The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Secondary Prevention
Recommendation 1.0
Nurses in all practice settings should screen clients for risk factors related to stroke in order to facilitate appropriate secondary prevention. Clients with identified risk factors should be referred to trained healthcare professionals for further management.
(Level of Evidence = IV)
Stroke Recognition
Recommendation 2.0
Nurses in all practice settings should recognize the new onset of the signs and symptoms of stroke as a medical emergency to expedite access to time dependent stroke therapy, as "time is brain."
(Level of Evidence IV)
Neurological Assessment
Recommendation 3.0
Nurses in all practice settings should conduct a neurological assessment on admission and when there is a change in client status. This neurological assessment, facilitated with a validated tool (such as the Canadian Neurological Scale, National Institutes of Health Stroke Scale, or Glasgow Coma Scale), should include at minimum:
- Level of consciousness
- Orientation
- Motor (strength, pronator drift, balance and coordination)
- Pupils
- Speech/language
- Vital signs (temperature, pulse, and respiration [TPR], blood pressure [BP], pulse oximetry [SpO2])
- Blood glucose
(Level of Evidence IV)
Recommendation 3.1
Nurses in all practice settings should recognize that signs of decline in neurological status may be related to neurological or secondary medical complications. Clients with identified signs and symptoms of these complications should be referred to a trained healthcare professional for further assessment and management.
(Level of Evidence IV)
Complications
Recommendation 4.0
Nurses in all practice settings should assess the client's risk for pressure ulcer development, which is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability (such as the Braden Scale for Predicting Pressure Sore Risk) is recommended.
(Level of Evidence IV)
Recommendation 4.1
Nurses in all practice settings should assess the stroke client's fall risk on admission and after a fall using a validated tool (such as the STRATIFY or timed "Up and Go").
(Level of Evidence IV)
Recommendation 4.2
Nurses in all practice settings should assess stroke clients for the following stroke complications: painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis in order to facilitate appropriate prevention and management strategies.
(Level of Evidence IV)
Pain
Recommendation 5.0
Nurses in all practice settings should assess clients for pain using a validated tool (such as the Numeric Rating Scale, the Verbal Analogue Scale, or the Verbal Rating Scale).
Level of Evidence IV
Dysphagia
Recommendation 6.0
Nurses should maintain all clients with stroke nothing by mouth (NPO) (including oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert.
Level of Evidence IIa
Recommendation 6.1
Nurses in all practice settings, who have appropriate training, should administer and interpret a dysphagia screen within 24 hours of the stroke client becoming awake and alert. This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. This screening should include:
- Assessment of the client's alertness and ability to participate
- Direct observation of signs of oropharyngeal swallowing difficulties (choking, coughing, wet voice)
- Assessment of tongue protrusion
- Assessment of pharyngeal sensation
- Administration of a 50 mL water test
- Assessment of voice quality
In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Nutrition
Recommendation 7.0
Nurses in all practice settings should complete a nutrition and hydration screen within 48 hours of admission, after a positive dysphagia screen and with changes in neurological or medical status, in order to prevent the complications of dehydration and malnutrition. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Cognition/Perception/Language
Recommendation 8.0
Nurses in all practice settings should screen clients for alterations in cognitive, perceptual, and language function that may impair safety, using validated tools (such as the Modified Mini-Mental Status Examination and the Line Bisection Test). This screening should be completed as follows: Within 48 hours of regaining consciousness:
- Arousal, alertness and orientation
- Language (comprehensive and expressive deficits)
- Visual neglect
In addition, when planning for discharge:
- Attention
- Memory (immediate and delayed recall)
- Abstraction
- Spatial orientation
- Apraxia
In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Activities of Daily Living
Recommendation 9.0
Nurses in all practice settings should assess stroke clients' ability to perform the activities of daily living (ADL). This assessment, using a validated tool (such as the Barthel Index or the Functional Independence Measure™), may be conducted collaboratively with other therapists, or independently when therapists are not available. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Bowel and Bladder Function
Recommendation 10.0
Nurses in all practice settings should assess clients for fecal incontinence and constipation.
Level of Evidence IV
Recommendation 10.1
Nurses in all practice settings should assess clients for urinary incontinence and retention (with or without overflow).
Level of Evidence IV
Depression
Recommendation 11.0
Nurses in all practice settings should screen clients for evidence of depression, using a validated tool (such as the Stroke Aphasia Depression Questionnaire, Geriatric Depression Scale, Hospital Anxiety and Depression Scale or the Cornell Scale for Depression in Dementia) prior to discharge throughout the continuum of care. In situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Recommendation 11.1
Nurses in all practice settings should screen stroke clients for suicidal ideation and intent when a high index of suspicion for depression is present, and seek urgent medical referral.
Level of Evidence IV
Caregiver Strain
Recommendation 12.0
Nurses in all practice settings should assess/screen caregiver burden, using a validated tool (such as the Caregiver Strain Index or the Self Related Burden Index). In situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence III
Sexuality
Recommendation 13.0
Nurses in all practice settings should screen stroke clients/their partners for sexual concerns to determine if further assessment and intervention is necessary. In situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management.
Level of Evidence IV
Client and Caregiver - Readiness to Learn
Recommendation 14.0
Nurses in all practice settings should assess the stroke client and their caregivers' learning needs, abilities, learning preferences and readiness to learn. This assessment should be ongoing as the client moves through the continuum of care and as education is provided.
Level of Evidence IV
Documentation
Recommendation 15.0
Nurses in all practice settings should document comprehensive information regarding assessment and/or screening of stroke clients. All data should be documented at the time of assessment and reassessment.
Level of Evidence IV
Education Recommendations
Recommendation 16.0
Basic education for entry to practice should include:
- Basic anatomy and physiology of the cerebrovascular system
- Pathophysiology of a stroke
- Risk factors of a stroke
- Signs and symptoms of a stroke
- Components of a client history and assessment specific to stroke
- Common investigations (tests)
- Validated screening/assessment tools.
Level of Evidence IV
Recommendation 16.1
Nurses working in areas with a focus on stroke should have enhanced stroke assessment skills.
Level of Evidence IV
Organization and Policy Recommendations
Recommendation 17.0
Organizations should develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Opportunities for reflection on personal and organizational experience in implementing guidelines. Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this regard, the Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the Heart and Stroke Foundation of Ontario-RNAO (HSFO-RNAO) best practice guideline Stroke Assessment Across the Continuum of Care.
Level of Evidence IV
Recommendation 18.0
Organizational policy should clearly support and promote the nurses' role in stroke assessment, either independently or in collaboration with other members of the interdisciplinary team.
Level of Evidence IV
Definitions:
Levels of Evidence
Ia: Evidence obtained from meta-analysis or systematic review of randomized controlled trials.
Ib: Evidence obtained from at least one randomized controlled trial.
IIa: Evidence obtained from at least one well-designed controlled study without randomization.
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.
IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
