Practice Recommendations

Secondary Prevention

1.0 Nurses in all practice settings should screen clients for risk factors related to stroke in order to facilitate appropriate secondary prevention. Clients with identified risk factors should be referred to trained healthcare professionals for further management.

Stroke Recognition

2.0 Nurses in all practice settings should recognize the sudden and new onset of the signs and symptoms of stroke as a medical emergency to expedite access to time dependent stroke therapy, as “time is brain”.

Neurological Assessment

3.0 Nurses in all practice settings should conduct a neurological assessment on admission using a validated tool (such as, the Canadian Neurological Scale, National  Institutes of Health Stroke Scale or Glasgow Coma Scale) and continue to monitor the client’s neurological status on an ongoing basis for any changes in:

• Level of consciousness;

• Orientation;

• Motor (strength,  pronator drift, balance and coordination);

• Pupils;

• Speech/Language;

• Vital signs (TPR, BP, SpO2); and

• Blood glucose.

Cognition/Perception/Language

3.1 Nurses in all practice settings should screen clients within 48 hours of the stroke client becoming awake and alert, using validated tools (such as, Montreal Cognitive Assessment [MoCA©], Modified Mini-Mental Status Examination, Line Bisection Test or Frenchay Aphasia Screening Test) for alterations in cognitive, perceptual and language function including:

• Abstraction;

•  Arousal, alertness and orientation;

• Attention;

• Apraxia;

• Language (comprehensive  and expressive deficits);

• Memory (immediate and delayed recall);

• Spatial orientation, Unilateral Spatial Neglect (formally Extinction) & Visual Neglect.

In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

Neurological Assessment

3.2 Nurses in all practice settings should recognize that signs of decline in neurological status may be related to neurological or secondary medical complications.  Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management.

Complications

4.0 Nurses in all practice settings should assess (where feasible using a validated tool) the client’s risk for and/or presence of any of the following complications of stroke:

• fall risk:

- fractures secondary to falls,

- bone loss secondary to immobility;

• fatigue;

• painful hemiparetic shoulder;

• pneumonia secondary to immobility and dysphagia;

• pressure ulcers (e.g.: Braden Scale for Predicting Pressure Sore Risk);

• spasticity/contractures;

• urinary tract infection (UTI);

• venous thromboembolism.

Advanced Care Planning

4.1 Nurses in collaboration with the interprofessional team will assess and support clients (family/substitute  decision maker [SDM]) to make informed decisions that are consistent with their beliefs, values and preferences to ensure client wishes are known and incorporated into the plan of care (includes advanced, palliative and end of life care planning).

Pain

5.0 Nurses in all practice settings should assess and monitor on an ongoing basis the client’s pain severity, quality, and impact on function using a validated tool (such as, Wong-Baker Faces Pain Rating Scale [WBFPRS], Numeric Rating Scale, the Verbal Analogue Scale or the Verbal Rating Scale).

Dysphagia

6.0 Nurses should maintain all clients with stroke NPO (including oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert.

6.1 Nurses in all practice settings who have the appropriate training should screen within 24 hours of the client becoming awake and alert for risk of dysphagia using a standardized tool (such as, Gugging Swallowing Screen, Standardized Bedside Swallowing Assessment [SSA] or Toronto Bedside Swallowing Screening Test [TOR-BSST©]). This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. In situations where impairments are identified, clients should be kept NPO and referred to a trained healthcare professional for further assessment and management.

Nutrition

7.0 Nurses in all practice settings should complete a nutrition and hydration screen within 48 hours of admission, after a positive dysphagia screen and with changes in neurological or medical status, in order to prevent the complications of dehydration and malnutrition. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

Activities of Daily Living

8.0 Nurses in all practice settings should assess stroke clients’ ability to perform the activities of daily living (ADL). This assessment, using a validated tool (such as, the Barthel Index, Functional Independence Measure™ or Alpha FIM®) may be conducted collaboratively with other therapists, or independently with training when therapists are not available. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

Bowel and Bladder

9.0 Nurses in all practice settings should assess clients for fecal incontinence  and constipation.

9.1 Nurses in all practice settings should assess clients for urinary incontinence and retention (with or without overflow).

Depression

10.0 Nurses in all practice settings should screen clients for evidence of depression, using a validated tool (such as, the Stroke Aphasia Depression Questionnaire, Geriatric Depression  Scale, Hospital Anxiety and Depression Scale or the Cornell Scale for Depression in Dementia) throughout the continuum of care. In situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management.

10.1 Nurses in all practice settings should screen stroke clients for suicidal ideation and intent when a high index of suspicion for depression is present, and seek urgent medical referral.

Caregiver Strain

11.0 Nurses in all practice settings should assess/screen caregiver burden, using a validated tool (such as, the Caregiver Strain Index or the Self Related Burden Index). In situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management.

Sexuality

12.0 Nurses in all practice settings should screen stroke clients/their partners for sexual concerns to determine if further assessment and intervention is necessary. In situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management.

Client and Caregiver – Readiness to Learn

13.0 Nurses in all practice settings should assess the stroke client and their caregivers learning needs, abilities, learning preferences and readiness to learn. This assessment should be ongoing as the client moves through the continuum of care and as education is provided.

Documentation

14.0 Nurses in all practice settings should document comprehensive information regarding assessment and/or screening of stroke clients. All data should be documented at the time of assessment and reassessment.