Stroke assessment in the perioperative orthopaedic patient.

A growing elderly population with an increasing number of comorbidities is presenting for orthopaedic procedures and interventions, lending themselves to greater risk for complications, including stroke. Prior stroke or transient ischemic attack, hypertension, diabetes mellitus, atrial fibrillation, carotid stenosis, and advanced age are the most common risk factors for perioperative stroke. A comprehensive neurologic assessment should include a thorough history including identification of risk factors, pertinent medications, and a physical examination. This assessment is important to establish a baseline for subsequent neurologic evaluations in the postoperative period. Neurologic physical assessment can be an intimidating task, especially for the orthopaedic nurse who lacks experience in caring for the neurologic patient. Patients who are found with a focal neurologic deficit that is suspicious for stroke require urgent assessment, exclusion of stroke mimics, and activation of the institution's stroke team to allow for brain saving interventions. Time is brain.

A randomized trial testing the superiority of a postdischarge care management model for stroke survivors.

OBJECTIVE: We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being. METHODS: This was a randomized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department. An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans. The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months. The intervention and usual care groups were compared using a global and closed hypothesis testing strategy. Outcomes fell into 5 domains: (1) neuromotor function, (2) institution time or death, (3) quality of life, (4) management of risk, and (5) stroke knowledge and lifestyle. RESULTS: Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain, which showed a significant effect of the intervention (P = .0003). CONCLUSIONS: Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population. The intervention did, however, fill a postdischarge knowledge gap.

Accuracy of a bedside dysphagia screening: a comparison of registered nurses and speech therapists.

Evidence-based guidelines suggest that stroke patients should be screened for dysphagia before oral intake. The purpose of this study was to validate a dysphagia screening tool comparing registered nurses (RNs) with speech therapists (STs). All stroke unit patients who received predetermined scores on specific items of the National Institutes of Health Stroke Scale were eligible for screening. The trial consisted of three parts (with swallow, cough, and vocal quality observed during each part): 1 teaspoon lemon ice, 1 teaspoon applesauce, and 1 teaspoon water RNs performed five screenings that were compared with independent screenings performed on the same patient within 1 hour by a speech therapist (ST). Eighty-three paired screenings were completed, with 94% agreement between the RNs and the STs. This screening identifies patients who are able to swallow and can eat from a safe menu until formally evaluated by an ST while maintaining nothing by mouth (NPO) status for those at risk for aspiration.