COMMENTARY

Stroke and Stroke Nursing: Safeguarding the Brain

Laura A. Stokowski, RN, MS

Disclosures

July 18, 2007

Roles in Stroke Nursing

Nurses have responded to the challenge of making stroke systems of care a reality in recent years. Stepping into new roles, such as stroke research nurse, stroke response nurse, stroke coordinator, and stroke nurse practitioner, stroke nurses are using evidence-based practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients.

Stroke Response Nurse

Time is what drives Maurie Whitson, a stroke response nurse for nearly 10 years at Inova Fairfax Hospital in Falls Church, Virginia. When paged that a patient with stroke-like symptoms is en route to the hospital, or that a current inpatient is suspected of having a stroke, Whitson must first determine when the stroke sufferer was last seen as "normal." This is critical, because when it comes to stroke intervention, the clock starts ticking with the onset of symptoms. Establishing this time frame, however, can require the tenacity of a police detective digging for information from family members, nursing home staff, neighbors, friends, or even other patients.

Her role, explains Whitson, is to be a catalyst, speeding up necessary assessments and diagnostic testing when a time-dependent treatment hangs in the balance. She works collaboratively with ED nurses and physicians when a possible stroke patient arrives. Whitson meets the patient in the ED and administers the NIH Stroke Scale, a necessary component of treatment decisions.

A key aspect of most stroke protocols is imaging with CT and CTA (angiography) to determine whether tPA is indicated or contraindicated. This imaging must be obtained as rapidly as possible -- so quickly, in fact, that most stroke centers routinely collect data on their "door to CT times" to monitor for possible delays in their admission procedures for stroke victims. As a stroke response nurse, Whitson accompanies the patient to radiology for imaging and expedites reading of test results. If the patient is a candidate for intravenous tPA, Whitson obtains the drug from the pharmacy and closely observes the patient during tPA administration for evidence of hemorrhage or extension of the stroke. If imaging suggests a large-vessel occlusion, and clot retrieval procedures are likely, or if the patient appears to be a candidate for intra-arterial thrombolysis, Whitson promptly notifies the interventional radiologist.

Stroke response nurses are on-call within the hospital 24 hours a day, 7 days a week. A stroke response nurse focused solely on the potential stroke patient keeps everything moving along at the proper pace and ensures that precious minutes are not wasted. Shortening the time until the patient receives treatment (door-to-needle time) is still considered the number-one priority in acute stroke care.

Stroke Nurse Practitioner

One in 4 strokes is a recurrent stroke, and the risk for a second stroke is highest during the first 30 days after the first ischemic symptoms.[18] Consequently, secondary prevention of stroke is a high priority for patient care in the early days of hospitalization. Karen Peper, a stroke nurse practitioner at Providence Hospital in Southfield, Michigan, makes certain that each and every vulnerable patient is thoroughly evaluated for the cause of stroke, with an eye toward instituting preventive therapies wherever possible.

In her unique role, Peper collaborates with the neurologist to plan the appropriate ongoing care for each patient admitted with stroke or stroke-like symptoms. Every day, Peper rounds on all stroke patients to ensure that essential diagnostic tests and evaluations are ordered, including brain and carotid imaging, lipid profiles, and dysphagia screening. She determines whether patients will be placed on appropriate pharmacologic agents, such as antiplatelet or anticoagulant drugs, cholesterol-lowering agents, and antihypertensive medications. Peper also orders dietary counseling for every patient, as well as physical, occupational, and speech therapy as indicated. While examining patients, Peper takes the opportunity to begin important teaching about the risk factors for stroke, signs and symptoms of stroke, and the diagnostic tests that patients might undergo.

Stroke Nurse Coordinator

Laura Owens, Stroke Nurse Coordinator at Mercy Hospital and Medical Center in Chicago, Illinois, has a passion for her work. Owens coordinates care for stroke patients from admission to discharge, including their in-house rehabilitation. She meets with every new stroke patient and family, providing comprehensive education and resources about stroke and what the future holds for the stroke survivor. Owens might, for example, tell patients with post-stroke dysphagia about VitalStim, a new technology that employs electrical stimulation to improve movement and control of the laryngeal muscles, or explain how transcranial Doppler ultrasound is used to evaluate the brain's collateral circulation in patients with internal artery occlusion. She also takes patients and families to tour the rehabilitation unit, counsels them about emotional changes and depression, and begins to educate them about risk-factor control and secondary prevention.

Owens instructs new nursing staff about the hospital's stroke protocol and mentors those learning to use the NIH Stroke Scale. She extends her teaching into the community by speaking about stroke prevention at retirement luncheons and church functions, participating in free cholesterol and blood sugar screenings for the public, and conducting Hip Hop Stroke,[19] educational programs with children.

Her role as a stroke nurse coordinator also involves quality improvement activities and research. Mercy Hospital is participating in the worldwide randomized controlled trial of ancrod (Viprinex) for emergency stroke. Ancrod, a proteolytic enzyme with anticoagulant properties, is derived from the venom of the Malayan pit viper.

Stroke Nurse Researcher

After years of working with stroke patients and trying to convince adults to change their risky behaviors to prevent stroke, a light bulb came on in Elaine Miller's brain. She was talking to people way too late in the game; in fact, she was talking to the wrong people altogether.

Health habits that influence a person's stroke risk, such as dietary preferences and exercise habits, and even the pessimistic view that embracing healthful habits is too difficult or impossible, are behaviors that often are established by the time an individual is an early adolescent. So Miller, Professor of Nursing at the University of Cincinnati, changed course dramatically and brought her stroke prevention efforts to the place she thought they would do the most good: middle-school.

Dr. Miller further targeted black and underprivileged teens and preteens, for 2 reasons: (1) the parents, grandparents, aunts, and uncles of these children are among those currently at greatest risk for stroke, primarily because of hypertension; and (2) because these middle-schoolers of today, without intervention, are likely to become the stroke sufferers of tomorrow.

Dr. Miller's research involves a nurse-led educational program for 10- to 14-year-olds. Working closely with school nurses, she teaches children the risk factors for stroke, signs and symptoms of stroke, healthy eating and exercise, and how to communicate the message to others. To appeal to her younger audience, Miller uses Stroke Heroes Act FAST, an engaging, 3-minute animated musical video that presents different scenarios for recognizing and responding to the signs of a stroke using the FAST model. Instructional lyrics describe each vignette and encourage the response of calling 911. The acronym FAST is a shortened version of the Cincinnati Prehospital Stroke Scale used by emergency medical service personnel and the National Institutes of Health Stroke Scale ( Table 4 ). Click here to view or purchase Stroke Heroes Act FAST.

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