Stroke Information

Welcome to Basic Rehabilitation Nursing Concepts for the care of the patient on an Acute Rehabilitation Unit

LEARNING CONTENT
 * Learning content will be based on the concept map ideas.



LEARNING OUTLINE
 * There is a lot of material presented on this wiki. As a guest (float nurse, agency nurse, or travel nurse)on our unit you may not need all the following information based on your expertise, experience and comfort level.  It is recommended that you read the sections one, two and three and then choose the other sections that may be of interest or of help to you.  Please leave feedback at the end for future topics you feel would be helpful in the successful orientation to float to the rehabilitation unit.  As always please use your professional nursing knowledge and practice to current standards.

SECTION ONE
 * What is an ARU/IRF?
 * An acute rehabilitation unit (ARU), sometimes referred to as an in-patient rehabilitation facility (IRF) is a unit in which patients who have experienced a life-altering event work to attain the highest level of functioning possible given their new circumstances.

SECTION TWO
 * What is a rehabilitation nurse?
 * Rehabilitation nursing is a specialty practice within the field of nursing. The Association of Rehabilitation Nurses (ARN) on page 5 in their fifth edition of the Core Curriculum defines rehabilitation nursing practice as “client centered, goal oriented, and outcome based.”
 * Think about that phrase for a minute. It sums up in six words what you will be focusing on during your shift with us.

SECTION THREE
 * What is the admit criteria and why is this important?
 * If you understand admit criteria then it can drive the care plan, it can identify barriers to discharge and it will drive your nursing care. It’s that simple.
 * Currently the Centers for Medicare and Medicaid (CMS) have the following admit criteria. Please note that CMS is a government agency whose regulations can change at any time.  Please check out their website listed in the resource section for the most current regulations.
 * The patient must be going home or to a home like setting such as a board and care.
 * The patient must be able to participate in and progress in three hours of therapy a day in two or more modalities. Modalities are physical therapy, occupational therapy and speech therapy.  Once the patient reaches a plateau or only requires one modality they are encouraged to move to the next level of care along the continuum.  A strategy to explain this to families is that just as the patient may have entered the hospital via the emergency room and then gone to ICU and then gone to the medical-surgical unit and then come to rehab, they are now going to the next level where they will continue to work towards their goals.
 * The patient’s medical condition or co-morbidities require a daily management by a physician. An example of this would be the patient who has experienced a hip fracture and is experiencing hypertension.  If the hypertension is being managed on the patient’s home dose of antihypertensives and is relatively stable (at their baseline) then a hip fracture alone probably would not qualify the patient for acute rehabilitation.  If the patient has a hip fracture and their hypertension is labile, requiring daily adjustments to antihypertensive medication then they would be more likely to be admitted.
 * The patient requires care and interventions twenty-four hours a day by a rehabilitation nurse.
 * The physician must certify that there is reasonable expectation that the patient will be positively impacted.
 * The “75% Rule” from CMS. CMS has identified thirteen medical diagnoses that they believe are appropriate for admission to ARU.  They mandated that 75% of your patient population should fall into these diagnoses.  These include:  stroke, spinal cord injury, amputation, major multiple trauma, brain injury, neurological disorders such as multiple sclerosis, Parkinson’s disease, some types of arthritis, some types of fractures and burns.  The list varies a little from year to year.  The bottom line is be prepared to take care of people with neurologic deficits and/or people who are coping with having unexpected things happen to them.

SECTION FOUR
 * Interdisciplinary team members and roles
 * There are many members on the interdisciplinary team. First and foremost is the patient.  Then comes the patient’s support system, they often become involved in care giving activities.
 * Other team members include the following:
 * physiatrist (physician who specializes in physical medication and rehabilitation)
 * physical therapist (specializes in large muscle movement)
 * occupational therapist (specializes in fine motor movement and transfers)
 * speech language pathologist (specializes in cognition and swallowing issues)
 * case manager (specializes in coordinating care prior to admit, during the stay and prior to discharge)
 * social worker (specializes in assisting the patient with obtaining any necessary support services during the stay and for discharge)
 * certified nursing assistant (assists with reinforcement of the rehabilitation program) Note our core staff of CNAs are very good at reinforcing transfer techniques and promotion of independence in activities of daily living such as grooming, eating, bathing and dressing
 * registered dietician (crucial in working with those patients with swallowing disorders)
 * As the RN for the patient we ask that you follow the interventions the team has set for the patient’s goals. This includes following the bowel and bladder program, positioning the patient correctly, and extensive teaching (see section eleven).  It sounds overwhelming, but remember you are not alone!
 * Communication is the key to performing effectively as a team. Information is communicated via the nursing kardex, via the patient’s chart, via the care plan.  Interdisciplinary team meetings are held on Mondays, Tuesdays, and Thursdays.  Barriers to achieving goals are discussed.  If there are any concerns or any issues access to a group voice mail is available.  Examples of a key concern the team would need to know about would be statements by the patient about change in discharge disposition, loss of support, changes in medical treatment.

SECTION FIVE
 * Rehabilitation specific language
 * You will hear a lot about activities of daily living or ADLs. These are everyday tasks people do such as eating, grooming, bathing, transferring, toileting, dressing, problem solving.  Each shift charts on the patient’s function in various ADL activities.  Your lead or the nurse buddy you are assigned to can go into further detail.
 * You will also hear about functional independence measurement or FIMs. This is a scale used in rehabilitation that uses numbers to describe the patient’s level of functioning.  As the patient gets better the FIM scores should go up.  Improving the FIM score improves the outcomes
 * You will hear other “alphabet soup” abbreviations. For example “ICP”.   If your specialty is neurology you are thinking intracranial pressure.  On the rehabilitation floor it means intermittent catheterization program. Two very different meanings for the same abbreviation.  If something doesn’t make sense ask us and we’ll explain.  There is no such thing as a silly question and it will provide us with an opportunity to correct misunderstandings with the next nurse that comes to help us out.
 * The NIH Stroke Scale. This is explained on line and in several reference books.  Ask us to show you how to access them.

SECTION SIX
 * Medical management of stroke
 * The medications used will depend on the type of stroke the patient has experienced and underlying co-morbidities. You will see anticoagulants used in the patient with an embolic or thrombotic stroke.  You will not see them used in the patient with a hemorrhagic stroke.
 * You may be concerned about the patient’s blood pressure being too high or too low. The physicians may want the blood pressure to run a little higher than normal if they are trying to get blood flow through the penumbra and oxygenate the brain.  They may want the blood pressure to run a little lower than normal if there is severe cardiac issues.  Each case is individualized. We love to teach on this unit so don’t be afraid to ask questions!

SECTION SEVEN
 * Nursing management of stroke
 * This is fairly standard for what you would do with any other patient. Think about the diagnosis, co morbidities and watch for potential complications.  An example would be change in mentation or a therapist’s report of change in function.  This could mean that the patient has extended their stroke, or it could mean they are sedated from medication, or it could mean they are tired.  It calls for reassessment and additional data collection.
 * Get to know your patient starting with walking bedside report. This will allow you to get a baseline. Hourly rounding will allow you to have frequent contact with the patient and perhaps catch changes sooner.
 * Ask questions of the patient, of the family, of other team members.
 * Monitor for side effects from medications.
 * Communication. Start off with simple questions the patient can answer yes or no to.  Only give one direction at a time.  Sometimes giving two directions at a time such as “Pick up your comb and comb your hair” can be too confusing.  It’s better to say “Pick up your comb” and wait until the person does this.  Then say “Comb your hair.”  Use the patient’s memory book as a cue and a reminder.
 * Safety. Often people with strokes can have increased impulsivity and decreased problem solving skills.  Always think about safety both here in the hospital and for discharge.  Participate in the hourly rounding.  Educate the family about safe swallow techniques.  Remind them of strategies such as not having the person use their weak hand to hold things while cutting with a knife.  Reinforce the strategies other disciplines have initiated to promote safety, these can include transferring a certain way for example.

SECTION EIGHT
 * Goal setting, care plans, documentation
 * This is basic nursing. Goal setting must involve the patient and family.  As the RN you can set wonderful goals however if they are not the patient’s goals there will not be any buy-in and the patient will not work towards achieving the goals.
 * Since restoration of function is the purpose of rehabilitation, functional based goals are written. An example for a patient with a neurogenic bowel would be:  Patient will be continent of bowel 100% of the time after self-insertion of a suppository and use of a bedside commode daily after lunch.
 * To write a function based progress note you could chart “After set up patient able to transfer to commode with stand by assistance and insert suppository independently. Patient able to perform personal hygiene independently with hands on assistance from RN to prevent loss of balance.”

SECTION NINE
 * Teaching
 * On our unit Orem’s theory of self-care deficit theory of nursing is used. This theory promotes independence and also supports the aspect of caregiver training.
 * Think what does this patient need to succeed at home? What is their current level of functioning? What are the barriers in the way? What can I do today to get them from their current level of functioning to independence? If you can answer these questions then you have just written the care plan, identified your interventions, and determined priorities for your shift.
 * An example would be the patient with a 20 year history of diabetes mellitus and a one week history of a left CVA, right sided hemiplegia, and who is right hand dominant. He has been managing his diabetes independently with sliding scale insulin for years.  Can he now manage to perform his blood sugar checks with his nondominant hand?  Can he now interpret a sliding scale with accuracy?   Can he draw up insulin correctly using one hand?  Can he self administer his insulin?  On our unit we don’t just relay on the patient’s answers to these questions we ask them to perform a return demonstration.  As a nurse new to rehabilitation you will be surprised by the number of patients who answer affirmatively to the questions yet are unable to perform the functions during a return demonstration.
 * Involve the support system. Teach them to be the back up to the patient.  In the above scenario the patient will be going home with his son.  The son will be working part of the day and the patient will home alone.  You would teach the son the same things you teach the patient.  Plus you will spend time problem solving other scenarios such as using a life line alert system.  Can you think of other examples?
 * As you are working with the patient, try to replicate what they will be doing at home as much as possible. An example would be to have the patient practice his fine motor skills by picking pills up one at a time.  Use the medication administration opportunity to teach subcutaneous injections for example.

SECTION TEN
 * Resources
 * For the nurse floating to an ARU there are a variety of resources for you to use. You are encouraged to ask questions of other staff, utilize your lead nurse (sometimes called a charge nurse in other facilities), and refer to current policies and procedures and protocols listed on the computer.  There are several rehabilitation reference books kept on the unit for referral in addition to computerized access to on-line nursing material. In addition to other interdisciplinary team members the nursing unit manager or house supervisor are good people to assist you with questions you might have.
 * For rapidly changing situations there is a rapid response team. Don’t hesitate to use it.
 * For patients please refer to patient education material approved by the facility. This is located both on-line and in a general file area.  Patient education material includes information on medications, disease related topics, and instruction material on how to perform care such as intermittent catheterization.  Staff will be happy to show you where this information is located.
 * For patients with diabetes, a diabetic educator consult can be obtained. Please note that you and she will work together to provide education to the patient and family.  Getting the consult does not abdicate your responsibilities for teaching.
 * For community based support issues, the social worker or case manager can help.
 * Web based links include:
 * ARN is at http://www.rehabnurse.org/
 * American Stroke Association is at http://www.strokeassociation.org/presenter.jhtml?identifier=1200037
 * CMS is at http://www.cms.hhs.gov/
 * The National Instititue of Health's Stroke Scale is at http://stroke.nih.gov/documents/NIH_Stroke_Scale.pdf

SECTION ELEVEN
 * Feedback
 * Please leave comments here as to what information was helpful, not helpful, needed clarification, needed expansion, or was missing. Suggestions for future topics would be appreciated.
 * You may contact the author at esharlan@usfca.edu. Please be patient for the response as I am a full time student who is also working full time.

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