higher risk of angioedema

35 Adverse Effects of t-PA Nausea & Vomiting 25% of patients 25% of patientsAllergy/Anaphylaxis <0.02% of patients <0.02% of patients Observe for skin eruptions, airway tightening Observe for skin eruptions, airway tightening Unexplained hypotension may occur as an immune reaction Unexplained hypotension may occur as an immune reaction

36 Follow-Up: Repeat CT scan or MRI scan at hrs (approx 24 hrs) post t-PA infusion Repeat CT scan or MRI scan at hrs (approx 24 hrs) post t-PA infusion Daily neuro assessments after first 24 hours Daily neuro assessments after first 24 hours

37 Continue Care to Prevent Complications of Stroke Continue Care to Prevent Complications of Stroke

38 Worsening speech problems Worsening speech problems Decreased responsiveness Decreased responsiveness BP climbing BP climbing Change in respirations Change in respirations What is happening?

39 Preventing Complications Preventing Complications Post Stroke Complications are related to: Increased length of stay Increased length of stay Poor outcomes Poor outcomes Increased healthcare costs Increased healthcare costs 60% stroke survivors experience complications

40 Post Stroke Complications Post Stroke Complications Hemorrhagic transformation- Dysphagia Hemorrhagic transformation- Dysphagia Hypertension- Depression Hypertension- Depression Cerebral Edema-Hyperglycemia Cerebral Edema-Hyperglycemia Elevated Temperature- UTI Elevated Temperature- UTI Aspiration Pneumonia - DVT Aspiration Pneumonia - DVT

41 Hemorrhagic Transformation Hemorrhagic Transformation Occurs in ~ 3% patients with ischemic stroke ~ 4% patients who received tPA ~ 4% patients who received tPA (within 36 hrs of infusion) Cause: Ischemic brain and damaged blood vessels Ischemic brain and damaged blood vessels Injured blood vessels become “leaky” Injured blood vessels become “leaky” Restored blood flow results in hemorrhage Restored blood flow results in hemorrhage

42 Hemorrhagic Transformation Hemorrhagic Transformation Occurrence influenced by: Size and location of infarct Size and location of infarct Degree collateral circulation Degree collateral circulation Use of anticoagulants and interventions (ie. tPA) Use of anticoagulants and interventions (ie. tPA)Symptoms: Neurological worsening Neurological worsening Increased BP Increased BP Respiratory changes Respiratory changes

43 Hemorrhagic Transformation Hemorrhagic Transformation Management CT CT Control BP Control BP Avoid use of anticoagulants Avoid use of anticoagulants Possible surgery Possible surgery

44 Hemorrhagic Transformation Hemorrhagic Transformation Blood Pressure Control Hold emergency HTN treatment unless: SBP > 220mmHg or DBP > 120mmHg SBP > 220mmHg or DBP > 120mmHg Be aware…aggressive lowering of BP may cause neurological worsening Lower BP cautiously: 15-25% within first day Maintain Blood Pressure Control - with t-PA

45 Hypertension During Acute Stroke Occurrence: Systolic BP > 160mmHg is seen in over 60% stroke patients (Robinson et al, Cerebrovasc Dis., 1997) Systolic BP > 160mmHg is seen in over 60% stroke patients (Robinson et al, Cerebrovasc Dis., 1997) Often transient, lasting hours and in most patients does not require treatment. Often transient, lasting hours and in most patients does not require treatment. BP declines within first hours after stroke without medical treatment BP declines within first hours after stroke without medical treatment Systolic BP has been noted to drop ˜ 28% during first day, even without medications Systolic BP has been noted to drop ˜ 28% during first day, even without medications Oliveira-Filho et al; 2003; Neurology; 61:

46 Why is Blood Pressure Increased? Elevated blood pressure may be the result of: Full bladder Full bladder Stress of cerebrovascular event Stress of cerebrovascular event Nausea Nausea Pain Pain Pre-existing hypertension Pre-existing hypertension Physiological response to hypoxia Physiological response to hypoxia Increased intracranial pressure Increased intracranial pressure Adams et al. Circulation; 2007; 115 :

47 Treatment of Hypertension with Cerebrovascular Disease Strongly consider blood pressure reduction Strongly consider blood pressure reduction in all patients after the acute phase stroke in all patients after the acute phase stroke Expect to use combination therapy Expect to use combination therapy ACE inhibitor, ARB, diuretic ACE inhibitor, ARB, diuretic

48 Management of Hypertension Target most patients still < 140/90 Target most patients still < 140/90 Home Measurement < 135/85 Home Measurement < 135/85 Diabetics < 130/80 Diabetics < 130/80 Lifestyle Modification: Lifestyle Modification: Sodium restriction, DASH diet, physical activity, weight loss, alcohol restriction, smoking cessation Sodium restriction, DASH diet, physical activity, weight loss, alcohol restriction, smoking cessation

49 Cerebral Edema Cerebral Edema Brain Tissue Shift: Clinical Worsening

50 Cerebral Edema Cerebral Edema Incidence highest within 2-5 days of ischemic stroke Symptoms: Neurological worsening Neurological worsening Widening pulse pressure Widening pulse pressure bradycardia, resp changes bradycardia, resp changesManagement Elevate HOB (prevent increasing ICP) Elevate HOB (prevent increasing ICP) Frequent neuro assessment Frequent neuro assessment Diuretics (ie. Mannitol) Diuretics (ie. Mannitol)

51 Hyperglycemia Patients with elevated blood sugars have a poorer prognosis Like hypertension, stress related hyperglycemia will resolve naturally within 24 hours.

52 Hyperglycemia Management Check sugar initially on all patients Check sugar initially on all patients Continue monitoring if sugars > 8mmol/ L or diabetic Continue monitoring if sugars > 8mmol/ L or diabetic sliding scale insulin as necessary sliding scale insulin as necessary Resume regular diabetic meds as soon as is possible Resume regular diabetic meds as soon as is possible Administer fluids without glucose Administer fluids without glucose

53 Increased respirations Increased respirations Increasing heart rate Increasing heart rate Fever Fever What is happening?

54 Elevated Temperature Patients with elevated temperature are more likely to have a poor outcome Can have elevated temperature without infection Management Treat temperature > 38.0 C with acetaminophen Treat temperature > 38.0 C with acetaminophen Use cooling measures (fans, cooling blankets) Use cooling measures (fans, cooling blankets) avoid shivering avoid shivering Investigate cause of temperature Investigate cause of temperature

55 Dysphagia Dysphagia Greek word meaning - “disordered eating” Swallowing difficulties cause by damage to enervation of cranial nerves IX, X, XI. Impaired coordination of swallowing muscles or limited sensation in mouth/throat Occurs in ~ 55% new onset strokes ~ 50% of these do not recover normal swallow by 6 months Can cause airway obstruction and aspiration pneumonia Can cause airway obstruction and aspiration pneumonia Can lead to dehydration, weight loss, malnutrition Can lead to dehydration, weight loss, malnutrition Up to 70% dysphagic patients aspirate Up to 70% dysphagic patients aspirate up to 20% of those with stroke-related dysphagia die within first year up to 20% of those with stroke-related dysphagia die within first year

56 Dysphagia Dysphagia Signs and Symptoms: Choking, coughing during meals Choking, coughing during meals Moist/ wet voice, nasal regurgitation Moist/ wet voice, nasal regurgitation Drooling or loss of food from mouth, pocketing food in cheeks Drooling or loss of food from mouth, pocketing food in cheeks Delay initiating swallow Delay initiating swallow Difficulty swallowing pills Difficulty swallowing pills Avoiding food or fluids Avoiding food or fluids Dehydration, malnutrition Dehydration, malnutrition

57 Dysphagia Dysphagia Management: NPO until swallow screen NPO until swallow screen Mouth care with minimal water - prevents colonization of bacteria Mouth care with minimal water - prevents colonization of bacteria Consult SLP, dietitian to recommend diet Consult SLP, dietitian to recommend diet Initiate enteral/parenteral feeds if unable to take PO fluids within 48 hrs Initiate enteral/parenteral feeds if unable to take PO fluids within 48 hrs Assist to eat: alert/calm environment Assist to eat: alert/calm environment position upright position upright one spoonful at a time - slow, small bites one spoonful at a time - slow, small bites keep upright for 30 min post feeding keep upright for 30 min post feeding

58 CSS 2010 Recommendations: Oral Care Upon or soon after admission: All Stroke patients should have All Stroke patients should have Oral/Dental assessment Oral/Dental assessment Assessment to determine if neuromotor skills present to safely wear full/partial dentures Assessment to determine if neuromotor skills present to safely wear full/partial dentures Implement Oral care protocol (including use of dentures) Implement Oral care protocol (including use of dentures) Consistent with Canadian Dental Assoc Consistent with Canadian Dental Assoc Identify frequency, types of products, and management with dysphasia Identify frequency, types of products, and management with dysphasia If concerns consult dentist, OT, SLP

59 Increased respirations Increased respirations Increasing heart rate Increasing heart rate Fever Fever Chest congestion Chest congestion What is happening?

60 Aspiration Pneumonia Aspiration Pneumonia More occurrence with severe strokes - immobile, poor cough, dysphagia, May result from: - vomiting, bed rest, seizures, mechanical ventilation

61 Aspiration Pneumonia Aspiration Pneumonia Signs and Symptoms: Tachypnea Tachypnea Tachycardia Tachycardia Fever Fever Wheezing Wheezing Rales Rales Chills Chills malaise malaise

62 Aspiration Pneumonia Aspiration Pneumonia Prevention and Management: Maintain NPO until swallow screen Maintain NPO until swallow screen Use minimal water with mouth care Use minimal water with mouth care Consult SLP Consult SLP Protect airway and suction PRN Protect airway and suction PRN Prevent nausea and vomiting Prevent nausea and vomiting Encourage deep breaths (prevent atelactasis) Encourage deep breaths (prevent atelactasis)

63 Post Stroke Depression Post Stroke Depression Risk Factors: Female Female History of depression or psych illness History of depression or psych illness Social isolation Social isolation Functional impairment Functional impairment Cognitive impairment Cognitive impairment Impact of PSD: Increased healthcare costs Increased healthcare costs Poorer functional outcomes Poorer functional outcomes Slower stroke recovery Slower stroke recovery Decreased quality of life Decreased quality of life Increased mortality Increased mortality

64 Post Stroke Depression Post Stroke Depression Symptoms: (often over looked)  sad, anxious, hopelessness, worthlessness, helplessness, loss of interest in activities, decreased energy, difficulty concentrating, insomnia, oversleeping, thoughts of death/suicide, irritability  Reported prevalence  53% at 3 months  42% at 12 months

65 Post Stroke Depression Post Stroke Depression Management:  pharmacological (Selective Serotonin Reuptake Inhibitors (SSRIs) and tricyclic antidepressants)  electroconvulsive therapy (ECT)  repetitive transcranial magnetic stimulation (RTMS)  music therapy  speech therapy  cognitive Behavioural therapy

66 Urinary Tract Infection Urinary Tract Infection usually following more severe stroke Potential serious complication - sepsis major cause is catheterization avoid prolonged use of catheters Symptoms: Fever, chills, nausea, vomiting, malaise Fever, chills, nausea, vomiting, malaise Frequency, urgency, burning Frequency, urgency, burning Cloudy, pink or bloody urine Cloudy, pink or bloody urine CONFUSION CONFUSION

67 Urinary Tract Infection Urinary Tract Infection Management: Maintain hydration and Maintain hydration and nutrition nutrition Administer antibiotics Administer antibiotics Treat fever and pain Treat fever and pain Monitor urine output Monitor urine output

68 Deep Vein Thrombosis (DVT) Deep Vein Thrombosis (DVT) A blood clot in the veins of the lower limbs Most DVT’s occur in first week after stroke Highest risk if immobilized, elderly, severe stroke Management: Ambulate ASAP Ambulate ASAP Intermittent pneumonic compression stockings Intermittent pneumonic compression stockings Maintain hydration Maintain hydration Antithrombotic stockings Antithrombotic stockings Anticoagulants as ordered Anticoagulants as ordered Monitor for possible PE Monitor for possible PE

69 CSS 2010 Recommendations: Mobilization Mobilize all stroke patients as early and frequently as possible - unless contraindicated Mobilize all stroke patients as early and frequently as possible - unless contraindicated Within 24 hours Within 24 hours Assess by rehab ASAP Assess by rehab ASAP Within hours Within hours CSS Best Practice Recommendations 2010

70 Prevent Complications: Return to Action!


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