Stroke Rehabilitation Across the Continuum of Care

RehabilitationNurses:Champions forOptimizing StrokeRehabilitationAcross theContinuum of Care

PresentersSandra Melchiorre RN, MN, ACNP, CNN (c)Regional Stroke Acute Care Advanced PracticeNurse, SEODelanya Podgers BSc, RNStroke Resource Nurse, Neuroscience Unit, KGHBarb Knapton RNSMOL, Neuro Rehabilitation NurseChristine Allison RN, HBScNSMOL, Neuro Rehabilitation Nurse

RehabilitationImprovesStrokePatientOutcomes

Workshop ObjectivesTo discuss the role of the RN inimplementing stroke rehabilitation &Stroke Best Practice Guidelines(2003) across the continuum of careTo discuss common barriers andstrategies for effective transitionmanagement

Definition of StrokeRehabilitation“A progressive, dynamic, goal-orientedprocess aimed at enabling a personwith an impairment to reach his orher optimal physical, cognitive,emotional, communicative and/orsocial functional levels”(HSFO, 2000)

Goals of Stroke Rehabilitation• Prevent & treat complications• Restore independent functioning• Facilitate psychosocial coping• Promote community re-integration• Enhance quality of life

Do you as a nurseimplement strokerehabilitation as partof your plan of care?

Stroke Rehabilitation• A “process” that begins at onset• Early rehabilitation optimizesstroke outcomes• Apply principles throughout thecontinuum of care

Stroke Rehabilitation NursingPrinciples• Continuity of Care (repetition)• Holistic approach to care• Integrated interdisciplinary teamapproach

2003 Cochrane DatabaseStroke Unit Trials Review• Stroke patients who receiveorganized inpatient care in a strokeunit are more likely to be alive,independent, and living at homeone year after the stroke

Stroke Unit Characteristics• Patients cared for in a geographicallydistinct location• Nursing Specialization and team expertise• Nursing integration with multidisciplinaryplan of care

Stroke Unit Characteristics• Coordinated multidisciplinary care• Family centered care• Staff, patient and caregiver education

Case StudyMrs.Percy

Mrs Percy’s Hx• 77 year old retired teacher, very active• Married, supportive family• Found in bed awake at 0800, responsiveand talking• Left facial drooping with left hemiplegia• She was last seen normal at 10 pm thenight before. Not a candidate for tPA• BP 165/100 in ER• No previous Stroke or TIAs

Diagnosis: Ischemic Stroke• CT Results: RtMCA IschemicInfarct

Mrs Percy’s Deficits• Left hemiplegia• Left shoulder sublexation with pain• Requires two person transfer• Dysphagia: pureed diet with thickenedfluids• Continent of bowel and bladder but needsassistance with dressing/undressing• Emotionally labile• Apraxia• Left body neglect

What are your plannedinterventions to preventcomplications andoptimize Mrs Percy’srecovery?

Maintaining Skin Integrity• Skin assessment weekly using Bradenscale• Collaborate with OT, PT, andNutritionist to manage risk factors• Turning/repositioning schedule

Promoting Early Remobilization• Complete risk for falls assessmentupon admission in collaboration withOT and PT• Post instructions for safetransferring, positioning, andambulation at the bedside and on thecare plan• Educate the patient/family

Promoting Safe Swallowing andFeeding• Collaborate with SLP and Nutritionist withswallowing and nutritional assessment• Implement feeding strategies and dietmodifications as recommended to reducerisk of aspiration• Reinforce diet education for MrsPercy/family

Preventing Aspiration PneumoniaMalnutrition, & Dehydration• Ongoing swallowing nutrition andrespiratory assessments• Report progress or concerns to theSLP and Nutritionist and implementchanges to diet and feedingstrategies suggested

Restoring MaximalIndependence with ADL• Collaborate with therapists• Provide education/coaching• Reinforce therapy at the bedside• On going assessment• Review Mrs Percy’s progress withInterdisciplinary team during StrokeRounds, Discharge Rounds, and Familymeetings

Protecting Hemiplegic Shoulder• Provide mechanical support of left arm (ie. Laptray, positioning)• Move gently and allow her time to participate• When side-lying, never position her directly on thehumeral head• Encourage Mrs Percy to pay attention to left arm

Pain Management- Assess for pain using a pain scale of1-10- Administer analgesia and evaluateeffectiveness- Collaborate with OccupationalTherapy and Physiotherapy for theappropriate positioning andtransferring techniques

Continence Promotion• Ensure bedpan and Commode chairare at the bedside• Ask family to bring in adaptive looseclothing to promote toileting• Encourage Mrs Percy to call forassistance when needed• Educate patient and family

Facilitating PsychosocialCoping and Adaptation• Assess behavior, mood, loss of interestin daily activities, sleeping pattern andloss of appetite• Assess risk of depression using aDepression scale (Score ResearchProject)• Encourage family participation dayswith therapists

What education do youwant to provide MrsPercy and her family?

Promoting Stroke Awareness• What is a stroke• Complications/deficits• Plan of Care• Risk Factors• Recognize & Reactto S&S• SecondaryStrokeprevention– Medication– Diet– Exercise– BP

SMOL Stroke RehabAdmission Criteria• >16 years of age• Recent stroke• Stable• Investigations completed• Agrees to participate in stroke rehab• Able to learn

Stroke RehabilitationMrs Percy isadmitted tothe in-patientStrokeRehabilitationProgram atSMOL

Mrs Percy’s Deficits: 3 weeks• One person pivot transfer• Left shoulder pain continues• Dysphagia: minced diet with thickenedfluids, but wants to eat regular meals anddrink water• Continues to need assistance withtoileting• Emotionally: Anxious to return home andresume her social activities and refusesto be discharged to a LTC home

What are yourinterventions for MrsPercy and her family?

Stroke Rehabilitation Nursing• Ongoing assessment• Prevention of complications• Achievement of patient goals• Ethical issues• Patient/family education• Community re-integration

Preventing Complications• Collaborate with SLP and Nutritionistto assess dysphagia and nutritionalstatus• Reinforce diet and safe feedingstrategies with patient and family• Complete risk for falls assessmentupon admission in collaboration withMrs Percy, OT, PT, and Nursing

Restoring Mobility andMaximal Independence• Post instructions for safe transferring,positioning and ambulation at the bedside• Promote toileting and mobilization• Educate Mrs. Percy/family aboutrehabilitation and the approach to care atSMOL

Restoring Mobility andMaximal Independence• Collaborate with Pain Team, PT OT andPhysiatrist to manage shoulder pain• Reinforce therapeutic interventions at thebedside (e.g. dressing, safe transferring)• Prepare Mrs Percy for cortisone injectionstudy in collaboration with Physiatrist

Facilitating Psychosocial Coping& Community Re-integration• Provide emotional support and educationre: stroke, secondary stroke prevention,community support, and caregiver stress• Monitor behavior, mood and affect forS/S of depression• Advocate for Mrs Percy and family atStroke Rounds and Discharge PlanningRounds• Collaborate with team to resolve ethicalissues

Transition Management• A stroke survivor mayundergo severaltransitions in care• Effective transitions arean integral part ofimproving strokemanagement(BPGs for Stroke Care, 2003)

Managing the TransitionAchieving excellence intransition management is• Collaboration amonghealthcare providers indifferent organizations• Sharing both informationresponsibility for the entireprocess”(BPGs for Stroke Care, 2003)

Barriers to EffectiveTransition• Unexpected orunexplained delays intransferring strokesurvivors to theappropriate placement(BPGs for Stroke Care, 2003)

Barriers to EffectiveTransition• Lack of communication• Inadequate informationupon admission• Lack of attention toemotional needs(BPGs for Stroke Care, 2003)

What Information Is MostHelpful?• Full discharge summary re:stroke interventions,education and supportprovided• Interdisciplinary team reportwith specific programsestablished

Direct Communication• Holistic approach• Complete picture of the client andfamily / caregiver– Functional status of the strokesurvivor– Prognosis, established goals– Family support available

Reflect on whatbarriers to effectivetransition managementexist in your facility?

Rehabilitation Nurses:Champions for OptimizingStroke Rehabilitation• Begin rehabilitation in acute care– Continue across the continuum of care• Prevent & treat complications• Integrated team approach• Transition management

Rehabilitation Nursing Role• Clinician• Collaborator• Coach• Educator• Advocate• Researcher