NUR 3480 Module 2 Stroke Paper: Time to Treatment, Fever, Sugar and Swallowing Example

Fever, Sugar, Swallowing: Nurse-Led Care After Stroke on a Newark Stroke Unit

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3480: Nursing Care of Clients with Acute and Chronic Conditions

Mentor Name

Month Day, Year

Fever, Sugar, Swallowing: Nurse-Led Care After Stroke on a Newark Stroke Unit

The Patient

The patient and the unit are invented. Mr. Washington, 69, a retired postal worker with high blood pressure and atrial fibrillation who had stopped his anticoagulant, woke with right-sided weakness and slurred speech and was brought in by ambulance within ninety minutes of when he was last known well. A CT scan showed no bleeding, and he received intravenous alteplase in the emergency department. On his first day on the stroke unit, the BSN student cared for him alongside an experienced stroke nurse.

Why Time Mattered

In the landmark NINDS trial (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995), investigators randomly assigned patients with acute ischemic stroke to intravenous tissue plasminogen activator or placebo within three hours of symptom onset. At three months, patients given the drug were at least 30 percent likelier to end up with little or no disability. Symptomatic brain hemorrhage was more common with treatment, about 6 percent compared with under 1 percent, but deaths were not increased overall. The trial established thrombolysis as standard care and made rapid recognition and transport essential.

After alteplase, nursing care focuses on frequent neurological and blood pressure checks, because bleeding is the main risk, and blood pressure must be kept below the limits set for patients who receive the drug.

Nurse-Led Protocols

Middleton et al. (2011) randomized whole stroke units in Australia, rather than individual patients, to two approaches. Units in the intervention group trained nurses to use protocols for managing fever, high blood sugar and swallowing in the first seventy-two hours after admission, supported by multidisciplinary workshops and site champions. At ninety days, patients in intervention units were less likely to be dead or dependent than those in control units, an absolute difference of about 16 percentage points. The protocols themselves were simple: treat temperature above 37.5 degrees Celsius with acetaminophen, treat glucose above 10 mmol/L, about 180 mg/dL, with insulin, and screen swallowing before any food, fluid or oral medicine.

Swallowing Screening

Hinchey et al. (2005) compared hospitals that used a formal dysphagia screening protocol with those that did not. Hospitals with formal screening had higher rates of screening and lower rates of pneumonia after stroke. The authors argued that a structured screen before oral intake should be standard.

Nursing Diagnoses

The student identified risk for ineffective cerebral tissue perfusion related to bleeding after thrombolysis, impaired swallowing, impaired physical mobility and impaired verbal communication.

Implementation

Neurological checks and blood pressure readings followed the post-alteplase schedule, every fifteen minutes at first and then less often. The student learned to use the NIH Stroke Scale items the unit tracked and to report any decline at once. Before Mr. Washington had anything by mouth, including his morning medicines, the nurse performed the unit's bedside swallow screen; he coughed on water, so he stayed nil by mouth and the speech-language pathologist was consulted. His glucose was 212 mg/dL on admission, and the nurse gave insulin as ordered under the protocol. On the second day his temperature rose to 37.8 Celsius; acetaminophen was given and the cause investigated.

Communication and Family

Mr. Washington's speech was slurred and he became frustrated. The student used short questions, gave him time to answer and used a picture board. His daughter learned how to help him communicate and was taught the signs of a new stroke.

Preventing Other Complications

Stroke patients face risks beyond the brain. The student checked that compression devices were on Mr. Washington's legs to prevent clots, since he could not walk, and repositioned him every two hours to protect his skin. She positioned his weak arm on a pillow to protect his shoulder and kept the call bell on his unaffected side. Because he could not swallow safely, she provided mouth care with a swab every four hours, which lowers the bacteria that cause aspiration pneumonia. She also watched his bladder; he had trouble starting urine, and a bladder scan showed retention, so the nurse used intermittent catheterization as ordered rather than leaving a catheter in place.

Restarting the Anticoagulant

Mr. Washington's stroke likely came from atrial fibrillation after he stopped his anticoagulant. The neurologist planned to restart it after several days, once the risk of bleeding into the stroke had lessened. The student learned why the timing matters and explained to his daughter why the medicine could not simply restart on day one.

Evaluation

By day three, Mr. Washington's weakness had improved, his blood pressure stayed within target, he passed a formal swallowing evaluation for soft foods and he had no fever, high glucose or pneumonia. He was referred to inpatient rehabilitation.

What the Student Learned

The student had expected stroke care to be about the dramatic first hour of treatment. The QASC trial showed her that the quieter work of the next three days, checking temperature, treating high glucose and screening swallowing before every pill, changes how many patients recover. She now treats these protocols as treatment, not paperwork.

Teaching Before Discharge

Before he left for rehabilitation, the student taught Mr. Washington and his daughter the BE FAST signs of stroke and why calling 911 at once matters, and explained the importance of taking his anticoagulant every day once it restarts.

Limits

The QASC trial took place in Australia, and protocols may work differently elsewhere. Thrombolysis criteria have changed since 1995, with a longer time window for some patients. A single patient cannot show the effect of the protocols.

Conclusion

Mr. Washington's recovery depended on fast treatment and careful nursing in the first days. The NINDS trial showed why time matters, the QASC trial showed that nurse-led protocols for fever, sugar and swallowing reduce death and dependency and dysphagia screening reduces pneumonia. Following all three, with communication support, gave him the best chance of recovery.

References

Hinchey, J. A., Shephard, T., Furie, K., Smith, D., Wang, D., & Tonn, S. (2005). Formal dysphagia screening protocols prevent pneumonia. Stroke, 36(9), 1972-1976. https://doi.org/10.1161/01.STR.0000177529.86868.8d

Middleton, S., McElduff, P., Ward, J., Grimshaw, J. M., Dale, S., D'Este, C., Drury, P., Griffiths, R., Cheung, N. W., Quinn, C., Evans, M., Cadilhac, D., & Levi, C. (2011). Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): A cluster randomised controlled trial. The Lancet, 378(9804), 1699-1706. https://doi.org/10.1016/S0140-6736(11)61485-2

National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. (1995). Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 333(24), 1581-1588. https://doi.org/10.1056/NEJM199512143332401