Rehabilitation Nurses: Champions for Optimizing Stroke Rehabilitation Across the Continuum of Care
Presenters Sandra Melchiorre RN, MN, ACNP, CNN (c) Regional Stroke Acute Care Advanced Practice Nurse, SEO Delanya Podgers BSc, RN Stroke Resource Nurse, Neuroscience Unit, KGH Barb Knapton RN SMOL, Neuro Rehabilitation Nurse Christine Allison RN, HBScN SMOL, Neuro Rehabilitation Nurse
Rehabilitation Improves Stroke Patient Outcomes
Workshop Objectives To discuss the role of the RN in implementing stroke rehabilitation & Stroke Best Practice Guidelines (2003) across the continuum of care To discuss common barriers and strategies for effective transition management
Definition of Stroke Rehabilitation A progressive, dynamic, goal-oriented process aimed at enabling a person with an impairment to reach his or her optimal physical, cognitive, emotional, communicative and/or social 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 nurse implement stroke rehabilitation as part of your plan of care?
Stroke Rehabilitation A process that begins at onset Early rehabilitation optimizes stroke outcomes Apply principles throughout the continuum of care
Stroke Rehabilitation Nursing Principles Continuity of Care (repetition) Holistic approach to care Integrated interdisciplinary team approach
2003 Cochrane Database Stroke Unit Trials Review Stroke patients who receive organized inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke
Stroke Unit Characteristics Patients cared for in a geographically distinct location Nursing Specialization and team expertise Nursing integration with multidisciplinary plan of care
Stroke Unit Characteristics Coordinated multidisciplinary care Family centered care Staff, patient and caregiver education
Case Study Mrs. Percy
Mrs Percy s Hx 77 year old retired teacher, very active Married, supportive family Found in bed awake at 0800, responsive and talking Left facial drooping with left hemiplegia She was last seen normal at 10 pm the night before. Not a candidate for tpa BP 165/100 in ER No previous Stroke or TIAs
Diagnosis: Ischemic Stroke CT Results: Rt MCA Ischemic Infarct
Mrs Percy s Deficits Left hemiplegia Left shoulder sublexation with pain Requires two person transfer Dysphagia: pureed diet with thickened fluids Continent of bowel and bladder but needs assistance with dressing/undressing Emotionally labile Apraxia Left body neglect
What are your planned interventions to prevent complications and optimize Mrs Percy s recovery?
Maintaining Skin Integrity Skin assessment weekly using Braden scale Collaborate with OT, PT, and Nutritionist to manage risk factors Turning/repositioning schedule
Promoting Early Remobilization Complete risk for falls assessment upon admission in collaboration with OT and PT Post instructions for safe transferring, positioning, and ambulation at the bedside and on the care plan Educate the patient/family
Promoting Safe Swallowing and Feeding Collaborate with SLP and Nutritionist with swallowing and nutritional assessment Implement feeding strategies and diet modifications as recommended to reduce risk of aspiration Reinforce diet education for Mrs Percy/family
Preventing Aspiration Pneumonia Malnutrition, & Dehydration Ongoing swallowing nutrition and respiratory assessments Report progress or concerns to the SLP and Nutritionist and implement changes to diet and feeding strategies suggested
Restoring Maximal Independence with ADL Collaborate with therapists Provide education/coaching Reinforce therapy at the bedside On going assessment Review Mrs Percy s progress with Interdisciplinary team during Stroke Rounds, Discharge Rounds, and Family meetings
Protecting Hemiplegic Shoulder Provide mechanical support of left arm (ie. Lap tray, positioning) Move gently and allow her time to participate When side-lying, never position her directly on the humeral head Encourage Mrs Percy to pay attention to left arm
Pain Management - Assess for pain using a pain scale of 1-10 - Administer analgesia and evaluate effectiveness - Collaborate with Occupational Therapy and Physiotherapy for the appropriate positioning and transferring techniques
Continence Promotion Ensure bedpan and Commode chair are at the bedside Ask family to bring in adaptive loose clothing to promote toileting Encourage Mrs Percy to call for assistance when needed Educate patient and family
Facilitating Psychosocial Coping and Adaptation Assess behavior, mood, loss of interest in daily activities, sleeping pattern and loss of appetite Assess risk of depression using a Depression scale (Score Research Project) Encourage family participation days with therapists
What education do you want to provide Mrs Percy and her family?
Promoting Stroke Awareness What is a stroke Complications/ deficits Plan of Care Risk Factors Recognize & React to S&S Secondary Stroke prevention Medication Diet Exercise BP
SMOL Stroke Rehab Admission Criteria >16 years of age Recent stroke Stable Investigations completed Agrees to participate in stroke rehab Able to learn
Stroke Rehabilitation Mrs Percy is admitted to the in-patient Stroke Rehabilitation Program at SMOL
Mrs Percy s Deficits: 3 weeks One person pivot transfer Left shoulder pain continues Dysphagia: minced diet with thickened fluids, but wants to eat regular meals and drink water Continues to need assistance with toileting Emotionally: Anxious to return home and resume her social activities and refuses to be discharged to a LTC home
What are your interventions for Mrs Percy 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 Nutritionist to assess dysphagia and nutritional status Reinforce diet and safe feeding strategies with patient and family Complete risk for falls assessment upon admission in collaboration with Mrs Percy, OT, PT, and Nursing
Restoring Mobility and Maximal Independence Post instructions for safe transferring, positioning and ambulation at the bedside Promote toileting and mobilization Educate Mrs. Percy/family about rehabilitation and the approach to care at SMOL
Restoring Mobility and Maximal Independence Collaborate with Pain Team, PT OT and Physiatrist to manage shoulder pain Reinforce therapeutic interventions at the bedside (e.g. dressing, safe transferring) Prepare Mrs Percy for cortisone injection study in collaboration with Physiatrist
Facilitating Psychosocial Coping & Community Re-integration Provide emotional support and education re: stroke, secondary stroke prevention, community support, and caregiver stress Monitor behavior, mood and affect for S/S of depression Advocate for Mrs Percy and family at Stroke Rounds and Discharge Planning Rounds Collaborate with team to resolve ethical issues
Transition Management A stroke survivor may undergo several transitions in care Effective transitions are an integral part of improving stroke management (BPGs for Stroke Care, 2003)
Managing the Transition Achieving excellence in transition management is Collaboration among healthcare providers in different organizations Sharing both information responsibility for the entire process (BPGs for Stroke Care, 2003)
Barriers to Effective Transition Unexpected or unexplained delays in transferring stroke survivors to the appropriate placement (BPGs for Stroke Care, 2003)
Barriers to Effective Transition Lack of communication Inadequate information upon admission Lack of attention to emotional needs (BPGs for Stroke Care, 2003)
What Information Is Most Helpful? Full discharge summary re: stroke interventions, education and support provided Interdisciplinary team report with specific programs established
Direct Communication Holistic approach Complete picture of the client and family / caregiver Functional status of the stroke survivor Prognosis, established goals Family support available
Reflect on what barriers to effective transition management exist in your facility?
Rehabilitation Nurses: Champions for Optimizing Stroke 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