The Role of the

Advanced Nurse Practitioner

in Stroke Care.
Imelda Noone,MSc,RGN,RM.
St. Vincents University Hospital,
Elm Park,
Dublin 4.
i.noone@st-vincents.ie

Introduction
Commission of Nursing (1998)
CNS /ANP (2001)
CNS 1,796
ANP 39 (2006)
6 CNS in Stroke Care (ROI)
New Post developed in relation to service

needs through intermediate pathway

St.Vincents University
Hospital
ECA

pop. 333,500
> 65 yrs 36,928
475 beds in SVUH
255 - 316 Strokes annually
< 65yrs - 11%
Stroke Team (Keating,D et al, IMJ,85,4,1992)

Stroke Team
Patients referred
seen within 24
25 Stroke Patients per week
Team meet weekly
Stroke Minimum data sheet
Goal Setting

Falls Risk Assessment Tool

Definition
The world health organization(WHO)
defines stroke as a sudden
neurological deficit which is vascular in
origin,with rapidly developed clinical
signs of focal or global disturbances of
cerebral function and persists for
more than 24 hours or leading to
death (1989)

O.C.S.P Classification of Stroke

Physical
Imp.

subtype

Aet.

Alive
Ind. %

Alive
Dep%

Risk
Recc.%

All 3 of:
Homonymous
Hemianopia
Weakness/2areas
face, arm, leg
New dist.of hcf

T.A.C.I.
Total
Anterior
Circulation
Infarct

Emb

36

2 of the above

P.A.C.I

Emb

55

29

17

either of:
Isolated H.H.
Unequivocal signs
brainstem

P.O.C.I

Thrombo

62

19

20

Any one of:

Puremotor/sensory

L.A.C.I

Thrombo

60

28

Common signs and symptoms

Carotid (ant)
Circulation
Unilateral Paralysis
Numbness
Language
disturbances
Visual disturbances
Monocular
Blindness

Vertebrobasillar (pos)
Circulation
Vertigo
Visual disturbances
Diplopia
Paralysis
Dysarthria
Ataxia

Members of the MDT

ANP (1)
Clinical Nurse
Specialist in Stroke
Care (1)
Registrar (1)
Physiotherapist (1.5)
Occupational
Therapist (1.5)
Speech and language
therapist (2)

Geriatrician with an
interest in Stroke
Consultant
Physician in
Rehabilitation
Psychiatrist
Dietician (0.5)
Social Worker(0.5)

Stroke Unit
9 bedded Unit in a 28 bedded care of the
elderly ward.
Admissions through A & E
Other wards
Acute Stroke Guidelines
Participate in the regular review of all stroke
patients

Purpose of Post
Improve quality, effectiveness and
efficiency
Rapid assessment
Specialist stroke nursing services
Interdisciplinary support and education

Core Concepts of :
CNS
(Post reg. education
relevant to specialist
practice)
Clinical Focus
Patient Advocate
Education and Training
Audit and Research
Consultant

ANP
(Masters Degree)
Autonomy in Clinical
Practice
Pioneering Professional
and Clinical Leadership
Expert Practitioners
Researcher

Autonomy in Clinical
Practice
Accept accountability/ responsibility for
clinical decision making at advanced
practice level.
Conduct comprehensive health
assessment, plans / initiates care and tx.
Uses professional judgement to refer pts

Reflected within:
Protocols for practice and policies for
intervention for each identified service need
1.

Protocol for the monitoring of

physiological parameters of stroke
patients within 72 hours of the event.

2.

Anti-platelet use in acute stroke.

3.

Protocol for the supply and

administration of identified medications

Acute management of stroke

Oxygen (Williams,1998)
Antipyretics (Bhalla,2001)
IV access & fluid replacement
Correction of electrolytes
Tight glucose control (www.gist-uk.org)
Protection of airway (Nil p.o if swallow unsafe)
Graduated support stockings (TEDS)
Catheter - avoid
NG (not for 1st 24 hours)
IV antibiotics if indicated
Hold anti platelet agent until after CT Scan

GUIDELINES
1. Practice of providing a comprehensive
2.
3.
4.
5.
6.

adult Health History.

Practice of undertaking a review of systems
and physical examination of the patient.
Requesting of diagnostic imaging by ANP
in Stroke Care.
Requesting of diagnostic blood assays by
the ANP in Stroke Care.
The management of constipation.
Management for Secondary Prevention of
Stroke.

Clinical Examination

Phase 1
History Taking
(Information Gathering)
Phase 2 Examination Physical & Mental
(Objective Findings)
Phase 3 Explanation
(Information
giving,
decision
making)
(Munro & Campbell 2000)

Comprehensive History
Date and time of history
Identifying Data age, gender, marital
status, occupation
Past Medical History
Current Medications & Known Drug /
Food Allergies
Current Health Status smoking, alcohol,
drugs, exercise, and immunizations.
Family History

Review of Systems
1.
2.
3.
4.
5.
6.
7.
8.
9.

General
Skin
Head
Eyes / Ears
Nose / Mouth / Throat
Neck
Breasts
Respiratory
Cardiac

1.
2.
3.
4.
5.
6.
7.
8.
9.

Gastrointestinal
Urinary
Genital
Peripheral Vascular
Musculoskeletal
Neurologic
Haematologic
Endocrine
Psychiatric

Professional and clinical

leadership
Articulates/ communicates a vision of areas of
nursing practice that can be developed beyond the
current scope of nursing practice
Contributes to professional and health policy at
local, regional, national level
Contributes to service planning
Demonstrates mentorship, preceptorship, teaching,
facilitation, professional supervisory skills
Identifies need and leads development of clinical
standards

Expert practitioner
Demonstrates advanced clinicaldecision making skills to manage a pt
workload
Identifies health promotion priorities
Implements health promotion strategies
for patients

Nurse - led stroke follow-up

clinic

Secondary Prevention
(B/P, weight, diet, information re-smoking etc)
Physical/ medical status
(medications, complications, pressure areas,
continence, falls, etc)
Functional Ability (Barthel, O.H.S,MMSE)

Social/environmental issues
( equipment, benefits, support)
Mood (HADS)
Carer/family issues (CSI)

Research
Identifies research priorities for the area of practice
Leads, conducts, disseminates and publishes
nursing research which shapes and advances
nursing practice educ.and policy
Identifies, critically analyses, disseminates nursing
and other evidence into the area of CP
Uses the outcome of audit to improve service
provision
Contributes to service planning and budgetary
processes through use of audit data and specialist
knowledge

Research projects
1. Screening for Visual Impairment in Elderly Rehab

Patients
2. The implementation of a falls risk assessment tool
3. THE Use of Cotsides in an Irish Hospital
4. The outcome of Stroke in the very old.
5. F.U of stroke survivors in ENC
6. Factors associated with delay in acute stroke
management
CLOTS

FALLS RISK ASSESSMENT TOOL

1.
2.
3.
4.
5.

circle the relevant answer and give total

score below
YES
=
1
NO
=
0
Was the patient adm. with a fall or
have they fallen since adm?
Is the patient agitated?
Is everyday function affected by
visual impairment?
Is frequent toileting required?
Is help/ supervision needed to
transfer or walk?

TOTAL SCORE..
If 2 or more the patient is at risk of falling.

YES = 1 NO = 0
YES = 1 NO = 0
YES = 1 NO = 0
YES = 1 NO = 0
Signature.
Date

FALLS REDUCTION
(n = 400)
80
70
60
50
40
30

No. of
falls

20
10
0

2003

2004

2005

Assessment
for Cotsides

Factors Associated with Delays in Acute

Stroke Management.
100 patients
51% female, mean age 76yrs
(95%, CI, 74 to 78)
Mean time from onset of symptoms to
arrival in A&E =10hrs
A&E to CT = 12 hrs
CT to APT = 15 hrs

N e u r o v a s c u la r C lin ic
W e e k ly in O P D
G . P 'S

R e f e r ra ls f r o m
A /E

O t h e r C o n s u lt a n t s

P a t ie n t s
c o n ta c te d
T e s ts o r d e r e d
C o lle c t s
r e s u lts

H e a lth
P r o m o t io n

S e c o n d a ry
p r e v e n t io n
T I A B o o k le t

Comparison of outcomes data

(1997 & 2006)

1997
n = 183 (50 weeks)
Mean age 72
<65 yrs 22%
CT 94.5%
Mean L.O.S 35 days
Mortality 25.7%
Discharge destination:
Institutional care 16.9%
rehabilitation 11.5%
Community 41.5%

2006
n = 240 (50 weeks)
Mean age 75.5
< 65yrs 11%
CT Brain 100%
Mean L.O.S. 28 days
Mortality 14%
Discharge destination:
Institutional care 5.4%
rehabilitation 13.3%
Community 62%

Future Plans
20 bedded Stroke Rehabilitation
Unit
Post- Registration Education
Nurse led clinic
F.U ENC patients

% of aspects of hospital
costs on stroke care

Overheads
14%

Other
5%

Nursing
81%

Doctoring

19%

Therapy

31%

Drugs

10%

Investigations

40%

Conclusion
Significant developments in the specialist role
The role of the nurse has been key in leading
the care pathway
The flexibility of the specialist role has
ensured that stroke patients and carers are
assessed promptly and transferred to the
most appropriate rehabilitation setting

St.Vincents University Hospital 2006

Thank you