Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Stroke Management in the Long-Term Care Setting" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.
Stroke management falls into three categories of urgency:
- Acute stroke is a medical emergency that should be addressed immediately.
- Post-stroke involves care for a patient who has had a stroke recently.
- Stroke prevention involves measures to prevent a first or recurrent stroke.
Certain steps in this guideline are particularly relevant in the context of an acute stroke, whereas others are applicable in the post-stroke or stroke prevention context. These differences are labeled in the text.
Step 1 (Acute Stroke)
Does the patient show signs or symptoms of an acute stroke?
Common presentations of an acute stroke include:
- Sudden confusion, difficulty speaking, or difficulty understanding speech
- Sudden difficulty seeing out of one eye
- Sudden difficulty walking, severe dizziness, or loss of balance or coordination
- Sudden numbness or weakness of the face or in an arm or leg, especially if confined to one side of the body
- Sudden severe headache with no other readily identifiable cause
If at any time a patient displays any of these acute neurological symptoms, go immediately to Step 4.
Step 2 (Post Stroke)
Has the patient had a previous stroke or a transient ischemic attack (TIA)?
A patient with a history of stroke or TIA is at high risk for a recurrent stroke. If a newly admitted patient has a history of stroke or TIA, the interdisciplinary team should review available medical records to determine whether the patient has received an appropriate diagnostic evaluation. If the patient has been evaluated appropriately, go to Step 7. If not, go to Step 6.
Step 3 (Stroke Prevention)
Does the patient have risk factors for stroke?
Many long-term care (LTC) patients who have not had a stroke or TIA may have one or more potentially modifiable risk factors for stroke (see table below). Identifying and treating modifiable risk factors is an effective way to reduce the chance of a first stroke or recurrent stroke. If the patient has not had a stroke but has potentially modifiable risk factors for stroke, go to Step 14.
|Table: Potentially Modifiable Risk Factors for Stroke
- Atrial fibrillation
- Diabetes mellitus
- Estrogen use
- Carotid artery stenosis
- Cigarette smoking
- Heavy alcohol use
- Sleep apnea
Step 4 (Acute Stroke)
Confirm that the patient is suffering an acute stroke.
- Clarify and describe the patient's signs and symptoms. Rapidly but thoroughly assess the patient who has signs or symptoms of an acute stroke. Carefully describe the patient's current level of consciousness, cognitive ability, speech, physical function, and physical condition.
- Determine whether the patient's signs and symptoms are caused by a condition that can resemble a stroke. Numerous conditions common in the LTC setting can cause signs and symptoms that resemble an acute stroke (see Table 3 in the original guideline document). If the patient has hypoxia, hypoglycemia, hypotension, or another acute medical condition that may mimic an acute stroke, go to Step 9.
- Reassess the patient to determine whether symptoms have resolved. If the patient's symptoms do not resolve within 20 minutes, go to Step 5. If the patient's symptoms are resolving quickly without specific treatment, the symptoms may have been caused by a TIA. A TIA is still considered a brain attack. Patients who have a TIA are at high risk for stroke and should be evaluated promptly and thoroughly (Step 6).
Step 5 (Acute Stroke)
Decide whether it would be appropriate to transfer the patient to the hospital for further evaluation and treatment.
Not all patients experiencing an acute stroke are appropriate candidates for transfer. Hospital transfers for LTC patients with an acute stroke may produce both benefits and risks (see Table 4 in the original guideline document). The practitioner, family or surrogate decision maker, and the patient (if possible) should be involved in deciding whether it is appropriate to transfer the patient to a hospital.
Step 6 (Acute Stroke)
Perform a diagnostic evaluation for acute stroke.
The diagnostic evaluation may take place at the hospital (if the patient has been transferred) or at the LTC facility (if it has been decided not to transfer the patient).
Table 5 in the original guideline lists recommended and optional diagnostic tests for the initial evaluation of patients presenting to a hospital with stroke signs and symptoms.
Step 7 (Acute Stroke, Post Stroke)
Perform an interdisciplinary functional assessment.
If the diagnostic evaluation confirms the occurrence of a stroke or TIA, perform a broad interdisciplinary assessment of the patient. Transitions from one level of care to another or from one care facility to another should trigger an interdisciplinary assessment.
The findings of this assessment should guide decision making about further diagnostic testing, treatment, rehabilitation, prevention, and monitoring (see Table 6 in the original guideline document).
The assessment should characterize the patient's:
- Cognitive and psychosocial abilities and impairments, including safety awareness
- Physical abilities and impairments, including ability to perform activities of daily living (ADLs)
- Current and expected level of physical endurance
- Presence and severity of chronic medical conditions
- Risk of stroke complications (e.g., bladder and bowel dysfunction, deep vein thrombosis [DVT], dysphagia, falls, and pressure ulcer)
- Presence of stroke complications (e.g., urinary tract infection [UTI], DVT, aspiration, malnutrition, pain, depression, dementia, and skin breakdown)
Step 8 (Acute Stroke, Post Stroke)
Summarize the patient's condition.
When a patient is admitted to the facility with a history of stroke, it is appropriate to review all relevant information that has been identified thus far.
Step 9 (Acute Stroke)
Treat medical conditions that may mimic an acute stroke.
If the assessment identifies an acute medical condition such as hypoglycemia, hypotension, or hypoxia, treat that condition immediately. If this treatment begins to reverse the patient's neurological symptoms within 20 minutes, nursing staff should notify the attending physician and discuss the need for further evaluation or treatment. If symptoms suggestive of a stroke persist after 20 minutes, go back to Step 5.
Step 10 (Acute Stroke, Post Stroke)
Develop and implement a care plan to identify and address stroke-related complications.
Table 8 in the original guideline document lists several common stroke complications and some preventive interventions that may be considered as part of a plan to prevent stroke-related complications. The complications include:
- Urinary tract infection
- Deep vein thrombosis
- Pressure ulcer
- Spasticity or contracture
- Shoulder displacement
Step 11 (Acute Stroke, Post Stroke)
Develop and implement an interdisciplinary treatment plan that treats stroke complications.
When the assessment identifies complications of stroke, implement appropriate curative, restorative, or palliative treatment on the basis of a shared decision that reflects the patient's wishes and treatment goals.
Step 12 (Post Stroke)
Develop and implement a rehabilitation plan to maximize function.
After the patient with an acute stroke has been stabilized, the interdisciplinary team can determine the patient's specific rehabilitation needs. Stroke rehabilitation may help the patient to optimize physical, cognitive, psychosocial, and vocational functioning (see Table 10 in the original guideline document). It is important to develop the rehabilitation plan in collaboration with the patient and family and to individualize each patient's rehabilitation regimen to reflect the patient's prognosis, comorbid conditions, and personal goals.
Rehabilitation and restorative therapies may include:
- Occupational therapy to enhance dexterity of the arms and hands
- Physical therapy to improve motor strength and promote independence in ADLs
- Speech therapy to optimize communication, chewing, and swallowing
- Restorative nursing programs, which could include
- Range of motion (passive)
- Range of motion (active)
- Splint or brace assistance
- Bed mobility
- Dressing and/or grooming
- Eating and/or swallowing
- Amputation/prosthesis care
Step 13 (Post Stroke)
Develop and implement a plan for preventing recurrent strokes.
Decisions about using interventions to prevent recurrent stroke should be based on the causes of the patient's previous stroke, an assessment of the patient's modifiable risk factors, and the benefits and risks of relevant treatment options.
Step 14 (Stroke Prevention)
Address stroke risk factors.
Lifestyle changes, diet, exercise, and treatment to address modifiable risk factors can reduce the risk of a recurrent stroke and postpone a first stroke.
Appendix 1 in the original guideline document provides examples of risk factors, interventions, treatment goals, and monitoring strategies for addressing modifiable stroke risk factors.
Monitor and periodically document the physical, functional, and psychosocial progress of the patient with an old or new stroke.
Treatment goals may change as the patient either recovers from the stroke or experiences decline. The interdisciplinary team should regularly re-evaluate both the treatment goals and progress made toward those goals. The team should monitor the continued appropriateness of the treatment plan by taking into consideration the patient's clinical condition and ability to meet treatment goals, as well as the presence of adverse treatment effects.
Monitor the patient to ensure that modifiable risk factors for stroke are adequately controlled.
Reassess the treatment plan regularly to ensure that modifiable risk factors for a first or recurrent stroke have been controlled to the extent feasible, in accordance with the patient's treatment plan and goals.
Monitor the facility's management of stroke and stroke risk factors.
The successful prevention and management of stroke depend on staff education and on interdisciplinary assessment and treatment. Facilities may wish to incorporate stroke quality-of-care indicators into their quality improvement process. Possible indicators include:
- Staff awareness of symptoms of acute stroke
- Timeliness of response to possible signs and symptoms of acute stroke
- Documentation of the patient's care goals
- Implementation of interventions to prevent acute complications of stroke
- Occurrence of common complications of stroke
- Adequacy of control of modifiable stroke risk factors