Prevention of

Complications after
Stroke
Toni R. Rougeou, RN
Stroke Program Coordinator

University Medical Center New Orleans |

www.UMCNO.org
 Objectives
 Team member will identify
potential complications during the
Prehospital, Hyper acute care,
Acute Care and Rehab phases of
care after a stroke.
 Team member will identify multiple
treatment options to prevent
complications after a stroke.

2 University Medical Center New Orleans |

www.UMCNO.org
 Stroke Facts:
 Stroke is the leading cause of serious long term
disability in the United States and across the globe.
 Early action and treatment is crucial in preserving
brain during a stroke to minimize neurological injury.
 The healthcare team plays an integral role in caring
for the stroke patient with:
Effective communication with EMS
Rapid physical and neuro evaluation
Administer thrombolytic, when indicated
Stroke work-up for etiology
Assist with expediting treatments quickly
 With timely delivery, of stroke care we can
significantly improve neurological outcomes.
3 University Medical Center New Orleans |
www.UMCNO.org
If left untreated, Stroke Kills
32,000
• brain cells per second

1.9 million
• brain cells per minute

120 million
• brain cells per hour

4 University Medical Center New Orleans |

www.UMCNO.org
 Prehospital Care: Prevention of
complications begins during the initial
management of stroke in the field.
 Assess/Manage  Determine
ABC’s LKW, and
 Initiate cardiac family contact.
monitoring  Triage and
 Supplemental transport
O2  Notify hospital
 Establish IV of pending
 Check Blood stroke arrival
Glucose  Maintain NPO
5 University Medical Center New Orleans |
www.UMCNO.org
Hyper acute care phase:
 “Stroke is a primary failure of focal tissue
oxygenation and energy supply.” (Stroke,
March 2013)
 Avoid systemic tissue hypoxia
 Avoid hypotension
 Avoid hypoglycemia
 Continuously re-assessing ABC’s and
Neuro status.
 The stroke savvy nurse plays a key role in
the hyper acute phase with timely delivery
of skilled stroke care.
6 University Medical Center New Orleans |
www.UMCNO.org
Hypoxia: In one small study of hemi paretic
patients, 63% developed hypoxia within 48
hours of stroke.
Common cause of Prevention plan
Hypoxia post stroke  Frequent observation
 Partial airway of rate and pattern
obstruction  Cheyne-Stokes resp.
 Hypoventilation common in stroke pts.
 Aspiration  O2 to maintain O2 sat
 Atelectasis >94% with least
 Pneumonia invasive method.
 Most are due to AMS  Intubation and
Mechanical Ventilation
 Brain stem may be required
dysfunction

7 University Medical Center New Orleans |

www.UMCNO.org
Blood Pressure: Management of BP is
one of the most important factors in
caring for a stroke patient.
 Blood pressure can rise during
acute stroke as a compensatory mechanism,
allowing increased cerebral perfusion and
enhancing collateral circulation.
 If SBP rises too high, blood brain barrier may
be disrupted > risk of cerebral edema,
hemorrhagic transformation or expansion of
hemorrhagic stroke.
 Extreme increase in arterial BP can lead to
encephalopathy, cardiac complications and
renal insufficiency.
 BP is not usually treated until determination of
stroke type, unless >220/120 mmHg.
8 University Medical Center New Orleans |
www.UMCNO.org
 Blood Pressure - Acute
Ischemic Stroke (AIS)
 Alteplase (rtPA) eligible patients
 New rtPA label (Genentech 2015) has
contraindication of – Current severe
uncontrolled hypertension.
 Current AHA/ASA guidelines define
HTN associated with rtPA eligibility as
SBP> 185 mm Hg or DBP> 110 mm
Hg.
 AHA/ASA guidelines also recommend
during initiation and for 24 hours post
treatment with rtPA – B/P < 180/105
mm Hg.
9 University Medical Center New Orleans |
www.UMCNO.org
AHA/ASA Guidelines

10 University Medical Center New Orleans |

www.UMCNO.org
 Blood Pressure - Acute
Ischemic Stroke (AIS)
 For AIS NOT Eligible for rtPA
 SAVE THE PENUMBRA!!!
 Permissive hypertension for 48 hours
– Hold BP meds and only treat if BP >
220/120 mm Hg.
 Facilitates increase in perfusion to the
acutely infarcted brain tissue.
 If BP is reduce dramatically, perfusion
pressure may be inadequate for the
penumbra, leading to extension of
infarct or loss of penumbra.
11 University Medical Center New Orleans |
www.UMCNO.org
 Blood Pressure - Acute Ischemic
Stroke (AIS) - Hypotension
 Hypotension is rare  Treatment plan
during AIS
 Prevent further
 Impairs cerebral
autoregulation
infarct.
 Look for other  Urgent evaluation,
causes, shock, aortic diagnosis and
dissection or cardiac correction of the
issues cause
 Associated with poor
outcomes
 Vasopressor
agents and/or
fluids if needed to
elevate BP

12 University Medical Center New Orleans |

www.UMCNO.org
Hemorrhagic Stroke

13 University Medical Center New Orleans |

www.UMCNO.org
Blood Pressure Management
Hemorrhagic Stroke
 ICH –  SAH –
Intracranial Subarachnoid
Hemorrhage Hemorrhage
 Acute reduction  After acute
of SBP to 140- SAH, BP
160 is thought reduction to
to be lower than
reasonable and 160/90 is
safe. reasonable.
(Connolly, et al.,2012)

14 University Medical Center New Orleans |

www.UMCNO.org
 INTERACT 2 Trial
 Largest clinical trial evaluating
intensive blood pressure lowering
in 2839 patients with SBP between
150 and 220 mm Hg within 6 hours
of ICH.

15 University Medical Center New Orleans |

www.UMCNO.org
 AHA/ASA B/P Recommendations
based on INTERACT2 trial
 For ICH patients presenting with SBP
between 150 and 220 mm Hg and without
contraindication to acute BP treatment,
acute lowering of SBP to 140 mm Hg is safe
(Class 1; Level A) and can be effective for
improving functional outcome. (Class IIb;
level C).
 For ICH patients presenting with SBP >220,
it may be reasonable to consider
aggressive reduction of BP with a
continuous intravenous infusion and
frequent BP monitoring (Class IIb; level C).
 http://stroke.ahajournals.org/content/early/2
015/05/28/STR.0000000000000069
16 University Medical Center New Orleans |
www.UMCNO.org
Blood Pressure Management
Hemorrhagic Stroke
 NEJM Published June 8, 2016
ATACH-2 trial – “Intensive Blood-
Pressure Lowering in Patients with
Acute Cerebral Hemorrhage.
 Randomly selected eligible patients
(1000) with intracerebral hemorrhage.
 500 were assigned intensive
treatment SBP range – 110-139
 500 were assigned standard
treatment SBP range – 140-179.
17 University Medical Center New Orleans |
www.UMCNO.org
ATACH-2 Conclusion
 The treatment of participants with
ICH to achieve a target SBP of 110
-139 mm Hg did not result in a
lower rate of death or disability
than standard reduction to a target
of 140-179 mm Hg.

18 University Medical Center New Orleans |

www.UMCNO.org
Hemorrhagic Stroke - Care
 Blood Pressure  Prevention Plan
management is  Assess for
crucial in coagulopathy
preventing re-  Assess current
bleed or med list
expansion.
 Hemostasis is  FFP, Cryo or Vit K
critical to prevent  Prothrombin
continued Complex
bleeding. Concentrate –
KCENTRA/Feiba
 Use reversal
agents; Praxbind
reversal for
Pradaxa
19 University Medical Center New Orleans |
www.UMCNO.org
Aneurysmal SAH -
Vasospasm
 At risk between  Prevention Plan
day 6 and 21 post  Nimodipine 60 mg
hemorrhage. Q 4 hours for 21
 Occurs when days
arteries narrow,  If patient has
leading to neurologic
decreased blood deterioration
flow causing  Triple “H”
ischemia Therapy
 SAH patients  Hypervolemia
should be  Hypertension
monitored in the  Hemodilution
ICU
20 University Medical Center New Orleans |
www.UMCNO.org
Management of elevated
Intracranial Pressure (ICP)
 Increased ICP is  Prevention Plan
most likely to  Elevate HOB
occur in ICH or  Keep neck aligned
SAH and patients  Reduce stimulation
with large vessel  Osmotherapy;
ischemic strokes. Mannitol or hypertonic
saline
 For ICH/SAH, if
 CSF diversion;
ICP titrate MAP Ventriculostomy
to maintain CPP  Maintain Temp <99.0F
at least > 60.
 Mechanical ventilation
 Barbiturate coma
 Craniectomy
21 University Medical Center New Orleans |
www.UMCNO.org
 Management of Blood
Glucose - Hypoglycemia
 Hypoglycemia is rare during AIS, and
is usually related to antidiabetic
medications.
 Can mimic stroke and cause seizures,
but is easily and rapidly correctable.
 If severe and prolonged, can result in
worsening of brain injury.
 Blood glucose should be measured
pre-hospital, and treated urgently if
low.
22 University Medical Center New Orleans |
www.UMCNO.org
 Management of Blood
Glucose - Hyperglycemia
 Elevated BS is very  Prevention Plan
common during AIS,
presenting in > 40% of  Avoid Hypoglycemia
cases. with aggressive
 Increases anaerobic hyperglycemia
metabolism, lactic acidosis correction
and free-radical production.
 Avoid IV solutions
 Can lead to infarct
expansion, hemorrhagic with glucose
transformation and  Sliding Scale Insulin
reduced recanalization. orders
 Increases length of stay
and mortality.
 Accu-checks and SQ
insulin should be
punctual to reduce
peaks and valleys

23 University Medical Center New Orleans |

www.UMCNO.org
Management of Temperature
Hyperthermia
 Approx 1/3 of stroke pts  Prevention plan
develop hyperthermia  Maintain
(T>37.6 C) within first
few hours. normothermia
 Inflammatory response  Determine source of
may result from fever - UTI, sepsis
damage to the pneumonia or may be
thermoregulatory due to stroke.
center.
 Acetaminophen,
 Increases metabolic aspirin, ibuprofen
demand
 Accelerates the  Surface cooling;
ischemic cascade avoid shivering
leading to conversion of  Educate family to
penumbra to infarct limit blankets
 Independently
contributes to death  Avoid warm room
and disability at 30 temperatures
days. 24 University Medical Center New Orleans |
www.UMCNO.org
Acute Care of Stroke Patient

 Multiple studies – indicate post stroke

care in a designated stroke unit will
lessen the rate of mortality and
morbidity.
 63% of patients have 1 or more
complications after AIS when not
cared for in a stroke unit.
 Severity of the stroke affects the
development of complications, which
usually occur in the first 4 days.
25 University Medical Center New Orleans |
www.UMCNO.org
Admission, Length of Stay and
Interdisciplinary team

26 University Medical Center New Orleans |

www.UMCNO.org
Deep Vein Thrombosis (DVT)
and Pulmonary Embolus(PE)
 Stroke patients are in  Prevention Plan
bed 50% of the time for  Early Mobilization
the first 2 weeks.  Early involvement with
 Immobility, limb PT/OT
paralysis common  Anti-thrombotics
 PE account for 10% of  SCD’s especially for pts
deaths post stroke with ICH/SAH
 DVT and PE were more  Heparin SQ
likely to occur in first 3  Low-Molecular weight
months after stroke heparin - Lovenox
 PE usually occur for
venous thrombi that
develop in a paralyzed
lower extremity or
pelvis. 27 University Medical Center New Orleans |
www.UMCNO.org
 Dysphagia – Impaired
Swallowing
The Join Commission Requires
“All patients exhibiting stroke symptoms
are screened for dysphagia prior to receiving
any oral intake of fluids, food, or
medication.”

28 University Medical Center New Orleans |

www.UMCNO.org
 Dysphagia – Impaired
Swallowing
 Prevention Plan
 Affects 37% to 78%  Starts in ED – use a
of patients with acute validated tool to assess
stroke. swallow
 Associated with  Assess for possible
increased risk of aspiration
aspiration,  Strict NPO if fail
pneumonia,  Consult Speech therapist
prolonged hospital  Feed only when awake
stay, disability, and and alert
death.  Elevate HOB upright
 Suction available
 Avoid rushed or forced
feeding
 Provide thickened liquid or
pureed diet when
recommended by SLT.
 Provide frequent oral care.
29 University Medical Center New Orleans |
www.UMCNO.org
 Seizure Post Stroke
 AIS is one of the Prevention Plan
highest causes of  Prophylactic
epilepsy in the anticonvulsants should not
be routinely given with ICH.
elderly population.  Anticonvulsants are often
 ICH patients are at prescribed in acute phase if
having clinical S/S of
high risk for
seizures.
seizures in first 24  Assess for other causes of
hours seizures
 Hematomas in the  Protect airway, protect from
harm
temporal lobe and
 Ativan during acute phase
cerebral cortex if can inject before
have higher risk for spontaneous resolution
seizure  Continuous EEG
30 University Medical Center New Orleans |
www.UMCNO.org
 Maintenance of
Nutrition/Hydration
 Hypovolemia may lead  Prevention plan
to hypoperfusion and  If NPO – IV fluids –
exacerbate the bolus followed by
ischemic brain tissue, maintenance fluids
cause renal impairment  Isotonic solution
and lead to thrombosis.
 Hypervolemia may lead  NG or Duotube for meds
to cerebral edema and and feedings
increase stress on  PEG placement
heart.  Bowel management
 Dehydration and  Consult dietician
malnutrition may slow  Speech to continue to
recovery assess swallow function
 Strict NPO due to
dysphagia or AMS

31 University Medical Center New Orleans |

www.UMCNO.org
Infection – Pneumonia
 Pneumonia is responsible for
approximately 35% of acute stroke patient
deaths.
Common Causes of Pneumonia Post
Stroke:
 Suppression of immune responses which
predispose to infection.
 Dysphagia is associated with risk for
pneumonia and increased risk of death.
 Immobility and atelectasis
 Mechanical Ventilation can also increase
incidence.
32 University Medical Center New Orleans |
www.UMCNO.org
Infection - Pneumonia
 Patients at greatest risk  Prevention Plan
for pneumonia due to
dysphagia
 NPO if fail Swallow
screen
1. Brain stem infarcts
2. Multiple strokes  Early Mobilization
3. Major hemispheric  Early PT/OT/Speech
lesions consults
4. Severe AMS  Turn patient
5. Impaired Frequently
gag/cough  Good pulmonary
6. High NIHSS care; deep breaths
 Good frequent oral
care.

33 University Medical Center New Orleans |

www.UMCNO.org
 Infection – Urinary Tract
Infection (UTI)
 Occur in up to  Prevention Plan
60% of stroke  Early mobilization
patients and are  Urinalysis if
associated with indicated
poor outcomes.
 Incidence highest  Avoid indwelling
in patients with catheters;
indwelling cath. Remove ASAP
 Loss of sphincter  Intermittent Caths
can increase risk may reduce risk
 Can lead to  Antibiotics, if
sepsis or indicated
bacteremia
34 University Medical Center New Orleans |
www.UMCNO.org
 Impaired Mobilization
 Usually due to stroke  Prevention Plan
causing mobility  Consult
deficits; PT/OT/Speech early
hemiparalysis. to develop plan for
 66% of patients are rehabilitation
immobile for a period  PROM early to
of time post stroke prevent joint
 33% will continue to contractures and
have mobility issues atrophy
up to three months.  Teach families PROM
 Early mobilization to involve in care
will reduce risk for  Monitor BP with
complications and position changes
improve functional
outcomes.

35 University Medical Center New Orleans |

www.UMCNO.org
 Falls – Post Stroke
 increased risk for  Prevention Plan
fall due to motor,  Assess for falls risk
 Frequent Nursing
sensory, rounds
communication,  Frequently orient patient
visual, balance and to environment and
stress not getting out of
cognitive deficits bed without assistance
 Additional risk  Call bell/bedside table
within reach
include, nursing  Offer toileting Q2 hours
staffing levels, hx of  Bed or chair alarm on
falls, continence  Bed in low position
status, medications  Assess for need of sitter
and procedures.

36 University Medical Center New Orleans |

www.UMCNO.org
Skin Breakdown Post Stroke
 Occurs in 9% of all  Prevention Plan
hospitalized pts.  Assess for skin
 Stroke patients are breakdown risk
high risk due to using a valid tool;
immobility, paresis, Braden scale
decreased  Turn frequently Q2
sensation and  Keep skin clean
cognition as well and dry
as diabetes
 Bony areas at  Avoid friction and
more risk sheering
 Moisture from  Maximize nutrition
incontinence also  Adequate padding
a risk and mattress
37 University Medical Center New Orleans |
www.UMCNO.org
Incontinence/Constipation
 Constipation common  Prevention Plan
during first 2 weeks post
stroke  Assess bowel and
 Caused by: decrease
bladder function
mobility, pain medications,  Avoid constipation and
dehydration, and straining – will cause
depression spikes in BP
 Urinary incontinence  Bowel training – stool
occurs in as many as 60%
of stroke patients early after softeners, laxatives,
stroke. enemas
 Caused by: Neurogenic  Avoid urinary catheters
bladder, hyperreflexia, urge  Retrain Bladder –offer
incontinence and AMS frequent toileting,Q2
when awake and Q4 at
night.
 Lessen fluid intake in the
evening hours.

38 University Medical Center New Orleans |

www.UMCNO.org
Pain/Positioning Post Stroke
 Stroke patients are at  Prevention plan
 Early PT/OT consults for
risk for contractures splinting to prevent
pain and joint damage contractures
 Position paretic limb
due to a paretic limb.
 Progressive ROM
 Shoulder pain occurs  Electrical stimulation
in up to 80% of pts  Heat
 Anti-inflammatory agents or
with arm paresis due analgesics
to: poor positioning  Proper handling of paretic
and traction on arm extremity
 Spasticity treatment-
during transfer stretching, splinting, and
 Spasticity occurs in up medications.
 Botox injections
to 65% of stroke  Oral Baclofen,
patients benzodiazepines.

39 University Medical Center New Orleans |

www.UMCNO.org
Depression Post Stroke
 Present in more than Prevention Plan
1/3 of ischemic stroke  AHA/ASA recommends
patients screening
 Can negatively affect  Should use a validated
cognition and motor depression screening
recovery tool: PHQ2, PHQ9,
 Associated with HADS, DT
increased mortality  Antidepressants improve
 Can increase caregiver outcomes
distress  Avoid alcohol
 Caused by: loss of  May take up to 4-6
function/independence, weeks to feel full effect
biological impact of of antidepressant
alteration of brain
neurotransmitter
function.

40 University Medical Center New Orleans |

www.UMCNO.org
Prevention of Future Stroke

 EDUCATE, EDUCATE, EDUCATE!!!

 Of the 795,000 stroke that occur each
year, approximately 25% are
recurrent events.
 Provide individualized education for
each patient and his/her family
 Should ALWAYS include the patient
and family in facilitation of care goals
and options.
41 University Medical Center New Orleans |
www.UMCNO.org
 Successful Stroke Care and
Rehabilitation is ALWAYS a TEAM
approach.

42 University Medical Center New Orleans |

www.UMCNO.org
 Patient Prevention Plan –
Education
 Identify patient specific stroke risk factors
 List medications and treatment plan to
control risk factors
 Explain cause of stroke if known
 Review medical, nursing and other
therapeutic interventions to manage the
stroke
 Review interventions to prevent another
stroke; Ex; Quit smoking, routine exercise
 Stress importance of recognizing signs
and symptoms of stroke and the
importance of calling 911.
43 University Medical Center New Orleans |
www.UMCNO.org
 References
 AHA Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral
Vascular Disease, & Council on Clinical Cardiology. (2013). Guideline for the
Early Management of Patients With Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the AHA/ASA. Stroke (44), pp. 870-947.
Retrieved from AHA Web site: http://stroke.ahajournals.org/content/44/3/870

 The Joint Commission. (2014, January 17). Prepublication Requirement.

Retrieved from:
http://www.jointcommission.org/assets/1/6/PSC_DSC_March2014.pdf

 Schepp, S., Tirschwell, D., Miller, R., and Longstreth, W. (2012, December 8).
Swallowing Screens after Acute Stroke: A Systematic review. Stroke(43)3: 869-
871. Retrieved from American Heart Association Web site:
http://stroke.ahajournals.org/content/43/3/869

 Morrison, K., (2014). Fast Facts for Stroke Care Nursing An Expert Guide in a
Nutshell, (1st ed.). New York, NY: Springer Publishing Company, LLC.

 Livesay, S., (Ed.). (2014) AANN Comprehensive Review for Stroke Nursing.
Chicago, Il: American Association of Neuroscience Nurses.
44 University Medical Center New Orleans |
www.UMCNO.org
 References
 Hemphill, C., Greenberg, S., Anderson, K., Bendok, B., Cushman, M., Fung,
G., Goldstein, J., Macdonald, R., Mitchell, P., Scott, P., Selim, M., Woo, D.,
(2015, May 28). Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From
the American Heart Association /American Stroke Association Stroke(43)3:
869-871. Retrieved from American Heart Association Web site:
http://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000
069

45 University Medical Center New Orleans |

www.UMCNO.org