Fever management practices of neuroscience nurses: what has changed?

Current evidence shows that fever and hyperthermia are especially detrimental to patients with neurologic injury, leading to higher rates of mortality, greater disability, and longer lengths of stay. Although clinical practice guidelines exist for ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury, they lack specificity in their recommendations for fever management, making it difficult to formulate appropriate protocols for care. Using survey methods, the aims of this study were to (a) describe how nursing practices for fever management in this population have changed over the last several years, (b) assess if institutional protocols and nursing judgment follow published national guidelines for fever management in neuroscience patients, and (c) explore whether nurse or institutional characteristics influence decision making. Compared with the previous survey administered in 2007, there was a small increase (8%) in respondents reporting having an institutional fever protocol specific to neurologic patients. Temperatures to initiate treatment either based on protocols or nurse determination did not change from the previous survey. However, nurses with specialty certification and/or working in settings with institutional awards (e.g., Magnet status or Stroke Center Designation) initiated therapy at a lower temperature. Oral acetaminophen continues to be the primary choice for fever management, followed by ice packs and fans. This study encourages the development of a stepwise approach to neuro-specific protocols for fever management. Furthermore, it shows the continuing need to promote further education and specialty training among nurses and encourage collaboration with physicians to establish best practices.

Predictors of poor hospital discharge outcome in acute stroke due to atrial fibrillation.

Atrial fibrillation (AF) is a frequent cause of acute ischemic stroke that results in severe neurological disability and death despite treatment with intravenous thrombolysis (intravenous recombinant tissue plasminogen activator [rtPA]). We performed a retrospective review of a single-center registry of patients treated with intravenous rtPA for stroke. The purposes of this study were to compare intravenous rtPA treated patients with stroke with and without AF to examine independent predictors of poor hospital discharge outcome (in-hospital death or hospital discharge to a skilled nursing facility, long-term acute care facility, or hospice care). A univariate analysis was performed on 144 patients receiving intravenous rtPA for stroke secondary to AF and 190 patients without AF. Characteristics that were significantly different between the two groups were age, initial National Institutes of Health Stroke Scale score, length of hospital stay, gender, hypertension, hyperlipidemia, smoking status, presence of large cerebral infarct, and hospital discharge outcome. Bivariate logistic regression analysis indicated that patients with stroke secondary to AF with a poor hospital discharge outcome had a greater likelihood of older age, higher initial National Institutes of Health Stroke Scale scores, longer length of hospital stay, intubation, and presence of large cerebral infarct compared with those with good hospital discharge outcome (discharged to home or inpatient rehabilitation or signed oneself out against medical advice). A multivariate logistic regression analysis showed that older age, longer length of hospital stay, and presence of large cerebral infarct were independent predictors of poor hospital discharge outcome. These predictors can guide nursing interventions, aid the multidisciplinary treating team with treatment decisions, and suggest future directions for research.

Women's interpretation of and cognitive and behavioral responses to the symptoms of acute ischemic stroke.

Delay seeking medical assistance for acute ischemic stroke remains a barrier to the provision of optimal care, including the administration of tissue plasminogen activator. Although women report greater knowledge of stroke symptoms and stroke risk factors than men, earlier hospital arrival in women has not been consistently reported. The purposes of this study were to examine women's interpretation of stroke symptoms and compare cognitive and behavioral responses between women who arrived at the hospital within 3 hours of symptom onset and women who arrived after 3 hours. More than half of the participants arrived at the hospital greater than 3 hours after first noticing symptoms. Most women did not recognize the cause of symptoms. Knowledge about a treatment of stroke was limited, and a minority of the women knew they were at risk for stroke despite having known risk factors. Maladaptive responses to symptoms were reported more frequently by women with hospital arrival greater than 3 hours after symptom onset than by women with earlier arrival. Efforts are needed to reduce maladaptive responses to stroke onset that may contribute to delay seeking medical assistance for the symptoms of acute ischemic stroke.

Development and initial testing of the stroke rapid-treatment readiness tool.

No instruments are currently available to help health systems identify target areas for reducing door-to-needle times for the administration of intravenous tissue plasminogen activator to eligible patients with ischemic stroke. A 67-item Likert-scale survey was administered by telephone to stroke personnel at 252 U.S. hospitals participating in the "Get With The Guidelines-Stroke" quality improvement program. Factor analysis was used to refine the instrument to a four-factor 29-item instrument that can be used by hospitals to assess their readiness to administer intravenous tissue plasminogen activator within 60 minutes of patient hospital arrival.

Somatic awareness and symptom attribution in ischemic stroke patients.

PROBLEM: Patient delay in seeking treatment for stroke symptoms is a major factor in morbidity and mortality due to stroke. Every 4 minutes, someone dies of a stroke, and 54% of those deaths occur before the patient reaches the hospital. OBJECTIVE: The aim of this study was to determine the relationship of somatic awareness and symptom attribution to treatment-seeking behaviors in ischemic stroke patients. DESIGN: This was a descriptive, correlational pilot study. SETTING: This study was carried out in three tertiary-care hospitals in Philadelphia, Pennsylvania, and Binghamton, New York. SAMPLE: Twenty patients diagnosed with ischemic stroke were included. INSTRUMENTS: The Modified Somatic Perception Questionnaire measured somatic awareness, and the Symptom Interpretation Questionnaire measured symptom attribution. RESULTS: There was no relationship identified between somatic awareness or symptom attribution and treatment-seeking behaviors. Significance was identified, using t-test comparisons, between physical attribution scores and insurance status (p = .038) and family history of stroke (p = .026). Significant correlations, r = .386 and r = .433, respectively, were identified between somatic awareness and symptom attribution and education. CONCLUSION: Somatic awareness and symptom attribution were not found to be significantly correlated to time to care. These results must be tempered with the knowledgethat the data were derived from a small sample and that some data were missing due to a lack of recall. Significance was identified, in a comparison of the group means, involving insurance status and family history of stroke, to somatic awareness and symptom attribution. Significant correlation was identified between education and these factors. Future research involving these factors, using a revised methodology, should be considered.

Emergency department nurses' perceived barriers and facilitators to caring for stroke patients.

Stroke is currently the 3rd leading cause of death in the United States and is the leading cause of severe, long-term disability. With the advent of recombinant tissue plasminogen activator/alteplase, there is a treatment option for ischemic stroke. Unfortunately, only a small number of eligible patients receive this treatment. Whereas much research has been performed on barriers to treatment related to prehospital delays, less research has been performed on in-hospital delays related to hospital staff's perceptions of stroke patients. In this qualitative exploratory study, focus group interviews were conducted to examine emergency nurses' experiences in caring for stroke patients. A convenience sample was recruited using flyers distributed in the emergency department. Three groups of emergency nurses were interviewed in a private location within the facility. The 30-minute, semistructured interviews included 2 to 4 emergency nurses and were moderated by the investigator. Individual transcripts were analyzed for trends, patterns, and recurring themes. Three major themes regarding barriers to and facilitators of stroke care emerged: (a) nurses' comfort with assessment of stroke patients, (b) feedback regarding nurse performance and patient outcomes; and (c) environmental issues such as staffing, competing priorities, and patient and family needs. Despite the various challenges facing emergency nurses, all groups verbalized a desire to provide excellent care to these patients. Further research is recommended to address these challenges and to explore potential solutions identified in this study to improve the care of stroke patients.

Utilidad de las secuencias potenciadas en susceptibilidad paramagnética (SWI) para diferenciar crisis somestésicas de accidentes isquémicos transitorios en un paciente con angiopatía amiloide cerebral / The use of SWI-MRI to differentiate between seizures and transient ischemic attacks in a patient with cerebral amyloid angiopathy

Introducción. La angiopatía amiloide cerebral (AAC) secaracteriza por el depósito de β-amiloide en la pared delas arterias de pequeño y mediano calibre de la cortezacerebral y leptomeninges. La sintomatología puede incluireventos transitorios de diverso origen, pudiendoser difícil el diagnóstico diferencial en el momento agudo.Caso clínico. Varón con antecedente de ictus isquémico,que presentó crisis somestésicas secundarias a microsangradocerebral por AAC que simulaban ataques isquémicostransitorios. Se redujo la medicación antiagregante yposteriormente se inició tratamiento antiepiléptico desapareciendolos episodios. Las secuencias de susceptibilidadparamagnética en Resonancia Magnética cerebralfueron de gran utilidad para el diagnóstico (SWI-RM).Conclusiones. Los microsangrados de la AAC puedenmanifestarse en forma de crisis, simulando déficits focalessensitivos transitorios que pueden ser atribuidoserróneamente a isquemia cerebral. Este caso sugiereque, incluso si existe historia de accidentes cerebrovascularesisquémicos, deberían considerarse microsangradospor AAC como causa posible de pseudoaccidentesisquémicos transitorios. Las secuencias SWI-RMpueden ser útiles para identificarlos. De este modopuede prevenirse el inicio o escalada del tratamientoantiagregante o anticoagulante, evitando complicacionespotencialmente devastadoras (AU)

Background. Cerebral amyloid angiopathy (CAA) ischaracterized by the deposit of β-amyloid on the wallsof small and medium-sized arteries of the cerebral cortexand leptomeninges causing cerebral bleeding. Clinicalpresentations may include transient neurologicalevents for which differential diagnosis can be difficult.Case report. We report a subject with a medical historyof recent stroke who presented somesthetic seizuresmimicking transient ischemic attacks owing to CAAmicrobleeding. Antiplatelet treatment was reduced andafter lamotrigine was commenced the episodes disappeared.Susceptibility-weighted magnetic resonanceimaging was very helpful for diagnosis (SWI-MRI).Conclusions. CAA microbleeding can be manifested inthe form of seizures mimicking focal transient sensitiveneurological deficits that can be erroneously attributedto cerebral ischemia. The present case report suggeststhat, despite the presence of a past medical history ofstrokes, neurologists should consider CAA microbleedingas a possible cause of pseudo-transient ischemicattacks. High-resolution neuroimaging including SWIMRIimaging can be helpful in identifying cortical microbleedings.In this way, the start or increase of antiplatelettreatment can be avoided, and the risk of potentiallyfatal complications minimized (AU)

Family support for stroke: one year follow up of a randomised controlled trial.

BACKGROUND: There is evidence that family support can benefit carers of stroke patients, but not the patients themselves. OBJECTIVE: To extend the follow up of a single blind randomised controlled trial of family support for stroke patients and carers to one year to ascertain whether there were any late effects of the intervention. METHODS: The study was a randomised controlled trial. Patients admitted to hospital with acute stroke who had a close carer were assigned to receive family support or normal care. Families were visited at home by a researcher 12 months after the stroke, and a series of questionnaires was administered to patient and carer. RESULTS: The benefits to carers mostly persisted, though they were no longer statistically significant because some patients were lost to follow up. There was no evidence of any effects on patients. CONCLUSION: Family support is effective for carers, but different approaches need to be considered to alleviate the psychosocial problems of stroke patients.

[Determining the support needs of patients who live at home following a stroke]. / Studie zur Ermittlung des Unterstützungsbedarfes von Patientinnen und Patienten, die nach einem Schlaganfall zu Hause leben.

The study "determining the support needs of patients who live at home following a stroke" was chosen because stroke is (one of) the most significant causes of permanent handicap in the elderly. (This project was developed as part of the studies for the degree of Nurse Manager/Teacher:) The results are based on qualitative and quantitative data collected from focus groups and a standardised questionnaire. Due to the small number of participants (57) the study cannot be regarded as representative. Typical key issues such as "going out of the house" were highlighted in the standard questionnaires. The interviews which were evaluated using the Mayring technique give an impression of themes, such as reduced tolerance levels and (greater) increased anxiety, which together with the physical burden dominate their daily life. It was apparent that the persons concerned have a general lack of understanding of their condition. The most significant results of the study are presented together with life enhancing recommendations.