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INTRODUCTION: Stroke can have profound psychosocial health implications. These constructs are often overlooked and undertreated yet can be as devastating as the physical, functional, and cognitive consequences after stroke. AIM: This scientific statement aims to evaluate 5 important aspects of psychosocial health (depression, stress, anxiety, fatigue, and quality of life) after a stroke to provide a framework for related nursing care across the poststroke continuum. METHODS: A narrative review of the literature published from 2018 to 2023 was conducted with databases such as PubMed/MEDLINE, ClinicalTrials.gov, PsychInfo/EBSCOHost, PsychArticles, CINHAL, and the Cochrane Library. RESULTS: Findings reveal a gap in evidence-based nursing interventions for addressing poststroke psychosocial needs. Critical strategies for shaping therapeutic nursing care include enhanced screening with validated tools; educating stroke survivors, families, and staff on symptom recognition, prevention, and treatment; and ensuring appropriate pharmacological management and access to psychological and psychosocial interventions, including referrals to social services and other essential support systems. Care should be comprehensive and interdisciplinary. Nurse-led research can benefit from more inclusive inclusion, including individuals with recurrent strokes and preexisting psychosocial conditions, focusing on the impact of structural racism and care disparities and expanding evidence-based nursing interventions. CONCLUSIONS: Although there is limited high-level evidence on the nursing care for patients with suboptimal psychosocial health after stroke, nurses have a crucial role in addressing these needs. Enhanced screening, assessment, supportive services, and education are vital to ensure that patients receive the necessary treatment and care.
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Background: Prior to the conduct of the Head Position in Stroke Trial (HeadPoST), an international survey (n = 128) revealed equipoise for selection of head position in acute ischemic stroke. Objectives: We aimed to determine whether equipoise exists for head position in spontaneous hyperacute intracerebral hemorrhage (ICH) patients following HeadPoST. Design: This is an international, web-distributed survey focused on head positioning in hyperacute ICH patients. Methods: A survey was constructed to examine clinicians' beliefs and practices associated with head positioning of hyperacute ICH patients. Survey items were developed with content experts, piloted, and then refined before distributing through stroke listservs, social media, and purposive snowball sampling. Data were analyzed using descriptive statistics and χ2 test. Results: We received 181 responses representing 13 countries on four continents: 38% advanced practice providers, 32% bedside nurses, and 30% physicians; overall, participants had median 7 [interquartile range (IQR) = 3-12] years stroke experience with a median of 100 (IQR = 37.5-200) ICH admissions managed annually. Participants disagreed that HeadPoST provided 'definitive evidence' for head position in ICH and agreed that their 'written admission orders include 30-degree head positioning', with 54% citing hospital policies for this head position in hyperacute ICH. Participants were unsure whether head positioning alone could influence ICH longitudinal outcomes. Use of serial proximal clinical and technology measures during the head positioning intervention were identified by 82% as the most appropriate endpoints for future ICH head positioning trials. Conclusion: Interdisciplinary providers remain unconvinced by HeadPoST results that head position does not matter in hyperacute ICH. Future trials examining the proximal effects of head positioning on clinical stability in hyperacute ICH are warranted.
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Stroke center certification has evolved at a rapid pace and is now available at 4 different levels of service in the United States. Although certification standards provide guidance on stroke center process elements, lack of guidance on structural components such as workforce, staffing, and unit operations has resulted in heterogeneous services among hospitals credentialed at the same stroke center level. Such heterogeneity challenges public expectations and transparency about actual service capabilities within American stroke centers and in some cases may foster leniency in credentialing agency certification methods. Standards for other time-dependent diagnoses, including trauma, provide detailed guidance on structural elements that has improved patient triage and resuscitative care while enabling practitioners and administrators to more accurately gauge and plan service development to better support their communities. This scientific statement aims to provide similar structural guidance defined by each level of hospital stroke center services to reduce operational inconsistencies, to foster planning for service development, and to improve the interprofessional care of patients with acute stroke.
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American Heart Association , Accidente Cerebrovascular , Humanos , Estados Unidos , Accidente Cerebrovascular/diagnóstico , Hospitales , Certificación , Crecimiento y DesarrolloRESUMEN
BACKGROUND: Mobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported. METHODS: We performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified. RESULTS: 1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5-4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1-3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90-139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required. CONCLUSIONS: MSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.
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Isquemia Encefálica , Accidente Cerebrovascular Hemorrágico , Accidente Cerebrovascular , Angiografía , Isquemia Encefálica/cirugía , Angiografía Cerebral , Angiografía por Tomografía Computarizada/métodos , Humanos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Tomografía Computarizada por Rayos XRESUMEN
The year 2020 was the year of the nurse, celebrating nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy. As architects of stroke care, neuroscience nurses play a vital role in collaborating and coordinating care between multiple health professionals. Nurses improve accessibility and equity through telestroke, emergency medical services, and mobile stroke units and are integral to implementing education strategies by advocating and ensuring that patients and caregivers receive stroke education while safely transitioning through the health care system and to home. Stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process. Advanced practice nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units, participating as members of the stroke response team, and directing stroke care protocols in the emergency department. This scientific statement is an update to the 2009 "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient." The aim is to provide a comprehensive review of the scientific evidence on nursing care in the prehospital and hyperacute emergency hospital setting, arming nurses with the necessary tools to provide evidenced-based high-quality care.
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Servicios Médicos de Urgencia , Accidente Cerebrovascular Isquémico/terapia , Atención de Enfermería , American Heart Association , Humanos , Estados UnidosRESUMEN
Acute stroke assessment is classically supported by clinical localization whereby presenting disabilities are associated with key arterial territories in the brain. Clinical localization skills are rarely taught to nonneurologists; yet, these skills are essential to the provision of evidence-based nursing care of stroke, enabling rapid patient identification, diagnosis, and ultimately, the delivery of acute treatment. This article explores the process of clinical localization in relation to the physiology affected by stroke vascular insufficiency. Elements of the neurologic examination are described as they relate to discreet areas in the brain and the National Institutes of Health Stroke Scale.
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Encéfalo/patología , Dominancia Cerebral/fisiología , Examen Neurológico , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Arterias Cerebrales/patología , Hemianopsia , Hemiplejía , Humanos , Enfermería en Neurociencias , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/enfermería , Estados UnidosRESUMEN
PURPOSE: The aim of the study was to analyze factors affecting sexual activity in individuals with and without stroke, ages 40-59 years, in a national, cross-sectional, population-based sample derived from the National Health and Nutrition Examination Survey (NHANES). DESIGN: Descriptive, cross-sectional survey. METHODS: Data were obtained from the NHANES (2011-2012) data set from individuals (N = 3,649) completing items related to cardiovascular risk factors, drugs, and sexual activity. Data were analyzed using chi-square, t tests, and logistic regression. FINDINGS: Overall, number of drugs, smoking, and depression significantly predicted sexual activity. When comparing sexually active to not sexually active, those with stroke had significantly less sexual activity (t = 2.822, p = .005) and reduced sexual activity per week or month (χ = 16.275, p = .005, df = 4). Those taking angiotensin-converting enzyme inhibitors and statins had reduced sexual activity. CONCLUSIONS/CLINICAL RELEVANCE: Findings illustrate the importance of risk factor modification and nurses engaging in sexual assessment, education, and counseling to support sexual quality of life in younger individuals with stroke.
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Depresión/complicaciones , Medicamentos bajo Prescripción/efectos adversos , Conducta Sexual/fisiología , Conducta Sexual/psicología , Adulto , Estudios Transversales , Depresión/psicología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Medicamentos bajo Prescripción/uso terapéutico , Factores de Riesgo , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/psicologíaRESUMEN
Alteplase is a tissue plasminogen activator approved for treating acute ischemic stroke (AIS), acute myocardial infarction (AMI), and acute massive pulmonary embolism. Two additional tissue plasminogen activators, tenecteplase and reteplase, are also approved for AMI treatment. However, neither tenecteplase nor reteplase is approved for AIS treatment. The U.S. Food and Drug Administration has received reports of accidental administration of tenecteplase or reteplase instead of alteplase in patients with AIS, which can lead to potential overdose. Primary factors contributing to medication errors include use of the abbreviations "TPA," "tPA," or "TNK" in written or verbal orders and use of these agents in similar settings. Steps to reduce the likelihood of accidental substitution include use of full brand or generic names and inclusion of the indication in written and verbal orders, addition of alerts in automated dispensing machines and ordering systems, and use of stroke boxes containing alteplase and materials for administration.
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Isquemia Encefálica/tratamiento farmacológico , Toma de Decisiones , Servicio de Urgencia en Hospital , Accidente Cerebrovascular/tratamiento farmacológico , Tenecteplasa/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Humanos , Errores de Medicación/prevención & control , Proteínas Recombinantes/uso terapéutico , Estados Unidos , United States Food and Drug AdministrationRESUMEN
Background and Purpose- The impact of a mobile stroke unit (MSU) on access to intraarterial thrombectomy (IAT) is a prespecified BEST-MSU substudy (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). On the MSU, IAT decision-making steps, such as computed tomography, neurological exam, and tPA (tissue-type plasminogen activator) treatment are completed before emergency department arrival. We hypothesized that such pre-ED assessment of potential IAT patients on an MSU improves the time from ED arrival to skin puncture time (door-to-puncture-time, DTPT). Methods- BEST-MSU is a prospective comparative effectiveness study of MSU versus standard management by emergency medical services (EMS). We compared ED DTPT among the following groups of MSU and EMS patients: all IAT patients, IAT patients post-tPA, and IAT patients post-tPA meeting thrombolytic adjudication criteria over the first 4 years of the study. Results- From August 2014 to July 2018, a total of 161 patients underwent IAT. Ninety-four patients presented to the ED via the MSU and 67 by EMS. One hundred forty patients received tPA before IAT, 85 in the MSU arm, and 55 in the EMS arm. One hundred twenty-six patients received tPA within thrombolytic adjudication criteria: 76 MSU and 50 EMS. DTPT in minutes was shorter for MSU patients (all IAT MSU versus EMS 89 versus 99, P=0.01; IAT post-tPA MSU versus EMS 93 versus 100, P=0.03; and IAT post-tPA within adjudicated criteria MSU versus EMS 93 versus 99.5, P=0.03). From 2014 to 2018, DTPT decreased at a faster rate for EMS compared with MSU-managed patients, improving by about an hour. Conclusions- Pre-ED IAT evaluation on an MSU results in faster DTPT compared with arrival by EMS. Since 2014, dramatic improvement in ED IAT metrics has attenuated this difference. However, DTPT in all groups indicates substantial room for improvement.
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Ambulancias/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Accidente Cerebrovascular/terapia , Tiempo de Tratamiento/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Toma de Decisiones Clínicas , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Examen Neurológico , Estudios Prospectivos , Trombectomía , Activador de Tejido Plasminógeno/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: Timely treatment of acute ischemic stroke is crucial to optimize outcomes. Mobile stroke units (MSU) have demonstrated ultrafast treatment compared to standard emergency care. Geospatial analysis of the distribution of MSU cases to optimize service delivery has not been reported. METHODS: We aggregated all first-year MSU dispatch occurrences and all cases classified by clinical teams as true stroke by zip code and calculated dispatch and true stroke incidence rates. We mapped dispatch and stroke cases and symbolized incidence rates by standard deviation. We confirmed visual impressions of clusters from map inspection by local Moran's I, boxplot inspection, and t test. We calculated service areas using drive times to meet dispatch and true stroke need. RESULTS: A significant cluster of high dispatch incident rate was confirmed around our MSU base in urban Memphis within a 5-min driving area supporting the initial placement of the MSU based on 911 activation. A significant cluster of high true stroke rate was confirmed to the east of our MSU base in suburban Memphis within a 10-min driving area. Mean incident longitude of cases of true stroke versus disregarded status was significantly eastward (p = 0.001785). CONCLUSION: Our findings will facilitate determination of socio-spatial antecedents of neighborhood overutilization of 911 and MSU services in our urban neighborhoods and service delivery optimization to reach neighborhoods with true stroke burden.
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BACKGROUND: Variance from guideline-directed care for glucose and temperature control remains unknown in the United States at a time when priorities have shifted to ensure rapid diagnosis and treatment of acute stroke patients. However, protocol-driven nursing surveillance for control of hyperglycemia and hyperthermia has been shown to improve patient outcomes. METHODS: We conducted an observational pilot study to assess compliance with American guidelines for glucose and temperature control and association with discharge outcomes in consecutive acute stroke patients admitted to 5 US comprehensive stroke centers. Data for the first 5 days of stroke admission were collected from electronic medical records and entered and analyzed in SPSS using descriptive statistics, Mann-Whitney U test, Student t tests, and logistic regression. RESULTS: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a sample of 235 acute stroke patients; the sample was 87% ischemic and 13% intracerebral hemorrhage. Poor glucose control was found in 33% of patients, and the most frequent control method ordered (35%) was regular insulin sliding scale without basal dosing. Poor temperature control was noted in 10%, and 39% did not have temperature recorded in the emergency department. Lower admission National Institutes of Health Stroke Scale score and well-controlled glucose were independent predictors of favorable outcome (discharge modified Rankin Scale score, 0-2) in reperfusion patients. CONCLUSION: Glucose and temperature control may be overlooked in this era of rapid stroke diagnosis and treatment. Acute stroke nurses are well positioned to assume leadership of glucose and temperature monitoring and treatment.
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Glucemia , Fiebre/prevención & control , Adhesión a Directriz/normas , Enfermería en Neurociencias , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Glucemia/análisis , Glucemia/metabolismo , Femenino , Humanos , Hiperglucemia/prevención & control , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/complicaciones , Estados UnidosRESUMEN
AIM: The aim of this systematic review was to examine determinants of sexual function and dysfunction in men and women poststroke, and to evaluate effectiveness of interventions. METHODS: A systematic review was conducted using the databases of PubMed, Medline, CINAHL, Cochrane, and Psychinfo, for studies published between January, 2000 and October, 2016. Included were original research, adult ≥18 years, English language, and experimental and non-experimental designs. Excluded were studies of stroke caused by sexual activity, stroke triggered unusual behaviours, and changes in sexual orientation. Studies were evaluated for quality using The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Of 19 studies reviewed, 13 were descriptive, three case-controlled and three intervention/randomised controlled trials (RCTs) designs. RESULTS: Participants across studies were predominantly men (90%), with moderate erectile dysfunction (ED), and mild depression. Changes in sexual activity, sexual dissatisfaction and sexual dysfunction were common, including decreased libido, orgasmic problems and ED, significantly worse from pre to poststroke. Results for side of hemiparesis and sexual dysfunction were inconclusive. Sexual rehabilitation interventions differed, but resulted in improved sexual satisfaction, sexual activity frequency and erectile function in two studies. CONCLUSIONS: Sexual dysfunction commonly occurred poststroke, continuing for months or as long as 2 years. Intervention studies were limited, with only two RCTs, thus, firm conclusions cannot be made. Few studies included women or younger stroke patients, indicating the need for further RCTs with larger and more diverse samples.
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Disfunciones Sexuales Fisiológicas/etiología , Disfunciones Sexuales Psicológicas/etiología , Accidente Cerebrovascular/complicaciones , Femenino , Humanos , Masculino , Factores de Riesgo , Disfunciones Sexuales Fisiológicas/diagnóstico , Disfunciones Sexuales Fisiológicas/terapia , Disfunciones Sexuales Psicológicas/diagnóstico , Disfunciones Sexuales Psicológicas/terapia , Resultado del TratamientoRESUMEN
Now well-established throughout Europe, mobile stroke unit (MSU) programs are in the early stages of development in the United States. The concept aims to improve outcomes by bringing diagnostic capabilities and clot-busting care to the patients experiencing stroke, thereby reducing the time to treatment. In October, New York Presbyterian/Weill Cornell Medical Center in New York became the first medical center on the East Coast to deploy an MSU, and in July, the University of Tennessee College of Medicine in Memphis deployed a first-of-its-kind MSU that is larger and more robust than other MSUs currently in use. In the first month of operation, the MSU in New York responded to 29 calls and brought 12 patients to the hospital with suspected strokes. Two of these patients received tissue plasminogen activator in the field and both made full recoveries by the next day. The MSU deployed in Memphis is larger and carries more sophisticated diagnostic equipment than other MSUs. The program also replies on doctorally prepared, vascular neurology fellowship-trained nurse practitioners, instead of relying on telemedicine connections to external experts. Now operating with the assistance of grant funding, leaders of both programs hope that strong outcomes will prove convincing to hospitals and prayers, although the U.S. healthcare model complicates the establishment of a reimbursement structure for MSUs.
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Ambulancias , Accidente Cerebrovascular/terapia , Eficiencia Organizacional/economía , Servicio de Urgencia en Hospital/economía , Humanos , Calidad de la Atención de Salud , Resultado del TratamientoRESUMEN
Patients with cardiovascular disease and their partners frequently have concerns about sexual intimacy, and sexual counseling is needed across health care settings to ensure that patients receive information to safely resume sexual activity. The purpose of this review is to provide practical, evidence-based approaches to enable health care providers to discuss sexual counseling, illustrated by several case scenarios. Evidence shows that patients expect health care providers to initiate sexual activity discussions, although providers may be hesitant and often rely on patients to ask questions. Although some providers cite lack of knowledge or confidence in their ability to provide sexual counseling, others mention time pressures in the clinical setting. Although such barriers exist, sexual counseling can be individualized to the cardiac condition of a patient with a few select questions. The representative examples of patients with angina pectoris, myocardial infarction, coronary artery bypass surgery, heart failure, and implantable cardioverter defibrillator are used to illustrate key points and provide a model for sexual counseling in practice.