Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial.

PURPOSE: To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke. PATIENTS AND METHODS: An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up. RESULTS: Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001). CONCLUSION: Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

Depressive Symptoms After Ischemic Stroke: Population-Based Comparisons of Patients and Caregivers With Matched Controls.

Background and Purpose- Persistent depression after ischemic stroke is common in stroke survivors and may be even higher in family caregivers, but few studies have examined depressive symptom levels and their predictors in patient and caregiver groups simultaneously. Methods- Stroke survivors and their family caregivers (205 dyads) were enrolled from the national REGARDS study (Reasons for Geographic and Racial Differences in Stroke) into the CARES study (Caring for Adults Recovering from the Effects of Stroke) ≈9 months after a first-time ischemic stroke. Demographically matched stroke-free dyads (N=205) were also enrolled. Participants were interviewed by telephone, and depressive symptoms were assessed with the 20-item Center for Epidemiological Studies-Depression scale. Results- Significant elevations in depressive symptoms (Ps<0.03) were observed for stroke survivors (M=8.38) and for their family caregivers (M=6.42) relative to their matched controls (Ms=5.18 and 4.62, respectively). Stroke survivors reported more symptoms of depression than their caregivers (P=0.008). No race or sex differences were found, but differential prediction of depressive symptom levels was found across patients and caregivers. Younger age and having an older caregiver were associated with more depressive symptoms in stroke survivors while being a spouse caregiver and reporting fewer positive aspects of caregiving were associated with more depressive symptoms in caregivers. The percentage of caregivers at risk for clinically significant depression was lower in this population-based sample (12%) than in previous studies of caregivers from convenience or clinical samples. Conclusions- High depressive symptom levels are common 9 months after first-time ischemic strokes for stroke survivors and family caregivers, but rates of depressive symptoms at risk for clinical depression were lower for caregivers than previously reported. Predictors of depression differ for patients and caregivers, and standards of care should incorporate family caregiving factors.

Resilience among stroke survivors: A cohort study of the first 6 months.

AIMS: To explore (a) resilience among patients over the first 6 months following a first ischaemic stroke; (b) factors associated with resilience at hospitalization, 1, 3, and 6 months postdischarge; (c) baseline predictors of resilience at 6 months postdischarge. DESIGN: a cohort study. METHODS: From February 2017-January 2018, 217 patients presenting at two hospitals with a first ischaemic stroke were recruited. Their resilience, medical coping styles, general self-efficacy, functional independency, socio-demographic, and clinical data were assessed while they were still in hospital (baseline) and at 1, 3, and 6 months after discharge. RESULTS: Resilience among stroke patients decreased significantly 1 month after hospital discharge and remained stable. Predictors of resilience were as follows: self-efficacy and resignation at baseline; number of children, functional independency, general self-efficacy, and resignation at 1 month; and religion, resignation, self-efficacy, confrontation at 3 months and 6 months. The baseline factors that predicted resilience at 6 months were income level, religion, stroke severity at discharge, self-efficacy, and resignation. CONCLUSION: Stroke survivors experienced a significant decrease in resilience from hospitalization until 1-month postdischarge. Factors contributing to resilience after a stroke varied across time. Self-efficacy and coping styles were particularly important and contributed to long-term resilience. IMPACT: Understanding resilience among stroke survivors is needed to inform the development of interventions to enhance the psychological recovery of survivors. The levels of resilience among stroke survivors were low compared with those in the normal older population. Nurses should provide greater psychological support during hospitalization to stroke survivors and especially to those with lower income, higher stroke severity at discharge, no religion, lower self-efficacy, or who use resignation as a coping strategy as those survivors may have lower resilience 6 months later. Future studies are needed to test interventions designed to change or modify stroke survivors' coping styles and promote self-efficacy, thereby enhancing higher resilience.

Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management.

BACKGROUND: In-hospital strokes account for up to nearly 1 in 5 strokes. Clinical outcomes, such as length of stay, disability, and mortality are worse for in-hospital strokes than for those that occur in the community. For a variety of reasons, stroke can be more difficult to recognize and treat in hospitalized patients. Earlier recognition of stroke results in better clinical outcomes, presumably due to faster diagnosis and subsequently, prompt treatment. METHODS: This investigation was a retrospective, interrupted time series, observational study of all in-hospital stroke patients between 2008 and 2017. This investigation was a quality improvement project, and a waiver was granted from the institutional review board. We used Lean methodologies to standardize our stroke protocol and optimize skill-task alignment to improve the time from onset of symptoms to brain imaging (primary outcome). RESULTS: Overall, we observed significant improvement in the time from onset of symptoms to brain imaging from a median of 69 minutes to 37 minutes (P = .002). CONCLUSIONS: If successfully implemented, this approach may be useful in other care settings with potential to improve stroke outcomes, and decrease associated complications of stroke.

Acute Ischemic Stroke.

Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation.

Low-Molecular-Weight Heparin or Heparinoids vs. Unfractionated Heparin in Acute Ischemic Stroke.

Editor's note: This is a summary of a nursing care-related systematic review from the Cochrane Library. For more information, see http://nursingcare.cochrane.org.

Temporal Profiles of Cerebral Perfusion Pressure After Subarachnoid Hemorrhage.

INTRODUCTION: Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). METHOD: CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. RESULTS: Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (ß = 0.06, SE = 0.006, p < .001). The covariance (-0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). CONCLUSIONS: The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.

Baseline feature of a randomized trial assessing the effects of disease management programs for the prevention of recurrent ischemic stroke.

BACKGROUND: Comprehensive and long-term patient education programs designed to improve self-management can help patients better manage their medical condition. Using disease management programs (DMPs) that were created for each of the risk factor according to clinical practice guidelines, we evaluate their influence on the prevention of stroke recurrence. METHODS: This is a randomized study conducted with ischemic stroke patients within 1 year from their onset. Subjects in the intervention group received a 6-month DMPs that included self-management education provided by a nurse along with support in collaboration with the primary care physician. Those in the usual care group received ordinary outpatient care. The primary end point is a difference of the Framingham risk score-general cardiovascular disease 10-year risk [corrected]. Patients were enrolled for 2 years with plans for a 2-year follow-up after the 6-month education period (total of 30 months). RESULTS: A total of 321 eligible subjects (average age, 67.3 years; females, 96 [29.9%]), including 21 subjects (6.5%) with transient ischemic attack, were enrolled in this study. Regarding risk factors for stroke, 260 subjects (81.0%) had hypertension, 249 subjects (77.6%) had dyslipidemia, 102 subjects (31.8%) had diabetes mellitus, 47 subjects (14.6%) had atrial fibrillation, and 98 subjects (30.5%) had chronic kidney disease. There were no significant differences between the 2 groups with respect to subject characteristics. CONCLUSIONS: This article describes the rationale, design, and baseline features of a randomized controlled trial that aimed to assess the effects of DMPs for the secondary prevention of stroke. Subject follow-up is in progress and will end in 2015.

Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study.

The patients at a neurointensive care unit are frequently cared for in many ways, day and night. The aim of this study was to investigate the amount of secondary insults related to oral care, repositioning, endotracheal suctioning, hygienic measures, and simultaneous interventions at a neurointensive care unit with standardized care and maximum attention on avoiding secondary insults. The definition of a secondary insult was intracranial pressure > 20 mm Hg, cerebral perfusion pressure < 60 mm Hg and systolic blood pressure < 100 mm Hg for 5 minutes or more in a 10-minute period starting from when the nursing intervention began. The insult minutes did not have to be consecutive. The study included 18 patients, seven women and 11 men, aged 36-76 years with different neurosurgical diagnoses. The total number of nursing interventions analyzed was 1,717. The most common kind of secondary insults after a nursing measure was high intracranial pressure (n = 93) followed by low cerebral perfusion pressure (n = 43) and low systolic blood pressure (n = 14). Repositioning (n = 39) and simultaneous interventions (n = 32) were the nursing interventions causing most secondary insults. There were substantial variations between the patients; only one patient had no secondary insult. There were, overall, a limited number of secondary insults related to nursing interventions when a standardized management protocol system was applied to reduce the occurrence of secondary insults. Patients with an increased risk of secondary insults should be recognized, and their care and treatment should be carefully planned and performed to avoid secondary insults.

The golden hour Performing an acute ischemic stroke workup.

Ischemic stroke is a medical emergency resulting from an embolic or thrombotic occlusion of an intracranial artery. The purpose of this article is to provide acute care nurse practitioners a summary of recent updates on the rapid evaluation and workup for patient selection and treatment with I.V. fibrinolysis.

Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: a correlational study.

OBJECTIVES: To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH). RESEARCH METHODOLOGY: Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6). RESULTS: DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%. CONCLUSIONS: These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study.

Peripheral immune response and infection in first-time and recurrent ischemic stroke or transient ischemic attack.

GOALS: The aims of this study were to determine if the infection rate differs between the first and recurrent ischemic stroke/transient ischemic attack (TIA), if the pattern of the peripheral immune response (PIR) differs between the first and recurrent ischemic stroke/TIA and if infection further influenced the pattern of the PIR. METHODS: Retrospective review of 500 stroke cases with strict exclusion criteria (e.g., hemorrhagic stroke, subarachnoid hemorrhage, or spontaneous intracerebral hemorrhage; history of cancer; on steroids or immune suppressive drugs; recent invasive procedure) resulted in inclusion of 198 cases. Independent variables were first stroke or recurrent stroke and not infected or infected cases. Main-effect dependent variables were the white blood cell (WBC) and differential leukocyte counts (percentages of 100 cell counts for neutrophils, lymphocytes, and monocytes and absolute counts of neutrophils, lymphocytes, and monocytes). FINDINGS: Infection rate was not different between the first versus recurrent stroke (p = .279). The pattern of WBC and differential counts were not different between groups, but addition of the covariate of infection showed group differences (p = .05). A four-group comparison of the dependent variables with the laboratory normal ranges showed lymphocyte percentages below the lower range limit in all four groups. Generalized linear modeling showed a modest rise (15%) in WBC counts in both groups with concomitant infection, a modestly low (-18%) lymphocyte percentage in recurrent stroke with infection, and a more substantial rise (22%-26%) in absolute neutrophil count in both groups with concomitant infection. CONCLUSIONS: Infection influences the pattern of the PIR in the first and recurrent stroke/TIA, and this difference can be quantified.

Acute ischemic stroke and hyperglycemia.

To increase the comprehension about the profound effects of hyperglycemia within the first 48 hours poststroke on the outcomes of acute ischemic stroke, the authors reviewed multiple studies and literature reviews. Research supports the detrimental effects of hyperglycemia on the morbidity and mortality of patients diagnosed with acute ischemic stroke. The studies that were examined revealed that although further research is necessary, controlling hyperglycemia is overall beneficial to support superior clinical outcomes. The purpose of this article was to discuss the importance of not only glucose control but also the vital role of nurses in controlling glucose levels efficiently and immediately during the first 48 hours poststroke.

The lived experiences of nurses in one hyper-acute stroke unit.

Hyper-acute stroke units (HASUs) admit all stroke patients across London. As a novel London stroke model, the integration of thrombolysis in acute ischaemic stroke is an important element of hyper-acute stroke care for patients. In this model, nurses working in a hyper-acute stroke unit are involved in the delivery of thrombolysis treatment. By use of a phenomenological approach, the study investigates the 'lived experiences' of nurses' preparation for their role and explores any factors that affect nurses' participation in thrombolysis treatment. The nurses' roles-which facilitate, support, monitor, anticipate and result in prevention-are central to effective thrombolysis treatment. However, factors such as communication, teamwork, clinical decision, training, staffing and safety affect their thrombolysis roles. Addressing factors that affect nurses' thrombolysis roles could lead to improved communication, collaborative teamwork and better patient outcomes.

Satisfaction with palliative care after stroke: a prospective cohort study.

BACKGROUND AND PURPOSE: The determinants of satisfaction for families of acute stroke patients receiving palliative care have not been extensively studied. We surveyed families to determine how they perceived palliative care after stroke. METHODS: Families of patients palliated after ischemic stroke, intracerebral, or subarachnoid hemorrhage were approached. Four weeks after the patient's death, families were administered the After-Death Bereaved Family Member Interview to determine satisfaction with the care provided. RESULTS: Fifteen families participated. Families were most satisfied with participation in decision making and least satisfied with attention to emotional needs. In stroke-specific domains, families had less satisfaction with artificial feeding, hydration, and communication. Overall satisfaction was high (9.04 out of 10). CONCLUSIONS: Families of patients receiving palliative care at our institution showed generally high satisfaction with palliation after stroke; specific domains were identified for improvement. Further study in larger populations is required.

Ischemic stroke: the first 24 hours.

Patients who have suffered a stroke are often left with a high incidence of physical and psychosocial impairments. Institutions must develop and implement clinical protocols and pathways to quickly and efficiently initiate evidence-based stroke therapies.

[Diagnostic accuracy of an automatic blood pressure device for ankle brachial index determination in ischemic stroke patients]. / Precisión diagnóstica de un dispositivo automático en la determinación del índice tobillo-brazo en pacientes con ictus isquémico.

INTRODUCTION: Ankle brachial index (ABI) is not widespread in clinical practice because the need for specific equipment and training. Doing it without these requirements, quicker and with a cheaper method would facilitate their routine use. AIMS: To evaluate sensitivity and specificity of an automatic blood pressure device detecting ABI < 0.90, when technique is performed by nurses. To evaluate agreement between two techniques for the ABI determination. PATIENTS AND METHODS. Diagnostic accuracy study in 30 ischemic stroke patients. For each patient, three measurements were performed with the automatic device, and one with the reference method. RESULTS: The automatic blood pressure device performance detecting ABI < 0.90 was acceptable for each of the three measurements (sensitivity: 78%, 87% and 100%; specificity: 95%, 100% and 100%; positive predictive value: 87%, 100% and 100%; negative predictive value: 91%, 96% y 100%; accuracy: 90%, 97% y 100%). The intraclass correlation coefficients for intra-observer, inter-observer and inter-method variability showed acceptable levels, with results of 0.64, 0.83 and 0.75, respectively. In the Bland Altman test only inter-method comparison had less than 5% of its values out of range. CONCLUSIONS: Sensitivity and specificity of an automatic blood pressure device detecting ABI < 0.90 shows acceptable levels when technique is performed by nurses. This suggests its potential as screening tool in transient ischemic attack/ischemic stroke patients.