• Heart and Stroke Foundation of Ontario (HSFO), Registered Nurses Association of Ontario (RNAO). Stroke assessment: across the continuum of care. Toronto (ON): Heart and Stroke Foundation of Ontario (HSFO), Registered Nurses Association of Ontario (RNAO); 2005 Jun. 120 p. [206 references]

This is the current release of the guideline.

Stroke

Note: For the purpose of this guideline, types of stroke include transient ischemic attacks (TIAs), ischemic and hemorrhagic stroke.

Evaluation
Screening

Neurology
Nursing
Physical Medicine and Rehabilitation

Advanced Practice Nurses
Nurses

To provide nurses with evidence-based recommendations regarding the assessment and/or screening of stroke survivors across the continuum of care

Adults (over age 18) who have experienced a stroke

Note: Children have unique assessment needs related to developmental stages that are beyond the scope of this guideline.

Stroke Assessment

1. Risk factor screening/referral
2. Recognition of new onset of signs and symptoms of stroke
3. Neurological assessment upon admission or change in client status, including:
   • Level of consciousness
   • Orientation
   • Motor ability
   • Pupils
   • Speech/language
   • Vital signs
   • Blood glucose
4. Risk assessment for complications including fall, pressure ulcer, painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis
5. Pain assessment
6. Administration and interpretation of dysphagia screen
7. Nutrition and hydration screening
8. Screening for alterations in cognition, perception, and language using validated tools
9. Assessment of activities of daily living (ADL) using validated tools
10. Assessment of bowel and bladder function
11. Depression screening using a validated tool
12. Assessment/screening of caregiver burden using a validated tool
13. Screening of stroke clients and their partners for sexual concerns
14. Assessment of stroke client and their caregivers' learning needs, abilities, learning preferences and readiness to learn
15. Referral for further assessment and management, as indicated
16. Documentation of all assessments and screenings

• Predictive value and sensitivity/specificity of tests for stroke and stroke complications
• Risk for and incidence of stroke and stroke complications

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

A database search for existing stroke assessment guidelines was conducted by a university health sciences library. An initial search of the MEDLINE, Embase, and CINAHL databases for guidelines and studies published from 1995 to 2003 was conducted using the following search terms: "stroke assessment," "CVA assessment," "cerebral vascular accident assessment," "symptoms of stroke," "clinical assessment," "neurological assessment," "neurological stroke assessment," "nursing assessment," "continuum of care - telehealth, acute, rehabilitation, community care, long-term care, home care," "practice guideline(s)," "clinical practice guideline(s)," "standards," "consensus statement(s)," "consensus," "evidence-based guidelines," and "best practice guidelines."

One individual searched an established list of Web sites for content related to the topic area in April 2003. This list of sites, reviewed and updated in October 2002, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another Web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

A Web site search for existing practice guidelines on stroke assessment was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the results of the search term results, the Web sites reviewed, date, and a summary of the results. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were asked to review personal archives to identify guidelines not previously found through the above search strategy. Results of this strategy revealed no additional clinical practice guidelines.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Systematic Review

Not stated

Expert Consensus

In September of 2003, a panel of nurses with expertise in stroke care from a range of practice settings across the continuum of stroke care was convened under the auspices of the Heart and Stroke Foundation of Ontario (HSFO) and the Registered Nurses Association of Ontario (RNAO).

The panel members established the scope of the guideline by reviewing which components of stroke assessment were consistent across the continuum and where there were unique assessment requirements. Existing evidence and tools related to assessment/screening were identified and obtained through a structured literature search (See Appendix A of the original guideline document).

The panel members divided into subgroups to review existing practice guidelines for stroke management, primary studies, other literature, and documents for the purpose of drafting recommendations for nursing assessment/screening. This process yielded a draft set of recommendations. The panel members reviewed the first draft of recommendations, discussed gaps, documented the supporting evidence, and came to consensus on a final draft set of recommendations.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

A draft was submitted to a set of external stakeholders for review and feedback - an acknowledgement of these reviewers is provided at the front of the original guideline document. Stakeholders represented various healthcare professional groups, clients, and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel; discussion and consensus resulted in revisions to the draft document.

Subsequent to the stakeholder review phase, members of the guideline development panel met with representatives of the Stroke Canada Optimization of Rehabilitation by Evidence (SCORE) Project to ensure congruence between the work of both projects. The panel team leader and a staff member from the Registered Nurses Association of Ontario (RNAO) also met with a representative of the Canadian Stroke Quality of Care Study to discuss linkages with both projects. Following these stakeholder meetings, additional revisions were made to the guideline prior to publication and evaluation.

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.

An algorithm is provided in the original guideline document for cognitive screening in stroke clients.

The type of evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Appropriate evaluation of stroke clients

Not stated

• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability or discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Heart and Stroke Foundation of Ontario nor the Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• It is acknowledged that the individual competencies of nurses vary between nurses and across categories of nursing professionals and are based on knowledge, skills, attitudes, critical analysis and decision making which are enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of stroke assessment/screening for which they have appropriate education and experience and that they will seek consultation in instances where the client's care needs surpass the nurse's ability to act independently.
• As a result of limited available research in the area of nursing assessment of stroke clients, the level of evidence for the majority of the recommendations in this document has been rated as Level IV (consensus). However, with the intent to strengthen the recommendations, the suggested tools have been selected, where possible, based on their validated psychometric properties and relevance to the stroke population. Further research is needed regarding nursing assessment of stroke.

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. 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 any clinical practice guideline in a healthcare organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring of Guideline

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines, illustrates selected indicators for monitoring and evaluation.

Implementation Strategies

The Heart and Stroke Foundation of Ontario, the Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline. See the original guideline document for a summary of these strategies.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Heart and Stroke Foundation of Ontario (HSFO), Registered Nurses Association of Ontario (RNAO). Stroke assessment: across the continuum of care. Toronto (ON): Heart and Stroke Foundation of Ontario (HSFO), Registered Nurses Association of Ontario (RNAO); 2005 Jun. 120 p. [206 references]

Not applicable: The guideline was not adapted from another source.

2005 Jun

Heart and Stroke Foundation of Ontario - Medical Specialty Society
Registered Nurses Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Stroke Assessment Across the Continuum of Care Development Panel

Panel Members:

Linda Kelloway, RN, BScN, CNN(c)
Team Leader
Regional Stroke Education Consultant
West GTA Stroke Network
Etobicoke, Ontario

Anna Bluvol, RN, MScN
Nurse Clinician, Stroke Rehabilitation
St. Joseph's Health Care
Parkwood Site
London, Ontario

Paula Christie, RN, MSN, ENC(c)
Clinical Nurse Specialist
Regional Stroke Advanced Practice Nurse
Kingston General Hospital
Kingston, Ontario

Charmaine Martin-Gaspar, RN, BScN,MSc(T),ACNP
Clinical Nurse Specialist/Acute Care Nurse Practitioner, Stroke
Hamilton Health Sciences Centre
Hamilton General Site
Hamilton, Ontario

Grace Gutierrez, RN, BScN
Stroke Nurse Clinician/Researcher
Toronto West Regional Stroke Centre
University Health Network
Toronto, Ontario

Debbie Holtom, RN, BNSc, MEd, ACNP, CNN(c)
Clinical Nurse Specialist/Nurse Practitioner
Kingston General Hospital
Kingston, Ontario

Heather McConnell, RN, BScN, MA(Ed)
Facilitator -- Program Manager
Nursing Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Marie McGilvery, RN
Staff Nurse
Trillium Health Centre
Mississauga, Ontario

Rhonda McNicoll, RN, BScN, CNN(c)
Education and Development Clinician
Hamilton Health Sciences Centre
Hamilton General Site
Hamilton, Ontario

Breeda O'Farrell, RN, MScN, ACNP, CNN(c)
Nurse Practitioner/Clinical Nurse Specialist
London Health Sciences Centre
University Campus
London, Ontario

Beverley Powell-Vinden, RN, BNSc, MEd
Senior Specialist -- Professional Education
Coordinated Stroke Strategy
Heart and Stroke Foundation of Ontario
Toronto, Ontario

Tracy Saarinen, RN, BScN
Regional Stroke Nurse
Thunder Bay Regional Health Sciences Centre
Thunder Bay, Ontario

Sandra Taylor, RN, BScN, MScN, ACNP
Nurse Practitioner/Clinical Nurse Specialist
Regional Stroke Program
London Health Sciences Centre
University Campus
London, Ontario

Shelley Yantha, RN, BScN
Program Manager
University Health Network
Toronto Western Hospital
Toronto, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses Association of Ontario.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on July 29, 2005. The information was verified by the guideline developer on August 8, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Heart and Stroke Foundation of Ontario and Registered Nurses Association of Ontario (2005). Stroke assessment across the continuum of care. Toronto, Canada: Heart and Stroke Foundation of Ontario, Registered Nurses Association of Ontario.