This is the current release of the guideline.

Stroke

Patients who have experienced or have risk factors for stroke

June 2005 Guideline

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.

2011 Supplement

One individual searched an established list of websites for guidelines and other relevant content. The list was compiled based on existing knowledge of evidence-based practice websites and recommendations from the literature. Members of the panel critically appraised 19 national and international guidelines, published since January 2004, using the "Appraisal of Guidelines for Research & Evaluation II" instrument. From this quality appraisal, 13 guidelines were identified to inform the review processes.

Concurrent with the review of existing guidelines, a search for recent literature relevant to the scope of the guideline was conducted with guidance from the Panel Leader. A search of electronic databases, (Medline, CINAHL and EMBASE) was conducted by a health sciences librarian. A Research Assistant (Masters prepared nurse) completed the inclusion/exclusion review, quality appraisal and data extraction of the retrieved studies, and prepared a summary of the literature findings. The comprehensive data tables and reference list were provided to all panel members.

A summary of the review process is provided in the Review/Revision Process Flow Chart in the original guideline supplement document.

June 2005 Guideline

Not stated

2011 Supplement

Thirteen guidelines and 696 studies were included and retrieved for review.

Level 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

Not stated

June 2005 Guideline

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 in 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.

2011 Supplement

The Registered Nurses' Association of Ontario has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline.

A panel of nurses was assembled for this review, comprised of members from the original development panel as well as other recommended individuals with particular expertise in this practice area. A structured evidence review based on the scope of the original guideline and supported by three clinical questions was conducted to capture the relevant literature and guidelines published since the publication of the original guideline in 2005.

Initial findings regarding the impact of the current evidence, based on the original recommendations, were summarized and circulated to the review panel. The revision panel members were given a mandate to review the original guideline in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations as published in 2005.

Not applicable

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

This 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 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.

Note from the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO): In December 2010, the panel was convened to achieve consensus on the need to revise the existing set of recommendations. A review of the most recent literature and relevant guidelines published since January 2004 does not support dramatic changes to the recommendations, but rather suggests some refinements and stronger evidence for the approach.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence."

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 sudden and 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 using a validated tool (such as the Canadian Neurological Scale, National Institutes of Health Stroke Scale or Glasgow Coma Scale) and continue to monitor the client's neurological status on an ongoing basis for any changes in:

• 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)

Cognition/Perception/Language

Recommendation 3.1

Nurses in all practice settings should screen clients within 48 hours of the stroke client becoming awake and alert, using validated tools (such as Montreal Cognitive Assessment [MoCA©], Modified Mini-Mental Status Examination, Line Bisection Test or Frenchay Aphasia Screening Test) for alterations in cognitive, perceptual and language function including:

• Abstraction
• Arousal, alertness and orientation
• Attention
• Apraxia
• Language (comprehensive and expressive deficits)
• Memory (immediate and delayed recall)
• Spatial orientation, Unilateral Spatial Neglect (formally Extinction) & Visual Neglect

In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

(Level of Evidence = IV)

Neurological Assessment

Recommendation 3.2

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 (where feasible using a validated tool) the client's risk for and/or presence of any of the following complications of stroke:

• Fall risk:
  • Fractures secondary to falls
  • Bone loss secondary to immobility
• Fatigue
• Painful hemiparetic shoulder
• Pneumonia secondary to immobility and dysphagia
• Pressure ulcers (e.g., Braden Scale for Predicting Pressure Sore Risk)
• Spasticity/contractures
• Urinary tract infection (UTI)
• Venous thromboembolism

(Level of Evidence = IV)

Advanced Care Planning

Recommendation 4.1

Nurses in collaboration with the interprofessional team will assess and support clients (family/substitute decision maker [SDM]) to make informed decisions that are consistent with their beliefs, values and preferences to ensure client wishes are known and incorporated into the plan of care (includes advanced, palliative and end of life care planning).

(Level of Evidence = IV)

Pain

Recommendation 5.0

Nurses in all practice settings should assess and monitor on an ongoing basis the client's pain severity, quality, and impact on function using a validated tool (such as Wong-Baker Faces Pain Rating Scale [WBFPRS], 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 screen within 24 hours of the client becoming awake and alert for risk of dysphagia using a standardized tool (such as Gugging Swallowing Screen, Standardized Bedside Swallowing Assessment [SSA] or Toronto Bedside Swallowing Screening Test [TOR-BSST©]). This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. In situations where impairments are identified, clients should be kept NPO and referred to a trained healthcare professional for further assessment and management.

(Level of Evidence = IIa)

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)

Activities of Daily Living

Recommendation 8.0

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, Functional Independence Measure™ or Alpha FIM®) may be conducted collaboratively with other therapists, or independently with training 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

Recommendation 9.0

Nurses in all practice settings should assess clients for fecal incontinence and constipation.

(Level of Evidence = IV)

Recommendation 9.1

Nurses in all practice settings should assess clients for urinary incontinence and retention (with or without overflow).

(Level of Evidence = IV)

Depression

Recommendation 10.0

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) 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 10.1

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 11.0

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 12.0

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 13.0

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 14.0

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 15.0

Basic education for entry to practice should include:

• Basic anatomy and physiology of the cerebrovascular system
• Types of stroke and associated pathophysiology
• Risk factors of a stroke
• Warning signs, symptoms and common presentations of stroke syndromes
• Components of a client history and assessment specific to stroke
• Common investigations (tests)
• Validated screening/assessment tools

(Level of Evidence = IV)

Recommendation 15.1

Nurses working in areas with a focus on stroke should have enhanced stroke assessment skills.

(Level of Evidence = IV)

Organization and Policy Recommendations

Recommendation 16.0

Organizations should develop a plan for implementation that includes:

• An assessment of organizational readiness to change 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 (HFSO)-RNAO best practice guideline Stroke Assessment Across the Continuum of Care.

(Level of Evidence = IV)

Recommendation 17.0

Organizational policy should clearly support and promote the nurses' role in stroke assessment, either independently or in collaboration with other members of the interprofessional team.

(Level of Evidence = IV)

Definitions:

Level 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

None provided

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

Appropriate assessment of stroke patients across the continuum of care

Not stated

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. The Registered Nurses' Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators, has developed a 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 guideline implementation. Specifically, the Toolkit addresses the following key steps:

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 an evaluation
6. Identifying and securing required resources for implementation and evaluation

Implementing practice guidelines 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

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 in the original guideline, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines, illustrates selected indicators for monitoring and evaluation of the implementation of the guideline Stroke Assessment Across the Continuum of Care.

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. A summary of these strategies follows:

• Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
• Conduct an organizational needs assessment related to stroke assessment in order to identify current knowledge base and further educational requirements. Initial needs assessment may include an analysis approach, survey and questionnaire, group format approaches (e.g., focus groups), and critical incidents.
• Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to lead the change initiative. Identify short term and long term goals. Keep a work plan to track activities, responsibilities and timelines.
• Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.
• Program design should include:
  • Target population
  • Goals and objectives
  • Outcome measures
  • Required resources (human resources, facilities, equipment)
  • Evaluation activities
• Design educational sessions and ongoing support for implementation. The education sessions may consist of presentations, facilitator's guide, handouts, case studies, etc.. Binders, posters and pocket cards may be used as ongoing reminders of the training. Plan education sessions that are interactive, include problem solving, address issues of immediate concern and offer opportunities to practice new skills.
• Provide organizational support such as having the structures in place to facilitate the implementation. For example, hiring replacement staff so participants will not be distracted by concerns about work and having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new assessment and documentation tools.
• Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done.
• Organizations implementing this guideline should adopt a range of self-learning, group learning, mentorship and reinforcement strategies that will, over time, build the knowledge and confidence of nurses in implementing this guideline.
• Beyond skilled nurses, the infrastructure required to implement this guideline may include access to specialized equipment and assessment resources. Orientation of the staff to the use of specific products and tools must be provided and regular refresher training planned.
• Teamwork, collaborative assessment and treatment planning with the client and family and interdisciplinary team are beneficial in implementing guidelines successfully. Referral should be made as necessary to services or resources in the community or within the organization.

In addition to the strategies mentioned above, the RNAO has developed resources that are available on the website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description about this Toolkit can be found in Appendix L of the original guideline document. A full version of the document in pdf format is also available at the RNAO website, www.rnao.org/bestpractices .

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

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

Guideline Development Panel

Revision Panel Members

Linda Kelloway, RN, MN, CNN(C)
Revision Panel Leader
Best Practices Leader, Ontario Stroke Network
Toronto, Ontario

Anna Kras-Dupuis, RN, MScN, CNN(C), CRN(C)
Clinical Nurse Specialist, Rehabilitation Program
St. Joseph's Health Care
Parkwood Hospital, London, Ontario

Charmaine Martin-Gaspar, RN(EC), MSc(T), BScN
Nurse Practitioner (Adult), Neurosurgery/Neuroendovascular, Neuroscience Ambulatory Clinic
Hamilton Health Science, General Site
Hamilton, Ontario

Rhonda Whiteman, RN, BScN, MN, CNN(C)
Stroke Best Practice Guidelines Clinical
Nurse Specialist, 7 South
Hamilton Health Sciences, General Site
Hamilton, Ontario

Breeda O'Farrell, RN(EC), MScN, CNN(C)
Nurse Practitioner, Neurology
London Health Sciences Centre, University Campus
London, Ontario

Laura MacIsaac, RN, MSc, CNN(C)
Clinical Nurse Specialist, District Stroke Centre
York Central Hospital, Richmond Hill, Ontario

Lisa Valentine-Lallion, RN, BScN, MN, CMSN(c)
Clinical Nurse Specialist/Case Manager
North & East GTA Stroke Network
Sunnybrook Health Sciences Center
Toronto, Ontario

Janet Liefso, RN, BScN, ENC(C)
Acute Stroke Coordinator, SWO Stroke Network
University Hospital, London, Ontario

Linda Gould, RPN
Stroke and Data Evaluation Specialist
Central South Regional Stroke System
Hamilton Health Sciences, Hamilton, Ontario

Elaine Edwards, RN, HBScN
Regional Stroke Educator
Northwestern Ontario Regional Stroke Network
Thunder Bay Regional Health Sciences Centre
Thunder Bay, Ontario

Gail Williams, RN, GNC(C)
Assistant Director of Care
Fairmount Home, Glenburnie, Ontario

Barbara Knapton, RN, CRN(C)
Program Educator, Physical Medicine and Rehabilitation
Providence Care-St. Mary's of the Lake
Kingston, Ontario

Brenda Kwiatkowski, RN, BScN, CCRP
Clinical Coordinator
Stroke Prevention Clinic, Saskatoon, Saskatchewan

Brenda Dusek, RN, BN, MN
Program Manager
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Andrea Stubbs
Administrative Assistant
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Not stated

This is the current release of the guideline.

Electronic copies: Available in English, Italian, and French in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site .

Print copies: Available from the Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

The following are available:

• Summary of recommendations. Stroke assessment across the continuum of care. Toronto (ON): Heart and Stroke Foundation of Ontario, Registered Nurses Association of Ontario (RNAO); 2011. 5 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses Association of Ontario (RNAO) Web site .
• Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Mar. 88 p. Electronic copies: Available in PDF from the RNAO Web site . See the related QualityTool summary on the Health Care Innovations Exchange Web site .
• Sustainability of best practice guideline implementation. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2006. 24 p. Electronic copies: Available in PDF and as a Power Point presentation from the RNAO Web site .
• Educator's resource: integration of best practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2005 Jun. 123 p. Electronic copies: Available in PDF from the RNAO Web site .

A variety of assessment tools and scales are available in the appendices to the original guideline document . A table in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines, illustrates some suggested indicators for monitoring and evaluation.

Print copies: Available from the Registered Nurses Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Mobile versions of RNAO guidelines are available from the RNAO Web site . A French version  of this mobile guideline is also available.

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. This NGC summary was updated by ECRI Institute on February 6, 2012. The updated information was verified by the guideline developer on February 14, 2012.

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 (2011). Stroke Assessment Across the Continuum of Care. Toronto, Canada: Heart and Stroke Foundation of Ontario, Registered Nurses Association of Ontario.