Care of the Patient with Acute Ischemic Stroke

Stroke

AHA SCIENTIFIC STATEMENT Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement A Scientific Statement From the American Heart Association Endorsed by the American Association of Neuroscience Nurses

Theresa L. Green, PhD, RN, FAHA, Chair; Norma D. McNair, PhD, RN, FAHA, Vice Chair; Janice L. Hinkle, PhD, RN, FAHA; Sandy Middleton, PhD, RN, FAHA; Elaine T. Miller, PhD, RN, FAHA; Stacy Perrin, PhD, RN; Martha Power, MSN, APRN, FAHA; Andrew M. Southerland, MD, MSc, FAHA; Debbie V. Summers, MSN, RN, AHCNS-BC, FAHA; on behalf of the American Heart Association Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council

ABSTRACT: In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their Downloaded from http://ahajournals.org by on March 12, 2021 families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

Key Words: AHA Scientific Statements ■ inpatients ■ nursing ■ standard of care ■ stroke

espite remarkable changes in the diagnosis and treat- Globally, there are 10.3 million new strokes (67% ment of acute ischemic stroke, it remains a devastat- ischemic) annually with higher disability rates in lower- Ding disease with significant personal, family, and health and middle-income countries.2 Disparities between high- system impacts. Because assessments, treatments, and and low-income countries have increased the incidence care for acute stroke have changed over the past decade, and burden associated with the costs of care and dis- the nursing and interprofessional care best practices require ability after stroke.2,3 revisions and updates to inform best practice standards. The World Stroke Organization and American Heart The landmark article written by Summers et al1 in 2009, Association/American Stroke Association suggest highlighting the importance of excellence in nursing and that, when available, patients should be treated in a interprofessional care in optimizing outcomes for patients specialized inpatient stroke unit that is geographically with stroke, provided the foundation for this update. defined, incorporates rehabilitation, and is staffed by an

Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 TBD 2021 e1 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES rehabilitation specialist. a physicianwithtraininginstroke care, anurse, and a an interprofessional stroketeamconsisting of atleast stroke ortransientischemic attack shouldbetreatedby available, patientsadmittedtoahospitalwithanacute suggests that,whenminimalhealthcareservicesare zation GlobalStrokeServicesGuidelinesandActionPlan Scientific Statement” ComprehensiveNursingCare Care): Updatetothe2009 Acute Ischemic Stroke (Prehospital and Acute Phase of with 2companionarticles(“CareofthePatient With adequate staffingisacknowledged. This articleisaligned advanced education/certificationinstrokenursing,and for furtherresearch intospecializednursingpractice, a hospital,arepresented.Within thisframework,theneed stroke-specific ordersets or pathways developed within ate screening,monitoring,andtreatmentaccordingto agement ofacuteischemic stroke,includingappropri- stroke guidelines,bestpracticesfortheupdatedman- of recovery. Based on a review of several international acute (posthyperacutephase)inpatientadmissionphase care topatientswithstrokeandtheirfamiliesduringthe relevant to the provision of nursing and interprofessional is tosummarizeandincorporatebestpracticeevidence with acuteischemic stroke. a comprehensiveupdateonnursingcareofthepatient prehensive Nursing Care ScientificStatement” Unit-Postinterventional Com- Therapy): Updateto2009 Care Acute Ischemic Stroke (Endovascular/Intensive e2 promised by multiple factors.Onesystematic review effective rehabilitation procedures. mobilization, thepreventionofcomplications,ormore diagnostic procedures,high-qualitynursingcare,early This effect couldbeattributedtostaffexpertise, better reported betteroutcomes. team ofhealthcareprofessionals haveconsistently to anacutestrokeunitforcarebyinterprofessional mented. Patients with acute ischemic stroke admitted The benefitsofastrokespecificunitarewelldocu- CARE NURSING STROKE UNIT FORACUTE CARE PRACTICES BEST interprofessional stroketeam. Green etal independent, andlivingathome1yearafterstroke. ize instrokemanagementaremorelikelytobealive, stroke unitfromaninterprofessional teamwhospecial- had astrokeandreceiveorganizedinpatientcarein a widerangeofpatientswithstroke.Patients whohave ent inunitsbasedadiscreteward,arenotedacross encing acuteischemic stroke. sions thatleadtohigh-quality careforpatientsexperi- care ordersetsorpathways toguidepatientcaredeci- viders should consider developing standardized stroke Implementation ofevidence-based practicesiscom- TBD 2021 TBD 5a 4,5 and“CareofthePatient With The maingoal of thisdocument 4,5 The benefits, mostappar- 4 The World StrokeOrgani- 8 7 Healthcarepro- 5b ) toform 6,7

evidenced-based care. outcomes, moreseverestrokes,andlesscoordinated pital patientswithstrokehavebeenshowntoworse gency departmentwithcommunity-onsetstrokes,in-hos- patients admittedtoanacutestrokeunitfromtheemer- patients with acute ischemic stroke, but compared with ent inoutcomesrelatingtomortality, dence supporting the value of stroke unit care is appar- according to the specific type of unit. The strongest evi- return tohome. as qualifiednursesandspecialists. institutional support,namelynothiringneededstaffsuch at 90 days to1yearafterstrokewas betterwhenthe at 90 after stroke. care, toimproveoutcomesandreducecomplications vide interprofessional care,includingspecializednursing The purposeofadedicatedacutestrokeunitistopro- UNITS NONSTROKE VERSUS UNITS STROKE IN OUTCOMES care. riers totheimplementationofacuteischemic stroke identified healthcareprofessionals’ perceptionsofbar- tion. stroke require the samelevelofcare and immediate atten- patients admittedtononstrokeunitsorwithin-hospital hospital withacuteischemic strokeinacuteunits, and Canada. Stroke mortalitywasexamined in3studies inAustralia Mortality, Function, andReturntoHome surgical unitswithstrokebestpractices. unfamiliarity ofhealthcareprovidersongeneralmedical/ therapy,to thrombolytic delayinstrokerecognition, and pital strokeexist such ascomorbidities,contraindications best evidence-basedstrokecarepractices. needed pertainingtomethodssuccessfullyimplement for patientsadmittedwithcommunityonsetstroke. sis, and timely evidence-based treatment, similar to goals goals forin-hospitalstrokearerapidrecognition,diagno- patients withcommunity-onsetstroke. for in-hospitalstrokecomparedwithhypertensionthose lation hasbeenidentifiedastheprimarycardiacriskfactor large vesselocclusionaccountedforonly12%.Atrial fibril- events,includingperiproceduralstrokes,whereas embolic of in-hospitalstrokesinthiscohortwerecausedbycardio- rosurgery (15%),andhematology/oncology(8%).One-half hospital strokewerecardiovascular(24%),neurology/neu- the top3admittingdiagnosesofpatientswhohadanin- of life andpatient-reportedexperience outcomes. patient-reported outcomessuch ashealth-relatedquality 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: In addition to management of patients admitted to the In additiontomanagementofpatientsadmittedthe Many barrierstoqualitycareforpatientswithin-hos- 11–13 9 The mostcommonlycitedreasonwasalack of In-hospitalstrokeaccountsfor≈ 7 18–20 However, achieving successdiffers widely 6 There isemergingevidenceforother Results indicated that overall mortality Care ofthePatient With AcuteIschemic Stroke 12,14,15 InastudybyCumbleretal, 14 9 Moreresearch is 8 4% to≈ function, 11 Management 17% of 17% of 7,10 7 14,17 and 16

CLINICAL STATEMENTS AND GUIDELINES 12 e3 indi- 12 Nursing Nursing 185/110 185/110 Given the Given the < 5 TBD 2021 5,12,20 Best practice practice Best 27 12 In patients with hyper- 5 28,29 Hg (by no more than 20%) over the Hg (by no more than 20%) over the Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care Hypotension and hypovolemia should Hypotension and hypovolemia should Hg in the first 24 hours after treatment. 12 Hg) is not recommended. not is Hg) Nurses should closely monitor the patient’s patient’s the monitor closely should Nurses 94% and as long as there are no contraindi- are no there as long and as 94% > 5,12,26 140mm 220/120 mm Hg before treatment with intravenous thrombolyintravenous with treatment before Hg - < Evidence from the QASC trial (Quality in Acute Stroke Furthermore, ongoing assessment of the patient by ongoing Furthermore, > 180/105 mm first 24 hours. BP in the first after stroke onset. 48 hours cated that fewer than half (48%) cated that fewer of patients with fever received acetaminophen/paracetamol within an hour, 30%and indicated, when hour 1 within insulin received - screen/assess swallow a received of patients 55% ment before food or drink consumption. Similar gaps in temperature, blood glucose, and dysphagia monitoring and treatment have been identified from various stud- with inadequate nursing oversight for ies internationally, these core parameters. tension, evidence suggests reducing BPtension, evidence suggests reducing to BPin BPreduction recommends cautious management to mm maintaining BPsis for patients who are eligible and at Care) reported that use of the fever, sugar, swallowing swallowing sugar, Care) reported that use of the fever, clinical protocols for the management of fever, (FeSS) hyperglycemia, and swallowing dysfunction in the first < regardless of the nurse should be on an individual basis The therapy. whether the patient received reperfusion should and observations all assessments of frequency be determined by the patient’s status. and Swallowing Hyperglycemia, Fever, Dysfunction monitoring of bodyThe temperature, blood glucose, and dysphagia is considered standard of care for all patients with stroke. Nonetheless, data from the 2019 audit national stroke Stroke Foundation Australian the patient’s vital signs, particularly oxygen saturation, saturation, oxygen vital signs, particularly the patient’s blood to measuring temperature, in addition and BP, screen/ bedside dysphagia performing a glucose and to all are applicable assessments These assessment. reper- those who receive stroke, including patients with these Monitoring and thrombectomy. fusion therapy important to prevent or to allow aspects of care is stroke complications. early detection of be corrected to maintain systemic perfusion levels nec- be corrected to maintain systemic perfusion essary to support organ function. - essen support and breathing is assessment of airway support. need for oxygen tial to determine continued the routine use of are not hypoxic, patients who For Supplemen- is not recommended. supplemental oxygen oxygen should be provided only to maintain tal oxygen saturation cations. varied evidence available, the BP level that should be to stroke ischemic acute with patients in maintained Intensive ensure the best outcome remains unknown. BP the acute phase after stroke (systolic lowering in BP Nurses 23 compared 21 7,20,24 Evidence-based nursing care 23 In the absence of a specialized and reduced mortality, 22 7,12,20,25 In a cluster randomized Australian trial, patients trial, patients randomized Australian In a cluster 21 In summary, acute stroke units appear to save lives, but acute stroke In summary, All patients with stroke should be admitted to an acute All patients with stroke should be admitted stroke unit, patients should still receive stroke nursing care consistent with best practice regardless the hospital they are admitted. In this instance, recom- unit to which mendations for vital sign monitoring in acute stroke units also apply to patients admitted to a general hospital unit. initial and ongoing clinical assessment for a patient The with stroke after admission to the hospital is critical to fol- improving long-term outcomes for the patient. The and guidelines evidence-based provide sections lowing protocols for nurses to focus their assessment on the overall health status of patients with acute stroke. and ongoing assessment are necessary to minimize and ongoing assessment are necessary adverse outcomes for patients after stroke. with patients from acute stroke units not using protocols. with patients from acute in-hos- different is difficult to compare because the research of outcome measures, and variablepital care, assessments (anywhere between 30time frames for follow-up and days researchMore studies. existing in used been have year) 1 measures, and time frames isusing consistent methods, for patients cared for in acute strokerequired, particularly is necessary to address the more research units. Specifically, stroke acute in outcomes patient on care nursing of impact in-hospital strokes. units and for patients experiencing Vital Signs Monitoring initial nursing assessment of the patient with stroke The after admission to the hospital should include evaluating stroke unit as soon as possible, ideally within 3 hours 3 within ideally possible, as soon as unit stroke of stroke onset. Nurses play a vital role in identifying patients at risk of Nurses play a vital role in identifying observation clinical deterioration by undertaking ongoing appropriate action and assessments, including timely and in patient health status. in response to changes NURSING ASSESSMENT: INITIAL ASSESSMENTS AFTER ADMISSION TO INPATIENTACUTE CARE patient was cared for in an acute stroke unit. Care in acute stroke unit. cared for in an patient was func- of increased chance unit resulted in an a stroke Barthel with assessed stroke acute from recovery tional scores. are expected to perform comprehensive and systematic to perform are expected with stroke, includ- physical assessments for all patients bodysigns: vital 5 main the monitoring ing temperature, blood pressure (BP), breathing effort (rate, patterns, and saturation, and mental status/ oxygen expansion), chest level of consciousness. cared for in acute stroke units using standardized proto- standardized using units stroke in acute for cared Short likely to have better significantly more cols were Survey scores, indicating better physical Health Form function at 90 days Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 Green et al et Green

Downloaded from http://ahajournals.org by on March 12, 2021 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES sion. performed within24hoursofacutestrokeunitadmis- sion, or when swallowing screening or assessment was cose wasmeasuredwithin72 hoursofstrokeunitadmis- acute strokeunitadmission,whenfinger-prick bloodglu- sured onadmissiontothehospitalorwithin2hoursof dayswhenbloodglucosewasmea- independent at90 onstrated thatpatientswithstrokeweremorelikelytobe FeSS protocolsarepresentedinTable 1. aged in a general inpatient ward. The key elements of the tocols arealsoapplicabletopatientswithstrokeman- sustained improvedsurvival,with unit thatimplementedtheFeSS protocolsdemonstrated tralian clinicalguidelinesforstrokemanagement. protocols arenow strongly recommended bytheAus- role ofassessmentbynursesinacutestrokecare.FeSS e4 the patients’admissiontoan acutestrokeunit. need toensuretimelymonitoring oftemperatureafter to reducetheoccurrenceofadverseoutcomes,nurses reduced mortalityanddependencyby16%. 72 hoursofacutestrokeunitadmissionsignificantly Green etal of patientswithacuteischemic stroke. Class Ievidence,andtheyarerecommendedinthecare tion guidelinesdescribetheseinterventionsbasedon American HeartAssociation/AmericanStrokeAssocia- likely tobealiveafter4years. protocols oraccording tothenurses’clinical judgment. 48 hoursandthenasperlocalstroke unit for thefirst monitoring shouldbeundertaken atleastevery4hours the Canadianguidelinesrecommend thattemperature international strokeguidelines agement. and bloodglucoselevelsimprovedswallowingman- these protocolsalsosignificantlydecreasedtemperature Table 1. (dysphagia) Swallowing Fever Elements (hyperglycemia) Sugar Data derivedfromMiddletonetal FeSS indicatesfever, sugar, andswallowing. Secondary analysis of the trial QASC data further dem- To maintainnormothermia in patientswithstroke and 30 TBD 2021 TBD These findings clearlydemonstratetheimportant Recommended Protocol forFeSS 22 Patients whoreceivedcareinanacutestroke insulin. speech pathologistforaswallowingassessment. Refer patientswhofailtheswallowingscreeningtoa before givingfood,fluids,ororalmedications. usingavalidatedevidence-basedtooland hospital form aswallowingscreenwithin24hofadmissionto A trainednurseoraspeech pathologistshouldper- 3 days)withtreatmentoftemperature Monitor temperatureatleast4timesperday(for Recommended protocol contraindicated. (intravenous, perrectum,ororal)unlessclinically (99.5° Treat elevatedglucose (for 3days). Measure finger-prick glucoseatleast4timesperday prick glucoseonadmissiontohospital. Measure formalglucose(venousblood)andfinger- F) with acetaminophen/paracetamol F) withacetaminophen/paracetamol 21 andMcNair. 13,25 21 The FeSS clinicalpro- > specifyfrequency, but > 20% ofpatientsmore 24 180 mg/dL (10 mol/L) with mg/dL(10mol/L) 180 5 > 37.5° C 22 Useof 31 12 Few The 13

hyperglycemia (bloodglucose cols supporttreatmentwithinsulinofmajorepisodes pital usingavalidatedscreeningtool. as earlyafterstrokepossibleonadmissiontothehos- ogist performsaformaldysphagiaassessment(Table 2). can eatordrinkorallybeforethespeech-language pathol- done byatrainednursetodeterminewhetherthepatient screening toolisnotdiagnostic;itapass/failprocedure phagia screeninganddysphagiaassessment.A is alsocrucialtoestablishoperationaldefinitionsfordys- needed or if swallowing or neurological status changes. It should be rescreened over the course of the admission as intravenously ifpatientsfailtheswallowscreen.Patients platelet therapymayneedtobeadministeredrectallyor glucose monitoringisoftenoverlookedinthesepatients. also forpatientswhoarenotdiabeticandhavehadastroke; necessary notonlyforpatientswithdiabetesandstrokebut ture monitoring at least 4 times a day for 72 hours. Similarly, theAustralianguidelinesrecommendtempera- hemorrhage. those athigherriskforcomplicationssuch asintracerebral tive measurementofchanging clinicalstatusandidentifies orendovascular therapy.for thrombolysis Itallowsobjec- tion ofstrokeseverityandisconsideredinpatienteligibility prognosis. Useofthisstandardizedscaleallowsquantifica- score indicatingalessseverestrokeandbetterpatient Stroke Scaleisthemostwidelyusedmeasure,withalower ing acuteinpatientcare.The NationalInstitutesofHealth sary for regular evaluation of the patient with stroke dur- The useof strokeassessmenttoolsbynursesisneces- ToolNational InstitutesofHealthStroke Scale ity administeringthescale. Stroke Scale,theyachieve highlevelsofreliabilityandvalid- usingtheNationalInstitutesofHealth are educatedabout ing assessment. referred to a speech-language pathologist for a swallow- been determined.Patients whofailthescreenshouldbe or medicationsgiven—untiltheirswallowingabilityhas to beplacedonnilperosstatus—nooralfoods,fluids, those withischemic stroke mg/dL [4.44and7.22 isnotrecommendedin mmol/L]) and 130 hyperglycemia (target blood glucose between 80 glycemic andnondiabetic.Ofnote,intensivetreatmentof negative results, particularly in patients with low National negative results, particularlyinpatientswith lowNational Stroke Scaleratherthanshortened versionstoavoidfalse- use thefullversionof National InstitutesofHealth tional recovery higher riskofmortalityandanincreasedpoorfunc- Patients whoarehyperglycemicafterstrokehavea3-fold temperature readings initiate temperature-reducingmeasures. dence istoincreasethefrequencyofmonitoringand 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: Nurses should assess the swallowing status of patients Nurses shouldassesstheswallowingstatusofpatients It is imperative to note that blood glucose monitoring is It isimperativetonotethatbloodglucosemonitoring 5 Research demonstratesthatwhennurses 33 comparedwithpatientswhoarenormo- 5,35 Care ofthePatient With AcuteIschemic Stroke This maymeanthatpoststrokeanti- > 37.5° 34 39 ; incontrast,theFeSS proto- Furthermore, nursesshould > C (99.5° 180 mg/dL[10mol/L]). 180 13 F), thebestevi- 13 Patients need 25 For 32

CLINICAL STATEMENTS AND GUIDELINES

4 67 68 e5 Nurs- Stud- 5 69 TBD 2021 When to start or start to When 70 Screening should also 70 with mouth care performed at with mouth care performed In a Danish Medical Registry 69 68 5,25 Care teams have an opportunity 71 40 Many of the nursing assessments and Many of the nursing Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care 26 7 days) in the hospital, accounting for 7 days) in the hospital, accounting for > - experi 25.2% stroke, with subjects 721 Implementing such protocols has the potentialhas the protocols such Implementing 5,13,25 518 patients with acute stroke treated in stroke units 518 patients with acute stroke treated Management strategies should be implemented implemented be should strategies Management 39% of the late deaths. least 3 times a day. practices described will reduce patient poststroke compli- practices described the following section. cations, as noted in be undertaken to assess for communication issues or hearing), sensory deficits (eg, impaired vision, speech, team members should to interprofessional and referrals be made as needed. Hence, shortly after admission to the hospital, all patients to the hospital, all after admission Hence, shortly havewith dentures, should including those with stroke, of implementation with subsequent an oral assessment consistent with evidence-based prac- oral care protocols tices. ing staff need to be trained in the assessment and man- ing staff need to be agement of oral hygiene, interrupt these treatments, which patients should be a interrupt these treatments, which and what parameters to monitor are uncertain priority, and require further research. Careful monitoring of clinical parameters is vital. for every patient with stroke to prevent complications. for every patient with stroke to prevent with stroke may experience difficulty with attending to their difficulty with attending may experience with stroke and cognitive impairments,because of physical oral care and comorbidities. level of consciousness, reduced ASSESSMENT: NURSING COMPLICATIONS IN ISCHEMIC ACUTE STROKE and manage- Anticipation, prevention, early recognition, complications are ment of potential poststroke medical because com- essential for patients with an acute stroke clinical out- affect plications may directly or indirectly Registry review of comes. Data from the Berlin Stroke 16 shorter length of revealed that, among patients with a of early deaths and poor between 60% and 70% stay, predictors. outcomes are attributed to nonmodifiable prestroke disabil- Stroke severity on admission, age, and factors modifiable contrast, In impact. highest have the ity death in patients are of major importance for in-hospital staying longer ( ies involving a small number of patients revealed that, revealed patients of number small a involving ies compared with intermittent monitoring with manual and supported monitoring continuous equipment, portable by automatic equipment significantly reduced death and discharge. or months at 3 disability to reduce the risk of stroke-associated pneumonia. to reduce the risk of to positively affect the outcome of patients with acute to positively affect stroke through the prevention and management of stroke complications. review of 13 of review all complications enced at least 1 medical complication; stay and a higher were associated with longer lengths of risk of adverse outcomes. An 25 36 39 Compensatory safe-swallowing strategies Head position including Head position head turn, tuck, chin head tilt and backward Dietary texture modification of liquids and solid food Small sips and no straws Multiple swallows clearing/cough- Throat ing Small bites Sips of liquids between bites of talkingAvoidance until all food and liquid are swallowed for pocketing Checking or of food in cheek under tongue Supervision and frequent cues Sitting upright Prophylaxis for deep Prophylaxis 66 13,65 38 5 Speech-language Speech-language formal pathologist assess- swallowing ment Cranial nerve examinaCranial nerve - tion Observation of oral anatomy Head position and swallowing techniques with different liquid and food consistencies to reduce aspiration and choking instrumentalPerforms examination, ie, VFSS or FEES Speech-language pathologist gives recommendations to clinical team to estab- for lish mechanisms nutrition 36,37 Dysphagia Screening and Assessment Dysphagia 3). (Table but nurses should first feed patients with swallow- but nurses should first 5 5,13,20 Nurses should assess patients for malnutrition on An assessment for oral hygiene, including screening Patients at high risk of deep venous thromboemboPatients - FEES indicates fiberoptic endoscopic evaluation of swallowing; and VFSS, vid- Nursing screening observe assessment: of for symptoms dysphagia Facial weakness Dysarthria Dysphonia Hoarseness Abnormal volitional coughing clearing Throat Choking Aspiration Unable to control secre- tions, drooling Table 2. Table eofluoroscopic swallowing study. eofluoroscopic swallowing study. venous thromboembolism is presented later in this article. Regular skin assessments also should be performed by nurses using objective scales (eg, Braden scale) to assess the risk of pressure injury. admission and at least weekly while in the hospital. for signs of dental disease, is often overlooked. Patients for signs of dental disease, is often overlooked. Patients lism are those who are unable to independently mobi- lize, those with comorbidities, and patients with a history of venous thromboembolism. Other Key Nursing Assessments Other Key by nurses Additional assessments to be undertaken with stroke to within 4 hours of admission of a patient assessments for the hospital include comprehensive thrombosisnutrition and hydration status, deep vein risk, ulcer risk, and oral mobilization needs, falls risk, pressure care Institutes of Health Stroke Scale scores. The Glasgow The scores. Scale Stroke Health of Institutes stroke. Coma Scale should not be used in acute ing difficulty with a nasogastric tube in the early phase of persistent swal- those with longer anticipated stroke. For insertion of a percutaneous gastrostomy lowing difficulty, tube may be warranted. enteral diet should be started within 7 days of admission, Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 Green et al et Green

Urinary andgastrointestinal Neurological Potential complication Dysphagia andpneumonia will experience malignant MCA syndrome will experiencemalignantMCA infarct incidence: 10%ofpatientswithMCA Cerebral edema,elevatedICP, herniation increased lengthofstay to decreasedfunctionaloutcomeand UTI incidence:10%–28%andleads to 14%ofpatientsreceivingalteplase sion withclinicalworseningmayoccurinup Evolution ofstrokeincidence:earlyreocclu- therapy 1.5% intheabsenceofreperfusion Hemorrhagic transformationincidence: 14% infirst7d Stroke-associated pneumoniaincidence: patients Dysphagia incidence:upto40%–78% of with acuteischemic stroke Seizure incidence:5%–12%ofpatients TBD 2021 TBD 40 45 Key NursingAssessments 41 47 41 40 Prompt notificationofabnormalassessment Risks: largeterritorialcerebralandcerebellarinfacts baseline withcomparisonto Ongoing neurologicalexamination aging diabetes, andearlyinfarctsignsonbaselineneuroim- Risks: advancedagestrokeseverity, hypertension, to baseline withcomparison Ongoing neurologicalexaminations disability, andincreasingage Risks: catheterization,bladderdysfunction,poststroke Monitor forfever Monitor forchange inLOC withnoknownreason Monitor forUTIsymptoms monitor forfever thepatient’slungs, hypoxia),(tachypnea, auscultate Monitor patientforsignsofrespiratorycompromise dysphagia assessment Consult speech-language pathologisttoperformformal There isnoconsensusonoptimalscreeningtool Bedside swallowscreenbynurse Risks: corticallocation,strokeseverity Assessment ofresultsmedicalintervention oftheseizure Assessment/documentation Neurological examination Risks: high NIHSS scoreandseverecarotidstenosis Risks: highNIHSS Assess forresultsofcarotidultrasoundorangiography withcomparisontobaseline Serial NIHSS Assessment parameters 40 > 38° C and altered mental status C andalteredmental 36 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: 42 38 40 40 (chlorhexidine) of stroke-associatedpneumoniafrom28%to7% Intensive oralhygieneprotocolsmayreducetherisk patient treatedwithantibioticsifindicated A urinalysisandurinecultureshouldbe doneandthe movement leadingtopossibleurethraltrauma drainage systemandsecuringthecatheter toprevent aclosed Recommendations includemaintaining tent catheterization Consider alternativestoindwellingcatheters,intermit- lead todermatitisandskinbreakdown Keep ascleanpossiblebecauseincontinencemay Handwashing include: Nursing interventionsthatpromotethereductionofUTI Daily reminderorstoporderhasshowntohelpreduceUTI use aseptictechnique Avoid insertingindwellingurinarycatheters;ifrequired therapy codestrokeifeligibleforreperfusion In-hospital necessary Decompressive craniectomyorventriculostomymaybe Hyperventilation Osmotic therapy Close monitoringforsignsofneurologicaldeterioration Consider cryoprecipitate Optimize BP Close monitoringforsignsofneurologicalworsening: ing compensatory strategiestopreventaspiration ing compensatory that willprovideadysphagiamanagementplanprovid- guage pathologisttodoaformaldysphagiaassessment If patientfailsdysphagiascreening,consultspeech-lan- Prophylactic seizuremedicationisnotrecommended seizure Antiseizure medicationforpatientswithdocumented outofproportiontothestroke status ordepressedmental status orachange inmental EEG Good pulmonarytoiletryandearlymobility incidence hasshownnodifferenceinaspirationpneumonia PEJ Use ofenteralfeedingbynasogastrictubeorPEG/ ment Train patientandcaregiverondysphagiamanage- cific nutritionalneedsortubefeedingrecommendations Consult dieticiantoprovidetheteamwithpatient-spe- screening completedwithin4–24hbytrainednurse untildysphagia Keep allpatientswithstrokeNPO Nursing interventions Routine perinealcleaning Ensuring goodpatienthygienecatheter hydration Maintaining Changes inrespiratorystatus New pupilchanges Worsening neurologicaldeficits Decreased LOC Care ofthePatient With AcuteIschemic Stroke 21,36 17 46 5 45 42,43 48 (Continued ) 39 5,44 24 44 CLINICAL STATEMENTS AND GUIDELINES e7 57 (Continued ) 100 mL, > 54 TBD 2021 44 61 5,56 52 100 mL consecutively for 3 times, 100 mL consecutively for 3 44 < 49 56 57 58 Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care scheduled intermittent catheterization will be neces- scheduled every 4–6 h sary, Nursing interventions Provide interventions to enhance rehabilitation and improve recovery Patients with PSD should be treated with antidepressants in the absence of contraindications and closely monitored for effectiveness and psychotherapy, Cognitive and emotional therapy, support groups about pseudo- of and education Acknowledgment bulbar affect can defuse potentially uncomfortable situations Dextromethorphan/quinidine is FDA approved and drugs with sedative or infection, dehydration, Avoid neuroactive effects Regulate sleep/wake cycles, day/night orientation Cognitive stimulation Early mobilization Consider having a family member stay with the patient and safetyto promote orientation, sense of security, Evaluate for reversible causes agents may be considered for the short Antipsychotic term short, frequent exercise Early, of the hemiplegic limbs may avoid Daily stretching contracture Patients and families should be taught- proper stretch ing techniques of the hemiplegic shoulder in maximum Positioning external rotation for 30 min every day in either in a can be useful for preventing shoulder bed or chair contracture and use of supportive devices and slings Positioning may prevent shoulder subluxation Resting ankle splints used at night and during assisted standing considered for the prevention of ankle may be contracture in the hemiplegic limb Frequent toileting, every 2 h during the day and every every 2 h during the Frequent toileting, 4 h at night Intermittent catheterization to obtainUse bladder scanning PVR or performance within 30of and in-and-out catheterization min of voiding. If the PVR is Mobility Prophylactic stool softener of antiplatelet or antico- Consideration of withdrawal agulation medications as necessaryAdminister blood products Cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning engagement with environments to increase Enriched cognitive activities monitoring can be discontinued. If PVRmonitoring can be discontinued. is

50 60 55 57 51 52 57 57 5,44 59 52 54 Formal rehabilitationFormal assessment altered LOC, Risks: hemiparesis, sensory changes, poststroke pain syndromes Assessment parameters Assessment The 4 Assessment Test for Delirium or the Confusion 4 Assessment Test The Assessment Method ICU Risks: older age, preexisting cognitive deficits, higher NIHSS location score, infection, right hemispheric Assess for mood swings and other mood disorders - Pathological Laughing and Crying Scale and the Cen ter for Neurological Study-Liability Scale Assess mental status as a component of the neurological examination Risks: baseline poor cognition, comorbid conditions, effect of the stroke, stroke complications Assess for history of depression Early depression screening severity of stroke, prestroke Risks: physical disability, depression, cognitive impairment Assess bladder for retention Assess bladder to obtainUse bladder scanning PVR disease, age, preexisting urologic Risks: potentially stool consistency, Assess prestroke bowel function: timing, frequency, bowel care practices use Risks: immobility and bedpan Assess for melanotic stool Assess for blood in any emesis Monitor hemoglobin and haematocrit or Risks: advanced age, history of peptic ulcer disease liver disease stroke in the dominant hemisphere stroke in the dominant 57 56 49,50 53 42 58 54,55 Impaired mobility Delirium incidence: 1:4 during acute period Depression incidence: up to one-third of stroke patients with ischemic Poststroke cognitive impairment incidence: cognitive impairment Poststroke 1 in 10 will develop dementia after a stroke Gastrointestinal bleeding: 1.2%–8.5% dur- Gastrointestinal bleeding: ing hospitalization Constipation incidence: 45% during acute Constipation incidence: 45% hospitalization Urinary retention incidence: commonly Urinary retention 72 h after acute stroke in seen in the first of patients 21%–47% Pseudobulbar affect incidence: 10%–48% Mobility

Psychosocial and neuropsychological Psychosocial

Potential complicationPotential Table 3. Continued Table Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 Green et al et Green

Downloaded from http://ahajournals.org by on March 12, 2021 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES e8 atrial fibrillationhas5times theriskofstroke. hypertension doublestherisk ofstroke,apatientwith emic stroke. Recent evidence suggests that although as atrial fibrillation are the most common causes of isch- mechanisms suchand hypertensioncardioembolic Stroke andheartdiseaseshare commonriskfactors, Cardiac Complications and nurses,ontheseprotocols. managers shouldeducatestaff,includingphysicians inpatient codestrokeprotocol.Nurseleadersandunit of time-sensitivecomplicationsstroke,includingan standardized approach torecognitionandmanagement neuro-intensive caresetting.Nursesshoulddevelopa priate management should they occur outside the the riskofthesecomplicationstofacilitateappro- acute ischemic strokeshouldbeknowledgeableabout care unit.However, allnursescaringforpatientswith plications arecommonlytreatedintheneuro-intensive rioration associatedwith poor outcomes. These com- poststroke seizures,result in earlyneurologicaldete- transformation, cerebraledema,strokeevolution,and Neurological complications,includinghemorrhagic Complications Neurological Green etal diac complications ofstrokeaccountfor 2% to6%of urinary tractinfection. poststrokedepression;PVR,postvoidresidual;andUTI, percutaneousendoscopicgastrostomy/percutaneousjejunostomy;PSD, nilperos;PEG/PEJ, NPO, NationalInstitutesofHealthStrokeScale; NIHSS, modifiedRankinScale; myocardialinfarction;mRS, LOC, middlecerebralartery;MI, levelofconsciousness;MCA, Table 3. Continued

Falls Potential complication BP indicates blood pressure; EEG, electroencephalography; US FDA, Food indicates blood pressure; EEG, and Drug Administration; ICP, infectionBP prevention and control; intracranial pressure; IPC, Pressure injury Venous thromboembolism Poststroke pain TBD 2021 TBD 16 length ofstay peripheral vasculardisease,incontinence,longer score,diabetes,anemia, on admission,higherNIHSS score3–5 Risks: olderage,beingunmarried,mRS Use ofanobjectivescalesuch astheBradenscale Regular skinassessmentanddocumentation risk overtimeafterstroke Risks: immobilityafterstrokeandpotentiallong-term cially inthelowerextremities Assess forsignsofvenousthromboembolismespe- syndromes andpoststrokeheadache ity movement,andsensorydeficits;poststrokepain Risks: increasedmuscletone,reducedupperextrem- assessment Formal rehabilitation Pain ratingscalesandphysicalexamination ing activitieswithoutsupervision Most fallsoccurduringtransfers,toileting,orattempt- orrenalinsufficiency ≥score8,historyofMI, NIHSS Risks: anxiety, delirium,fearoffalls,priormalesex, Fall riskassessmentwithavalidatedtool Assessment parameters 44 72,73 Car- 65 62 location andqualityoflife. increased mortality, andanimpactonpatientdischarge stroke-associated pneumonia,malnutrition,dehydration, stroke. 50% maycontinuehavingdysphagia6monthsafter swallowing functionreturnsin7days,but11%to patient andcaregiver. as needed,tomanageinterventions, andtoeducatethe to identifydysphagia,initiate screeningandreferrals hours areneeded andcardiacmonitoringforatleastthefirst24 line ECG experience dysphagia. and78%Between 40% ofpatientswith acutestroke Dysphagia andPneumonia and resourceallocation. health carecostsattributable toincreasedlengthofstay events maybenefitfromcardiacmonitoring. complicate stroke. Patients at the highest risk for cardiac syndromemay arrhythmias, heartfailure,ortakotsubo Myocardialinfarction,cardiac ular extrasystoles onECG. segmentorventric- atinine, severestroke,andalong-QT include ahistoryofheartfailure,diabetes,elevatedcre- in thefirst2weeks. Predictors ofcardiaccomplications mortality within the first 3months,withthe highestrisk 64 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: 75–77 Majorconsequencesofdysphagiainclude 44,63 Pain managementwithjudicioususeofmedications Train familymemberstoassist Short, frequentmobilization seating untilmobilityreturns Use specializedmattresses,wheelchair cushions,and Turn regularly adequatenutritionandhydration Maintain Avoid excessivemoisture Practice goodskinhygiene Provide supportsurfaces Minimize skinfrictionandpressure Consider bed/chair alarmsandvideomonitoring Prevent delirium Assist withtransfersandtoileting therapy Postural trainingandtask-oriented Music therapy Physiotherapy Fall preventionprogram Patient and family education on importance ofIPC Patient andfamilyeducationonimportance Aspirin andhydration care ifnocontraindicationsinadditiontousingroutine IPC Early mobilizationafterstroke Nursing interventions . 5 Care ofthePatient With AcuteIschemic Stroke 74 41 The majority ofthepatient’s Nursesareinaprimeposition 78 There mayalsobeincreased 44 40 Abase- 62 65 64 CLINICAL STATEMENTS AND GUIDELINES

50 e9 Factors 46 84,85 TBD 2021 86 Urinary incon- 37 A recent meta-analysis 86 513 patients with stroke; Behavioral therapies may Behavioral therapies may Patients with urinary tract with urinary Patients 50 86 Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care Urinary tract infection decreases functional out- Urinary tract infection 86 Voiding dysfunction after a stroke includes urinary dysfunction after a stroke includes urinary Voiding Nurses should establish goals of care and collaborate care establish goals of Nurses should tinence management includes using 3 interventions: tinence management includes using 3 interventions: as timed voiding and (1) behavioral strategies such bladder retraining, (2) complementary therapies using manual or electro-acupuncture, and (3) physical ther- and transcutaneous electric nerve stimulation apy with pelvic floor muscle training. reduce incontinent episodes, whereas physical therapy reduce incontinent episodes, whereas physical therapy interventions improve functional voiding capabilities. reviewed 16 studies with 13 - tract infec 19% of this population developed urinary tion. Bladder training strategies are part of the rehabilitation rehabilitation the of part are strategies training Bladder plan of care. Urinary and Gastrointestinal ComplicationsUrinary and Gastrointestinal and manage- Nurses play a key role in the assessment after ment of urinary and gastrointestinal complications complica- stroke. One of the most common poststroke tions is a urinary tract infection. incontinence and urinary retention. Elderly men and incontinence or reten- women also may have preexisting urinary inconti- review, tion. According to a Cochrane 40%nence may affect to 60% admitted of patients after a stroke; 25% continue at the time of discharge, and 15% continue 1 year after stroke. speech-language pathologist). A stroke may cause lower A stroke pathologist). speech-language Gastropa- dysfunctions. sphincter and gastric esophageal and gastroesophageal residual volumes, resis increases the regurgitation, increasing lead to vomiting and reflux can aspiration. caused by pneumonia risk for stroke-associated to prevent are vital with antiemetic medication Treatments of insertion the With aspiration. of risk further and vomiting tubes, there is a 38%feeding of stroke- higher incidence aspiration. from resulting pneumonia associated team on dysphagia manage- with the interprofessional and prevention of stroke-associated feeding, ment, safe should have education related to nurse pneumonia. The tubes, of feeding dysphagia management and the care monitor- regularly, tube position includes checking which for residuals, ing continuous or bolus checking feeding, of care. and flushing according to the standard comes, increases length of stay (median, 3 days longer comes, increases length of stay (median, and infection), than for patients without urinary tract costs. increases acute care infection also have an increased likelihood of discharge discharge of likelihood increased an have also infection to care homes or long-term care facilities. that lead to a higher incidence of pneumonia include thethat lead to a higher teeth,number of decayed the oral cavity, the in load bacterial may pre- nasogastric tubes, which poor oral hygiene, and gastroesophageal reflux and vomiting.dispose a patient to tube or percuta- by nasogastric feeding enteral use of The or jejunostomy tube has shownneously inserted gastrotomy in aspiration pneumonia incidence. no difference 000 37 Recent large 81 82,83 79 000 and $25 22,80 Older age and duration of intu- Older age and duration 79 Dysphagia management includes decreasing the risk of All staff caring for patients with stroke should be All staff caring for patients with stroke It is also crucial to assess for the presence of dys- It is also crucial to While the patient is nil per os, it is essential to maintain os, it is essential the patient is nil per While aspiration through diet and fluid modification and using com- outlined by strategies and rehabilitation exercises pensatory the therapists (physical therapist, occupational therapist, and Stroke-associated pneumonia is a respiratory infection Stroke-associated pneumonia is a respiratory infection occurring during the first 7 days after stroke, affecting ≈14% of patients with stroke. It is associated with a prolonged length 3-fold increase in in-hospital mortality, and poorer functional outcomes. of stay, Stroke-Associated Pneumonia Stroke-Associated knowledgeable about and trained on appropriate role The dysphagia. with patients for care optimize to skills patient and care- nurse has a vital role in educating the swallowing Persistent management. dysphagia on giver the patient and their caregiver. difficulties can affect interprofessional Studies have demonstrated that an management using evi- to dysphagia team approach care can dence-based protocols and standardized nurse is imperative in improve patient outcomes. The includes the team, which organizing the interprofessional pathologist, dietician, physi- physician, speech-language and social worker, cal therapist, occupational therapist, care of the patient to optimally monitor and manage the with stroke with dysphagia. phagia after patients are extubated. Increasing evidence Increasing are extubated. phagia after patients dysphagia of postextubation demonstrates the presence in all critically ill patients. hydration by administering maintenance fluid until dyspha- fluid until by administering maintenance hydration or small- A nasogastric tube is complete. gia assessment ispatient the if essential is placement tube bore feeding and medication access to provide swallow safely unable to the team identifies for A dietician consult enteral nutrition. regi- needs and tube-feeding patient-specific nutritional can lead lead to malnutrition, which mens. Dysphagia can Inad- functioning. mental and physical in impairment to lead to risk for increased weakness,equate nutrition will and skin breakdown, and put a of stay, weight loss, length immune response. patient at risk for impaired per occurrence; if associated with feeding tube place- if associated with feeding per occurrence; ments, even higher costs were incurred. retrospective studies in the United States reported individual costs of stroke-associated pneumonia caused by dysphagia as ranging between $19 Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 bation were the 2 main factors associated with the risk bation were the 2 main factors associated dysphagia in all intubated of developing postextubation dysphagia of risk at is stroke with patient The patients. worsen with intu- related to disease, and dysphagia may the nurse should bation. Once the patient is extubated, administering perform a dysphagia screening before patholo- to a speech-language anything orally and refer gist for formal dysphagia assessment. Green et al et Green

Downloaded from http://ahajournals.org by on March 12, 2021 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES in-hospital death. hood ofseveredisabilityand82%increasedlikelihood increasedlikeli- is independentlyassociatedwitha46% ventive interventionsforconstipation. occurrence, onday2ofadmission,callsforpromptpre- tion inordertomanageconstipationproperly. The early anxiety, and depression may affect poststroke recovery. e10 ticipate intherapy. Patients canexperience emotional canbesubtlesuch asdecliningtopar- Clues forPSD arepoorly understood. depression (PSD) pathophysiology andpathogenesisofpoststroke tive decline. vascular dementia and aggravate preexisting cogni - for the patient andfamily is animportant nursing function. Thus, anassessmentofpsychosocial needsafterstroke mortality. outcomes andqualityoflife, socialisolation,andhigher length ofstay, higherhealthcareuse,poorerfunctional delirium, andsleepdisordersmaycontributetoincreased bar affect (inappropriateinvoluntarylaughingorcrying), Poststroke cognitiveimpairment,depression,pseudobul- Complications Neuropsychological andPsychosocial stay anaverageof5.8days. death. including disability, poor neurological function, and even limitation of social activities, and adverse outcomes, Green etal tonergic, noradrenergic,and dopaminepathways. disruption ofneuralnetworks andalterationsinsero- tion, sleepdisturbance,and biologicalfactorssuch as patient responsetonew disability andsocialisola- mechanisms includepsychosocial factorssuch asthe cations andidealtreatmentstrategies. and methods for screening for neuropsychiatric compli- ther studiesarerequiredtodeterminetheoptimaltiming prompt evidence-basedmanagementareessential.Fur - treatment. Increasedawareness,timelyscreening,and aphasia maygoundiagnosedorreceiveinadequate (decreased motivation),orflataffect. Individualswith such asaprosodicspeech (lack ofinflection),abulia cal complications attributable to neurological symptoms in thediagnosisandassessmentofneuropsychologi- Table chological/psychosocial complicationsaredescribedin factors, andnursinginterventionsrelatedtoneuropsy- gist orneuropsychologist asneeded.The incidence,risk should refer patientstothespeech-language patholo- ing mildphysicalimpairmentsafterstroke.Nursingstaff and executive functionevenifthepatientisexperienc - screen forcognitiveissuessuch asproblem-solving Depression iscommonafterstroke;however, the Ischemic stroke can also facilitate the onset of Gastrointestinal bleedingincreaseshospitallengthof Constipation contributestodecreasedqualityoflife, 3. Patients with stroke present unique challenges 55 TBD 2021 TBD Itisessentialtohaveanappropriateevalua- 54,56 44,55 Psychosocial symptoms such asfatigue, Itisthereforeimperativefornursesto 53 53 Gastrointestinalbleeding 52 56 88 Proposed 89 87

stages ofstroke. seems to play a more important role in the long-term fatigue intheearlystageofstrokerecovery, depression severity andneurologicaldisabilityleadtoexertional fer accordingtothestageofstroke.Althoughstroke The impactofdepressiononpoststrokefatiguemaydif- fatigue. assessing depressionalsocontainitemsabout to evaluatebecausemanyoftheassessmenttoolsfor ischallengingship betweenpoststrokefatigueandPSD poststroke fatigueareoftendepressed,therelation- gastrointestinal symptoms. sleep disorderdetectionandearlytreatment. objective assessmentmethodsmayincreasepoststroke on thestrokestage.Combineduseofsubjectiveand be multifactorial, and occurrence may differ depending participation inphysicalactivitiesandrehabilitation. impact onapatient’sdailyactivitiessuch asdecreased encing poststroke fatigue. stroke, withatleasthalfofsurvivorsstrokeexperi- vidualized tothepatient. choice of drug and length of treatment should be indi- indications andcloselymonitoredforeffectiveness. The treated withantidepressantsintheabsenceofcontra- shouldbe antidepressant medication,patientswithPSD research cannotrecommendroutineadministrationof mobilization is attemptedearlyafter stroke, short, sure injury, When pain,andvenousthromboembolism. the patientwithacuteischemic stroke tofalls,pres- As outlinedinTable 3, impairedmobilitypredisposes ofImpaired Mobility Complications affect stroke recovery. for strokeandmaycontributetopoststrokefatigue which havebeenidentifiedasindependentriskfactors quality oflife, andincreasedmortality. reported tohaveapoorneurologicalrecovery, decreased Consequently, patients with poststroke fatigue are with PSD. prompting theteamtoerroneouslydiagnoseapatient lability orpseudobulbaraffect afterastroke,often 13.2% to94.0%. prevalence of poststroke sleep disorders ranges from disturbances, andexcessive daytimesleepiness.The among strokesurvivorsaresleepapnea,nighttime als were associated with increased bone fractures als wereassociatedwithincreasedbone on depression remission and response. Medications tri- therapies arelimitedbuthaveshownabeneficialeffect tional recovery. Trials of antidepressants and psychosocial pressants formanagingdepressionandpromotingfunc- recovery. interventions toenhancerehabilitationandimprove throughearlydepressionscreeningandprovidePSD 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: Fatigue isacommonanddebilitatingsequelaof It isimportanttoidentifyandassesssleepdisorders, Some dataareavailableontheusefulnessofantide- Some 56 Nursesshouldidentifypatientsatriskfor 92 97 Care ofthePatient With AcuteIschemic Stroke Poststroke fatigueexerts anegative The causative mechanism seemsto 95,96 5 The 3 main sleepdisorders 91 Althoughcurrentlyavailable 92 Although patients with 94 90 and 93

CLINICAL STATEMENTS AND GUIDELINES e11 Cli- 5,44 107 From this From TBD 2021 43,108–110 - Both show a reduc 5 Strong interprofessional Strong interprofessional 65 Both deep venous throm- Both deep 106 Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care 5 Key elements pertaining to the successful transition Key list, a coordinated and holistic assessment and specific plan for the patient with stroke and their family must be developed to facilitate a successful transition. nicians must determine whether the benefit of reduc- nicians must determine ing venous thromboembolism the risk of outweighs use of The hemorrhage. extracranial intracranial or for convenient is daily heparin low-molecular-weight is comfortable for patients. nurses and administration heparin is disadvantage of low-molecular-weight The older patients with the higher cost and bleeding risk in renal impairment. tion in deep venous thromboembolism,venous deep in tion slight a with hemorrhage. or extracranial risk of intracranial . The recommended dis- of care are listed in the Figure. The planning topics incorporate elements from sev- charge resources. eral poststroke discharge The discharge transition from the acute setting to the discharge The and signifi- community is one of the most vulnerable for patients with cant periods in the continuum of care dedicated communi- stroke and their families. Thus, health care team cation and organization among the principal goals of a healthy members are essential. The of stroke and their transition include preparing survivors ensuring optimal second- family members for discharge, recovery and ary stroke prevention, maximizing stroke and complications unnecessary avoiding rehabilitation, best achievable hospital readmissions, and ensuring the and their caregivers. Determi- for patients quality of life should be based nation of postacute rehabilitation needs of residual neuro- on this assessment and assessments - and psycholog logical deficits; cognitive, communication, of previous ical status; swallowing ability; determination fam- of level comorbidities; medical and ability functional ily/caregiver support; capacity of family caregivers to meet the care needs of their family member with stroke; likelihood of returning to community living; and ability to participate in rehabilitation. in one-third of patients. in one-third CARE TRANSITION INTERVENTIONS FOR SURVIVORS OF STROKE boembolism embolism and pulmonary increase the 30%. as high as risk of mortality stays after Hospital been a thus, there has currently very short; stroke are venous thromboembolismdecline in in the occurrences an have not defined Best practice guidelines hospital. of low-molecular-weight heparin advantage in the use heparin. versus unfractionated communication and collaboration are required among the maximize to members family and therapists, nurses, The rehabilitation. early of and efficiency effectiveness nursing rehabilitation involve may process discharge case managers and social workers who can assess psy- issues that may influence the transition. chosocial

44 65 102 Active partici- 4 Treatment of pain Treatment ; often considered The World Stroke Stroke World The 5 104 103 101 Among survivors of stroke, 99 Patients with stroke should receive stroke should receive with Patients 98 Patients with stroke are at risk of being with stroke are Patients 64,105 100 Venous thromboembolism encompasses both Venous deep Patients with poststroke pain experience greater cog- greater experience pain poststroke with Patients Pressure injury is a localized injury to the skin or soft injury is a localized Pressure Regardless of whether rehabilitation is started dur- Regardless of whether after stroke. The are a common complication Falls repeat fallers and suffering injury associated with falls. repeat fallers and suffering a hidden complication of stroke, pain may be caused by poststroke neuropathic and nociceptive (physical tis- as spasticity sue injury) elements. Stroke sequelae such and contractures, central poststroke pain syndrome, or shoulder pain are common causes. Organization states that family members should also that family members should also Organization states with mobilization. be trained to assist These complications can be fatal but are preventable in complications can be fatal but are preventable in These thromboembolism manifests patients. Venous immobile as deep venous thromboembolism in approximately two-thirds of patients and as a pulmonary embolism venous thromboembolism and pulmonary embolism. nitive and functional decline, lower quality of life, fatigue, nitive and functional decline, lower quality of life, often are syndromes pain Poststroke depression. and underdiagnosed and undertreated Falls may lead to increased cost and length of stay and may lead to increased Falls a loss of func- have been independently associated with gait severity, tion even after adjustment for age, stroke abnormalities, and previous stroke. tissue caused by long-term or strong pressure (including tissue caused by long-term or strong commonly around shear force or abrasion with pressure) bone are pain- not only injuries protuberances. Pressure lead to infection. ful but also restrict movement and may stroke prognosis and increase nursing care affect They and medical expenditures. time, length of stay, frequent mobilization is associated with a better a better associated with mobilization is frequent within early mobilization High-dose, very outcome. be performed should not onset stroke hours of 24 peo- some in risk increased an carry may it because ple with stroke. has been associated with improvements in cognition and quality of life. pation in exercise should be encouraged early after early after should be encouraged pation in exercise of bed rest the detrimental effects stroke to minimize on heightened neuroplas- to capitalize and inactivity, early poststroke period, and to ticity present in the process of fostering exercise begin the important self-efficacy and self-monitoring. undergo a all patients should ing the inpatient stay, clinicians with formal rehabilitation assessment by Activities of daily living, in rehabilitation. expertise mobility should communication abilities, and functional patient’s rehabilitation the evaluated to assess be needs before discharge. 73% in week to incidence ranges from 7% in the first the first year after stroke. rehabilitation at an intensity commensurate with with commensurate intensity an at rehabilitation and tolerance. anticipated benefits Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 22% to 48% a at least 1 fall during have experienced hospital stay. Green et al et Green

Downloaded from http://ahajournals.org by on March 12, 2021 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES e12 the majortopicareasaddressed.Data derivedfromWinstein etal, independentactivitiesofdailyliving;and TIA,transientischemic attack. indicatesactivitiesofdailyliving;IADL, *Listallresourcesprovidedfor ADL Figure. Recommendeddischarge planningtopicsforthesurvivorandfamilycaregiver. Green etal TBD 2021 TBD 44 Philpetal, 108 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: CamiciaandLutz, Care ofthePatient With AcuteIschemic Stroke 109 andStroke.Org. 110 CLINICAL STATEMENTS AND GUIDELINES

129 128 e13 TBD 2021 56,126 125 Examples of self-management of self-management Examples teaching problem-solving skills and skills problem-solving teaching With improved awareness of the With 119 126 Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care A systematic review and meta-analy- A systematic 77,120 and incorporating information provision provision information incorporating and 124 engaging patients in occupational ther- patients in occupational engaging 123 Moreover, team-coordinated early supported Moreover, 121,122 In 2013, ≈12% of US patients with stroke 127 115,116 - depres premorbid identify to is imperative it addition, In In a qualitative study of patient-reported indicators indicators patient-reported of a qualitative study In interventions include enhancing self-efficacy with activi- with self-efficacy enhancing include interventions living, of daily ties sis of 18 randomized trials of interventions that focused trials of interventions that focused sis of 18 randomized and coping strategies for on developing problem-solving effect revealed a positive further stroke family caregivers and a reduction in health psychological on caregivers’ use. health care resource for survivors of stroke and their caregivers on stroke care and their caregivers on stroke care for survivors of stroke after discharge. Although the sample size was small, the study sugges- the to applicable are preparation discharge for tions tailored individually an that in population stroke broader the of understanding of assessment and plan discharge are essential. Furthermore, plan by patients and caregivers patients should be oriented to location-specific available community resources and provided an early follow-up even is This discharge. before scheduled appointment for patients in rural and socioeconomically more critical Reducing Readmissions Hospital readmission during the 30 days after discharge Medicare & Med- has been identified by the Centers for for survivors of icaid Services as a key quality indicator stroke. sion and PSD, treatment, to provide prompt and targeted for supportive men- and to make any necessary referrals tal health therapy. complications and hospital read- poststroke Preventing effort. A nurse- missions requires an interprofessional the nurse performs clinic where led transitional stroke visits at reg- follow-up phone calls and conducts office may be an effective ular time intervals after discharge among survivors of model for reducing readmission rates stroke. strategies, reviews, self-management interventions were effective effective were interventions reviews, self-management among independence mortality and fostering in reducing of stroke. survivors presence of PSD, including its variability and detrimental and family more tailored patient among survivors, effects immediate needs interventions can be applied to address and to enhance stroke recovery. discharge helps prepare survivors of stroke and caregiv- and stroke of survivors prepare helps discharge ers for the transition period, incorporating the recom- planning topics outlined in the Figure. mended discharge of hospital readmission, participants identified several before preparation poor including factors, important of lack reconciliation, medication insufficient discharge, and lim- needs and resources, education on anticipated ited support to receive available community services. had a readmission within 30 90% days, of which were preventable. deemed were 13% and unscheduled apy programs, apy 111 - Teach 77,118 114 Another modality to 112 In addition, developing culturally tailored 113 In a study of a Swedish stroke cohort, patients In a study of a Swedish stroke cohort, However, this strategy requires regular com- regular requires strategy this However, 117 115,116 Although optimal secondary stroke prevention requiresAlthough optimal secondary stroke prevention - transition is the provision of stroke edu in this Foremost deliver stroke education is online programs, which are pre- which deliver stroke education is online programs, of stroke and allow education to by some survivors ferred period and in thebe delivered throughout the transition home setting. munication between the nurse and provider team and mayand team provider and nurse between the munication not be generalizable to resource-limited settings. educational interventions is critical to guarantee the suc- educational interventions is critical to for minoritiescess of stroke survivor education, especially - a multi in example, an As groups. underrepresented and educationalskills-based tailored, a culturally ethnic cohort, in reduc- effective program with telephone follow-up was ing systolic BP Hispanic patients at 12 months among programs. compared with standard discharge Self-management for survivors of stroke seeks to optimize independence in the posthospital environment by educating patients and caregivers on the skills of deci- establishing as well as problem-solving, and making sion goals for stroke prevention and recovery. Self-Management of the Survivor and Family Self-Management of the Survivor and Family Caregiver an interprofessional effort, nurse-led interventions may effort, an interprofessional and reduce approaches be among the most effective 30-day to readmissions of patients with stroke discharged home. cation to patients and families on the signs and symptomscation to patients and of stroke risk factor reduc- of stroke and the importance educationalthese of effectiveness the increase To tion. care providers should implementinterventions, health strategies that are individu- evidence-based educational to patients’ health needs and medicalalized and tailored for stroke education is the useconditions. One method have been demonstrated of educational pamphlets, which to improve patients’ knowledge method to be an effective stroke ischemic and awareness of risk factors for acute apnea. as obstructive sleep such Secondary Stroke Prevention Stroke Secondary requires collaboration stroke prevention Secondary from all includes treatment which of the health care team, members modifi- and reduction of stroke mechanism of the specific dyslip- diabetes, risk factors (eg, hypertension, able stroke stroke prevention also involvesidemia). Optimal secondary and exercise, through diet lifestyle promoting a healthy and addressing social concerns. smoking cessation, ing should begin in the acute setting before hospital In a meta-analysis of multiple systematic discharge. were assigned a specially trained nurse who would main- were assigned a specially trained nurse tain contact, perform needed educational interventions, assess patient and caregiver needs, ensure adherence identify emerging with the treatment schedule/regimen, as health issues, and request additional input and referrals needed. Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 Green et al et Green

Downloaded from http://ahajournals.org by on March 12, 2021 Downloaded from http://ahajournals.org by on March 12, 2021 12, March on by http://ahajournals.org from Downloaded CLINICAL STATEMENTS AND GUIDELINES and outcomes. sion making,aswellpatientandfamilysatisfaction core competencytoimprovethequalityofstrokedeci- use ofeffective communicationtechniques isacritical among providersandacrosssettings.Knowledge and der overallcareifthereisfragmentedcommunication a strokeunitmayimprovesite-specificcarebuthin- life, lessdepression,andprolongedsurvival. tory, outcomesare better, includingimprovedquality of patients receivepalliativecareearlyintheirillnesstrajec- inclusion ofthepatient’sfamilyandcaresystem.When emotional, spiritual,andpsychological distresswiththe options, advancecareplanning,andattentiontophysical, treatment munication, shareddecisionmakingabout as appropriate.The majorfociofpalliativecarearecom- with stroke and their families to palliative care resources thegoalsofcare.Cliniciansshoulddirectpatients about health careproviderstoinitiateandhaveconversations than theydesire.Mostpatientswithseriousillnesswant patients receiving more aggressive care and treatment nosis andtheanticipatedcourseofillnesscanresultin e14 approaches takeadvantageofthewide availabilityof often throughthesupportof homehealthnurses.New remotely topatientswithstroke afterhospitaldischarge, and telemedicineoffer newmethods toextend care ronment. Technological innovations in mobilehealth poststrokecareinthehomeenvi - to receivesuboptimal Despite currentbestpractices,manypatientscontinue Innovation inTransitions ofCare chaplains when appropriate.Lutz andGreen lishing goalsofcareandrefer tosocialworkersand diverse culturalandreligiouspreferences whenestab- or limitationsofcare. shared decisionmakingwhenconsideringinterventions ers shouldascertainandincludepatientpreferences in sible outcomesshouldtakeplacequickly, andcaregiv- stroke, iscomplex. Discussionofcareoptionsandpos- who experience acomplicationduringtheacutephaseof Decision makingfor patients withstroke,especially those Goals ofCare environment. important barrierstoasuccessfultransitionthehome tation servicesanddistancetoposthospitalfollow-upare disparate areaswhereaccesstoresourcesandrehabili- Green etal a supportsystemforpatientsandcaregivers. aging symptoms,integratingspiritualcare,andproviding care will be maintained, enhancing quality of life by man- family-centered care,ensuringfamiliesthatcorenursing needs ofpatientswithstroke,includingimplementing outlined theroleofnursinginaddressingpalliativecare The compartmentalizationofstrokecaredeliveryin Providers shouldbeknowledgeableandrespectfulof TBD 2021 TBD 43 130 Poor prog- communicationabout 131 havewell charge environment. good outcomesforpatientswithstrokeinthepostdis- will continuetooffer newwaystoensurestabilityand alizability ofthesenoveltechnologies, furtheradvances tigation is needed into the implementation and gener- ments inarmmotorfunctionregardlessofthesetting. and foundthatpatientsexperienced similarimprove- bilitation system versus traditional in-clinic rehabilitation randomized clinicaltrialtestedahome-basedtelereha- entific Statement” ComprehensiveNursingCareSci- Update tothe2009 Ischemic Stroke (Prehospital and Acute Phase of Care): 2 companionarticles(“CareofthePatient With Acute hensive NursingCareScientificStatement” Postinterventional Compre- Therapy): Updateto2009 Care Unit- Ischemic Stroke (Endovascular/Intensive and reducedselectedhospital-acquired infections, some patientoutcomessuch aslowerpatientfallrates suggest thatspecialtycertificationcanfavorablyaffect al ing andbuildingonthefoundationofSummerset ing intheprovisionofacutestrokenursingcare,updat- This scientificstatementdescribesthevitalroleofnurs- CONCLUSIONS virtual reality, and telemedicine. novel technologies such asgaming,sensors, robotics, tablets andsmartphonesincorporatearangeof via graduatecertificatesand onlinelearningmodules,but offer additionalopportunities to specializeinstroke care yet underexplored area of research. Other countries also the impactandbenefitsof stroke certificationareanas- after hospitaldischarge. allow remotedetectionofparoxysmal atrialfibrillation telemetry, implantablelooprecorders,andsmartwatches In termsofsecondarystrokeprevention,mobilecardiac patients whohadstrokes. certified registered nurses delivered more timely care to Registered Nurse.Onesmallstudyreportedthatstroke- roscience RegisteredNurseandtheStrokeCertified Board ofNeuroscienceNursing, States, 2certificationsareoffered fromtheAmerican if nursesarecertifiedinasubspecialtyarea.IntheUnited outcomes after stroke and whether it makes a difference cific contributionthatnursesmaketopatientandfamily lack of well-planned nursing research detailing the specialized stroke nursing care entails. Another gap is the or the literature, and consensus is needed onwhat spe- ing careisnotclearlydefinedinevidence-basedpractice ing ofthis scientific review. Oneisthat specializednurs- acute strokecarehavebecomeevidentduringthewrit- with acuteischemic stroke. comprehensive updateonnursingcareofthepatient 1 2021;52:00–00. DOI: 10.1161/STR.0000000000000357Stroke. 2021;52:00–00. DOI: 2009 statement.Integratingthisknowledgewiththe 2009 Several critical gaps in nursing research related to 5a Care ofthePatient With AcuteIschemic Stroke and“CareofthePatient With Acute 134,135 7 Althoughsomeresearchers Althoughadditionalinves- 132 136 A recent prospective, theCertifiedNeu- 5b ) formsa 137,138 133

CLINICAL STATEMENTS AND GUIDELINES e15 Other None None None None None None None None None TBD 2021 Consul- tant/advisory board None None None None None None None None None Owner- ship interest None None None None None None None None None Care of the Patient With Acute Ischemic Stroke Ischemic Acute With Patient of the Care Expert witness None None None None None None None Legal expert consultation, vascular neurology and stroke cases, plaintiffs and defense* None ’ Speakers bureau/ honoraria None None None None None None None None None The American Heart Association requests that this document be cited be cited that this document Heart Association requests American The AHA-commissioned documents (eg, scientific peer review of expert The enhancement, and/or alteration, copies, modification, Multiple Permissions: Acknowledgment University of fellow, Oyebola stroke research authors acknowledge Fasugba, The for her contributions to the article. Sydney, either “Search for Guidelines & Statements” or the “Browse by Topic” area. To area. To or the “Browse by Topic” for Guidelines & Statements” either “Search or email Meredith.Edelman@ reprints, call 215-356-2721 additional purchase wolterskluwer.com. McNair ND,Green TL, follows: Perrin as JL,Hinkle Middleton S, Miller ET, M, Southerland Heart on behalf of the American DV; AM, Summers S, Power of the Council on Cardiovascular Stroke Nursing Committee Association the Stroke Council. Care of the patient with acute and Stroke Nursing and 2009to update discharge): prehospital and (posthyperacute stroke ischemic scientific statement: a scientific statement from comprehensive nursing care 10.1161/ Stroke. 2021;52:e000–e000. doi: the American Heart Association. STR.0000000000000357 guidelines, systematic reviews) is conducted by the statements, clinical practice more on AHA statements and guidelines For AHA Office of Science Operations. the “Guide- Select https://professional.heart.org/statements. development, visit Development.” “Publication menu, then click lines & Statements” drop-down permission of are not permitted without the express distribution of this document Instructions for obtaining permission are located the American Heart Association. Re- A link to the “Copyright Permissions at https://www.heart.org/permissions. (https://www.heart.org/en/about- appears in the second paragraph quest Form” us/statements-and-policies/copyright-request-form). Other research support None None None None None None None None None Research grant Research None None None None None None None AHA (Innovative Project Diffusion Pharma- Award)†; ceuticals, Inc (PI, PHAST-TSC NIH Trial–NCT03763929)†; NSF CTSN)*; (ARCADIA Trial, (NSF-i-CORPS Program)* None 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under A relationship is considered to be “modest” if it is less than “significant” under 000 or more of the fair market value of the entity. ting stock owns 5% or more of the voting stock 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person Employment The University of The of Queensland School Nursing (Australia) Retired nursing Self-employed Australian Catholic Uni- versity Nursing Research Institute, St. Vincent’s Hospital (Australia) University of Cincinnati College of Nursing Grady Health System Virginia Retired (West University) University of Virginia Saint Luke’s Health System This updated statement describes the care of the the care of the statement describes updated This This statement was approved by the American Heart Association Science by the American Heart Association Science statement was approved This This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on as actual or reasonably perceived conflicts of interest as reported on table represents the relationships of writing group members that may be perceived This *Modest. †Significant. Writing group Writing member Theresa L. Green Norma D. McNair Janice L. Hinkle Sandy Middleton Miller Elaine T. Stacy Perrin Martha Power Andrew M. Southerland Debbie V. Debbie V. Summers Writing Group Disclosures Writing the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the to complete and submit. A relationship is considered to be “significant” if (a) the all members of the writing group are required the Disclosure Questionnaire, which person receives $10 or share of the entity, or owns $10 or share of the entity, the preceding definition. Disclosures ARTICLE INFORMATIONARTICLE avoid any actual or poten- American Heart Association makes every effort to The a may arise as a result of an outside relationship or tial conflicts of interest that of the writing panel. Spe- or business interest of a member personal, professional, and submit a members of the writing group are required to complete all cifically, relationships that might be perceived Disclosure Questionnaire showing all such as real or potential conflicts of interest. 2020, and the American Advisory and Coordinating Committee on October 26, 28, 2021. A copy of the Heart Association Executive Committee on January by using document is available at https://professional.heart.org/statements the evidence to support the efficacy of these in clinical efficacy of these to support the the evidence is also lacking. practice settings in the posthyperacute stroke acute ischemic patient with best practices, specialized evidence-based phase. Using stay, length of outcomes, decrease affect nurses can decrease event recurrence. Nursing decrease costs, and and expanding remains a cornerstone, building research care evidence-based and practice, knowledge, nursing living with stroke. for patients and families Stroke. 2021;52:00–00. DOI: 10.1161/STR.0000000000000357 Green et al et Green

of thefairmarketvalueentity. Arelationshipisconsideredtobe“modest”ifitless than“significant”undertheprecedingdefinition. 12-month period,or5%moreoftheperson’sgrossincome;(b)personownsvotingstock orshareoftheentity, orowns$10 tionnaire, which allreviewersarerequiredtocompleteandsubmit.Arelationshipisconsideredbe“significant”if(a)thepersonreceives$10 Reviewer Disclosures 5b. 5a. Olson DaiWai M. J.Lutz Barbara Tamilyn Bakas Reviewer 1. 2. 3. 4. 5. 6. 8. 7. †Significant. *Modest. This tablerepresentstherelationshipsofreviewersthatmaybeperceivedasactualorreasonablyconflictsinterestreportedonDisclosureQues- 2009;40:2911–2944. doi:10.1161/STROKEAHA.109.192362 Stroke. 2009;40:2911–2944. corrections appearinStroke.2010;41:e563and2011;42:e357]. a scientificstatementfromtheAmericanHeartAssociation[published of nursingandinterdisciplinarycaretheacuteischemic strokepatient: on CardiovascularNursingandtheStrokeCouncil.Comprehensiveoverview onbehalfoftheAmericanHeartAssociationCouncil N, MillerE,Mitchell PH; Summers D, Leonard A, Wentworth Simpson J, Spilker JA, Hock D, Saver JL, 2017;120:439–448. doi:10.1161/CIRCRESAHA.116.308413 2017;120:439–448. Feigin VL,NorrvingB,MensahGA. Globalburdenofstroke.CircRes. culation. 2020;141:e139–e596 statistics–2020 update:areportfromtheAmericanHeartAssociation.Cir- Heart disease and stroke Chamberlain AM, Chang AR, Cheng S, Delling FN. CallawayCW,Virani AlonsoA,BenjaminEJ,BittencourtMS, SS, CarsonAP, 2014;9(suppl A100):4–13.doi:10.1111/ijs.12371 nization globalstrokeservicesguidelinesandactionplan.IntJStroke. Lindsay P, DonnanGA,NorrvingB.World DavisSM, Furie StrokeOrga- KL, Stroke. 2019;50:e344–e418.doi:10.1161/STR.0000000000000211 Association [publishedcorrectionappearsinStroke.2019;50:e440–e441]. care professionals fromtheAmericanHeartAssociation/American Stroke for theearlymanagementofacuteischemic stroke:aguidelineforhealth- of patientswithacuteischemic stroke:2019updatetothe2018guidelines can HeartAssociationStrokeCouncil.Guidelinesfortheearlymanagement HohB,etal;onbehalfoftheAmeri- K, BillerJ,BrownM,Demaerschalk BM, Powers WJ, RabinsteinAA,Ackerson T, Becker BambakidisNC, AdeoyeOM, STR.0000000000000358 American Heart Association. hensive nursingcarescientificstatement:astatementfromthe compre- intensive careunit-postinterventionaltherapy):updateto2009 Council. Careofthepatientwithacuteischemic stroke(endovascular/ ciation CouncilonCardiovascularandStrokeNursingthe MardenFA;livan C,LivesaySL, on behalf of the American Heart Asso- FoxRodgers ML, E,AbdelhakT, Franker- LM, JohnsonBJ,Kirchner-Sul STR.0000000000000356 American Heart Association. prehensive nursingcarescientificstatement:astatementfromthe com- emic stroke(prehospitalandacutephaseofcare):updatetothe2009 Stroke NursingandtheCouncil.Careofpatientwithacuteisch- behalf oftheAmericanHeartAssociationCouncilonCardiovascularand Ashcraft S,Wilson NystrӧmKV, SE, DusenburyW, Wira BurrusTM;on CR, 10.1155/2014/798258 and alliedhealthinvolvement.Stroke.Res Treat. 2014;2014:798258. doi: admissions andnon-ASU years ofacutestrokeunitcare:comparing ASU Hubbard IJ,EvansM,McMullen-Roach S,MarquezJ,Parsons MW. Five 10.1002/14651858.CD000197.pub3 for stroke.CochraneDatabaseSyst Stroke UnitTrialists’ Organisedinpatient(strokeunit)care Collaboration. ence toclinicalguidelines improvespatientoutcomesinAustralian auditof Hubbard IJ,HarrisD,KilkennyMF, Pollack Faux CadilhacDA. SG, Adher- MR, TBD 2021 TBD Center ern Medical UT Southwest- Wilmington North Carolina– University of Cincinnati University of Employment Stroke. 2021;52:e000–e000. doi: 10.1161/ Stroke. 2021;52:e000–e000. doi: 10.1161/ None vention forpoststrokecare)† funded granttestinganinter- onaPCORI- (CO-I PCORI stroke familycaregivers)† (funding targeting NIH/NINR Research grant Rev. 2013;2013:CD000197. doi: None None None support Other research

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