Post Stroke Care: Immediate and Long-term Management

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Introduction

Ischemic stroke still remains the fifth leading cause of death in the United States. Stroke care has become “increasing complex in the new reperfusion era,” especially with ischemic (clot or blockage causing) stroke events, stated Susan Ashcraft DNP from Novant Health System (1). Nurses play a vital role in assessing patients, applying new protocols, and providing overall care in stroke treatment plans. Those of us who are involved in stroke treatment and the care of these patients at all levels must maintain competency whether the patient is acutely ill in the emergency room, intensive care unit (ICU), post-stroke unit, rehabilitation, or at home recovering. 

Pathophysiology 

The expression that “time is brain” is a statement that emphasizes the importance of transporting stroke patients to an acute care facility as soon as symptoms are observed. It is like the statement “time is muscle,” that is used in the care of acute myocardial infarction (MI) or heart attack victims. In both situations, the goal is to prevent irreversible damage to the tissue, cell deprivation of oxygen and nutrients, and cell death. Death of brain cells can lead to devastating outcomes and permanent disabilities (1). Similarly, the prevention and timely treatment of any post-stroke complications reduce long-term disability or adverse sequela. 

Nursing Role in Post Stroke Care

The role of the nurse has expanded in recent years not just to include knowledge of the newer endovascular thrombectomy (EVT) procedure for ischemic stroke, but nurses play key roles in prevention education, acute management as well as utilization of telehealth technology for diagnosis of stroke in the community. In some non-stroke centers, the use of newer imaging technology has enabled expert radiologists to diagnose a stroke and/or rule out brain hemorrhage via CT scan within minutes from off-site offices. The use of telehealth has enabled the health care team to “increase inequitable care and decrease morbidity and mortality” (1). Patients who live in rural settings or have limited access to care are particularly challenged in getting timely and specialized stroke care. 

Whether a patient has experienced an ischemic stroke or not, nurses in the acute care units are responsible for frequent vital signs, including temperature monitoring and neurological assessments. The nursing team is also accountable for glucose management, prevention of hospitalization complications, especially pressure injury, deep vein thrombosis, infections, and inadequate nutrition. We will later review various interventions and challenges that some stroke patients have related to dysphagia and swallowing issues. The health care team can assist the patients and families with any cognitive or functional changes with the goal of reducing suffering and improving quality of life.  

As we know, a large part of patient satisfaction is related to knowledge of their condition and the plan of care, not just today but in the near future. The care management team and social workers rely on the clinical team to provide them with up-to-date clinical information that can change daily; this data can be the determinant of whether the patient can safely go home or whether a rehabilitation stay is recommended. It is ideal that physical therapists, occupational therapists, registered dietitians, and the care management team be present for daily team rounds for up-to-date progress. I found it particularly helpful to have practitioner presence during rounds to explain and predict any diagnosis-related complications or needed imaging/tests that can be anticipated. Practitioners that are accessible can then communicate with families regarding the prognosis and medical plan in a timely fashion. 

Post Stroke / Post Procedure Monitoring 

Patients who received thrombolytics or clot-buster medications like IV alteplase (TPA) and those that had a mechanical thrombectomy (EVT) of a cerebral clot will have frequent vital signs and neurological monitoring per the American Heart Association (AHA) and American Stroke Association (ASA) 2019 Get with the Guidelines®.  

 These guidelines include vital signs and neurological assessments every 15 minutes for 2 hours, every 30 minutes for 6 hours, and every hour for 16 hours (2). It is safe to say that even if the stroke patient that did not receive intravenous alteplase (TPA) or procedure intervention should be monitored similarly. The NIHSS score is a standardized neurological tool using 11 specific clinical assessment items to measure stroke deficits; this is a commonly used assessment. 

The recommended blood pressure goal in acute ischemic stroke with IV medication or embolectomy is to maintain systolic BP less than 180 mmHg, and diastolic BP less than 100 mmHg. The medical treatment recommendations for blood pressure management are:  

• labetalol (Trandate) – a beta and alpha-blocker with dosing from 10-20 mg IV over 1-2 minutes, may repeat one time 
• Nicardipinne (Cardene) – a calcium channel blocker 5mg/hour IV infusion, titrate 2.5 mg/hour every 5-15 minutes for maximum 15 mg/hour to reach desired BP 
• Clevipidine (Cleviprex) – a calcium channel blocker 1-2 mg/hour IV infusion, titrate by doubling the dose every 2-5 minutes for a maximum of 21 mg/hour for desired BP. (3) 

New guidelines from the joint commission are specific in that the treatment or blood pressure goals be written in the medication orders and that the nurses are aware of titration recommendations from the manufacturer to prevent rapid swings in blood pressure if adjusted too quickly. 

Post Endovascular Thrombectomy Complications 

The nurse at the immediate post-procedure bedside or post-procedure transfer unit must recognize potential complications from arterial puncture. These include possible injury to the arterial vessel or the nerves that are near the puncture location. Neurovascular assessments post procedures are advised, including knowledge of any pre-procedure existing deficits or disabilities.  

Post-procedure access site complications may lead to hemorrhage; including retroperitoneal bleed (blood enters into space immediately behind the abdominal peritoneum). The symptoms of retroperitoneal bleed are not always immediately evident. The patient will appear to be in shock, with a sudden drop in hemoglobin and hematocrit lab results, blood pressure, and occasional back pain complaints. If an arterial vessel closure device fails, the patient is prone to bleeding at the arterial vessel access site (3). 

Some organizations use radial artery access for thrombectomy procedures which can reduce the immobile period post femoral access, but this can be an additional site of bleeding. The TR Band® is a compression device that can assist with preventing or treating radial artery bleeds. The device exerts a controlled amount of compression to the radial artery and is adjustable for bleeding as well as patient comfort (4). 

Post Intravenous Thrombolytic Intervention 

Patients who receive IV alteplase (TPA) to dissolve the clot producing stroke symptoms also need to be monitored closely. These patients are susceptible to localized as well as systemic bleeding. If an intracranial hemorrhage occurs, the patient will usually present with a sudden increase in neurological systems within the 36 to 48 hours post “clot buster” medication. The post thrombolytic patient should be watched for any excess bleeding from any puncture sites or orifices, hematuria, or hemoptysis. Rarely orolingual angioedema or tongue swelling has been noted as a side effect of TPA, especially in those taking ACE inhibitor drugs (3). This reaction can compromise the patient’s airway and breathing.

Other Complications and Assessments 

Patients as a result of a stroke may have difficulty protecting and maintaining their airway due to changes in mental status and cranial nerve deficits. In basic life support training, it is emphasized that the tongue in an unconscious patient can obstruct the airway. The nurse must observe respiratory rate, excursion, and ability to clear secretions in addition to basic oxygen monitoring. Remember that O2 Saturation does not reflect carbon dioxide levels, and arterial blood gases may be indicated in these patients, especially if endotracheal intubation is being considered. 

Fever and extremes in blood glucose levels are associated with worse outcomes after stroke. The nurse should recognize abnormal levels and administer treatments like acetaminophen (Tylenol) and/or insulin promptly. The glucose level in a stroke patient is a goal of 140-180 mg/dl.  

Patients can have secondary infections or a central fever from neurological impairment. The hypothalamus is a section of your brain that controls thermoregulation in the body; strokes affecting this area can create central fevers. 

Stroke patients are at risk for venous thromboembolism (VTE) events which include deep vein thrombosis (DVT) and pulmonary emboli (PE). This is due to various factors, including immobility, age, dehydration, and other predisposing factors. Mechanical pneumatic compression devices and/or chemical prophylaxis with heparin or enoxaparin (Lovenox) subcutaneously should be a standard protocol for your hospitalized or long-term patients. 

Urinary retention is common, especially in the first 24 hours of stroke. The nurse can assess for urinary retention from the patient’s complaints, lack of urinary output despite IV fluids, or using a bedside bladder scanner. Policies should be in place to avoid urinary catheterization if possible and should give guidance regarding what level of post-void residual volume is acceptable.  

Some hospitals have a protocol to use intermittent catheterization for a limited period to avoid permanent urinary catheterization. Avoid constipation with proper hydration, mobilization, and food modification. If needed, the nurse can advocate for the patient and request a bowel regimen or stool softener. 

Nutrition in Stroke Care 

Stroke patients are at risk for malnutrition secondary to procedures requiring NPO status, dysphagia, and food management/access difficulties; “Malnutrition influences stroke outcomes and serves as an independent predictor of morbidity and mortality” (3). I have observed stroke patients who have had difficulty opening food containers, holding cups and utensils, and needing assistance with feeding. If providing stroke care, staff must be available and have patience when attempting to feed patients, especially those with dysphagia. All staff should have education and competency training in stroke care to prevent and recognize aspiration risk. Acute stroke patients should have a basic swallow screen before any oral intake of fluids or food, including small amounts that may be given with medications. In some organizations, the basic dysphasia screen can be done by the nurse and begins with an evaluation of the patient’s alertness, the ability to sit 90 degrees, assessing for evidence of drooling and speech difficulties. It is followed by an assessment of the stroke patient’s ability to swallow small sips of water, observing for any signs of coughing, choking, wet or gurgling voice, drooling, or holding the liquid in the mouth. If they are successful in swallowing small amounts, a larger (60ml) amount of water is tried. If there are any difficulties observed, the patient is immediately made NPO until an experienced speech and swallow therapist can attend.  

The staff should observe for any respiratory compromise, especially post meals since aspiration can lead to pneumonia, increasing in-hospital mortality. I also observed that some patients post-intubation had struggles with swallowing that improved over time and withdrawal from ICU sedation. 

Dedicated Stroke Care Units

Not every hospital has a dedicated stroke unit. However, the standard of care should remain the same whether the patient is in a stroke care unit or not; however, this can be especially challenging to maintain competency for stroke care over multiple areas and staff. However, patients who receive care in a specialized stroke unit are more likely to be “alive, independent, and living at home one year after stroke,” (5).  

Initial Blood Pressure Goals 

During the initial phase of ischemic stroke, the best practice is to cautiously reduce any blood pressure over 220/120 mmHg for the first 24 hours. This seems like a high blood pressure range; however, the brain edema and potential intracranial pressure require higher upward cerebral artery flow from systemic blood pressure to maintain cerebral perfusion. Cerebral perfusion is determined by upward mean arterial pressure, which has the downward intracranial pressure subtracted. Remember, for those patients receiving intravenous thrombolytics, the goal is to maintain blood pressure less than 180/105 for the first 24 hours and thrombectomy stroke patients. (5)  

Cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP) – Intracranial pressure (ICP) the normal range is 60-70 mmHg. 

Psychological and Neuropsychological Concerns in Stroke Care

The rate of post-stroke cognitive changes, including dementia, is approximately 10%. Some will develop depressive symptoms long-term or acute delirium during the acute phase. Cognitive rehabilitation can be used to improve function and can include cognitive activities and a specialized environment to assist with mental stimulation. Some patients may experience mood swings and psychotherapy; support groups may be helpful for this group of people. Dextromethorphan/quinidine (Nuedexta) has been approved for use in some neurological patients that have intense mood swings. Staff on stroke care units should be trained to recognize delirium during the acute phase of recovery, which can be triggered from a variety of physiological or psychological disruptions. The promotion of proper sleep/wake cycles and early mobilization as well as an environment conducive to orientation is vital and should include family members and caregivers to create a sense of familiarity (5).

Mobility and Safety in Stroke Care

At every level of care, the priority should be to encourage the resumptions of previous activities to the best of the stroke patient’s ability. The patient should be provided with a physical therapist that can evaluate and provide the best plan for exercise and stretching. The patient may need supportive or assistive devices to prevent contractures and imbalance issues. Formal rehabilitation programs are designed to assess the patient for hemiparesis, weakness, or partial paralysis on one side of the body, which can involve the limbs or face. This can increase fall risk, and families will need a fall risk assessment of the home environment if the patient is discharged home. Occupational therapists are part of the team and can help the patient relearn tasks of daily living (transferring, bathing, dressing, cooking, and feeding, etc.) The rehabilitation units often have a life-size kitchen, bed, chair, and car models for training. 

Stroke Care Transitions 

Discharge to another level of care from the hospital is a critical period. Patients who are going home need a home care nurse to evaluate their care needs and the safety of the home environment. The goals are to prevent any secondary stroke as well as improve recovery and rehabilitation while avoiding complications. Through readmission evaluations, we have learned that some patients and families are not prepared for self-management, or their home environment is not conducive for the disabled family member. The level of family/caregiver support often determines the success of the transition, whether to home or to a rehabilitation facility. Communication among and with the care team is imperative to maximize success. The many supportive services and referrals for the patient to follow up can be overwhelming for caregivers. There must be education about the nature of the stroke and the signs and symptoms of TIA/stroke, stroke risk factor modifications, and necessary medical and specialist visits. The community at large should be familiar with how to quickly access emergency medical services if needed. Self-management skills that enhance self-efficiency with activities of daily living and problem solving are key interventions at all levels. If patients go to an acute rehabilitation center for a designated period, their skills should be continued in the home environment. Some organizations have a transitional stroke clinic for regular office visits, and follow-up nurse phone calls have been successful in easing transitions. Practitioners, nurses, and pharmacists are often the coordinators of medication reconciliation upon transfer to another level of care (5). Telehealth has expanded our ability to monitor patient’s progress in a variety of settings to ensure the plan of care and medication self-management. 

Conclusion

Nurses play a vital role in the care of stroke patients at all levels. The amount of time we spend at the bedside enables us to be able to determine a patient’s capabilities and deficits and from there, we can develop an appropriate and individualized plan of care with the interdisciplinary team. Stroke care can be complex but rewarding, and it is heartwarming to see our efforts in assisting the patient’s potential progress. It is also with compassion and care we provide information regarding advanced directives and palliative care for those patients who have succumbed to a serious life-altering stroke. 

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