nursing care across the acute stroke

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Acute Inpatient Stroke Care

Best Practice Best Practice Nursing Care Nursing Care Across the Across the Acute Stroke Acute Stroke ContinuumContinuum

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Acute Inpatient Stroke CareAcute Inpatient Stroke Care

This session includes presentations and This session includes presentations and activities to enhance your learningactivities to enhance your learning

The focus is on working with colleagues to The focus is on working with colleagues to discover best ways of using the tools in your discover best ways of using the tools in your clinical settingsclinical settings

So, sit back (or stand up) and have fun!!! So, sit back (or stand up) and have fun!!!

Welcome!

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So, what do you want to get out of this module?

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Expectations?


Identify the goal of acute inpatient stroke care within the stroke care continuum

Review the components and Best Practice Recommendations related to acute inpatient stroke care

Identify how you can help to implement these recommendations at your institution

Identify the benefits of early assessment and stroke rehabilitation

Identify your role in patient and caregiver education Create a stroke care action plan for acute inpatient stroke care

Objectives

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Introduction 15 min Stroke 101(optional) 15 min Acute Inpatient Stroke Care BPRs 45 min Break 15 min Components of Acute Inpatient Care BPRs 60 min Early Assessment & Stroke Rehab 15 min Patient and Family Education 15 min Putting It All Together 30 min

Agenda

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Prevention of strokePublic awareness & patient education

Prevention of strokePublic awareness & patient education

Hyperacute stroke management

Hyperacute stroke management

Acute inpatient stroke careAcute inpatient stroke care

Stroke rehabilitation & community reintegration

Stroke rehabilitation & community reintegration

Continuum of Stroke Care



Synthesis of best practice recommendationsfor stroke care across the continuum

Address critical topic areas Commitment to keep current and update

every two years First edition released in 2006 Current update released in 2008

With four new recommendations Elaboration of existing ones www.cmaj.ca December 2, 2008

Canadian Best Practice Recommendations for Stroke Care

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Intended only for audiences

with no previous knowledge of

stroke.

Intended only for audiences

with no previous knowledge of

stroke.

Stroke 101Stroke 101Acute Inpatient Stroke Care

Best Practice RecommendationsBest Practice Recommendations

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45 min

4.1: Stroke unit care

Patients admitted to hospital because of an acute stroke or transient ischemic attack should be treated in an interdisciplinary stroke unit Core interdisciplinary team should consist of people with appropriate

levels of expertise in medicine, nursing, occupational therapy, physiotherapy, speech– language pathology, social work and clinical nutrition

Interdisciplinary team should assess patients within 48 hours of admission and formulate a management plan

Clinicians should use standardized, valid assessment tools to evaluate the patient's stroke-related impairments and functional status

Best Practices Recommendations

OVERVIEWOVERVIEW



04/11/23 11TABLE DISCUSSIONTABLE DISCUSSION

1. At your tables, discuss: What are the benefits of a dedicated stroke unit vs. a

medical floor? What are some challenges you experience in getting

patients out of the ER? Identify what’s happening in your institution now and

brainstorm strategies to explore

1.1. Compared with alternative care, Compared with alternative care, stroke unit care showed a reduction stroke unit care showed a reduction in the odds of:in the odds of:

Death at final follow up Death at final follow up

Death or institutionalized care Death or institutionalized care

Death or dependency Death or dependency

Benefits of Stroke Care Unit

Data demonstrated improved patient outcomes when

treated in an organized stroke

unit with dedicated stroke

staff!


Stroke unit care can reduce Stroke unit care can reduce the likelihood of death and the likelihood of death and disability by as much as 30%disability by as much as 30%

Evidence suggests patients Evidence suggests patients treated in stroke units have treated in stroke units have fewer complications, earlier fewer complications, earlier recognition of pneumonia and recognition of pneumonia and earlier mobilizationearlier mobilization

Why Is This Important?


Characterized by a coordinated

interdisciplinary team approach for preventing

stroke complications

and recurrence, and accelerating mobilization and

early rehab.

Let’s take a break…Let’s take a break…15 min

Components of Acute Inpatient Care Components of Acute Inpatient Care Best Practice RecommendationsBest Practice Recommendations

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60 min

1. Referring to the case study in your PW, each table will prepare a set of Case Notes to bring to an interdisciplinary meeting to begin establishing rehabilitation goals

2. Base your notes on Best Practice Recommendation 4.2 Components of acute inpatient care

3. Venous thromboembolism, temperature, mobilization, continence, nutrition and oral care

4. When done, we’ll conduct our meeting with each table getting a turn to present

Interdisciplinary Meeting


TABLE ACTIVITYTABLE ACTIVITY

Mrs. C is a 76 year old right handed woman who was admitted to the Stroke Unit post thrombolysis. She lives with her 80 year old husband who requires some assistance with ADL’s due to his Parkinsons’ disease.

They live in a 2 bedroom condominium and have the support of 2 adult children nearby.

On admission Mrs. C is found to have expressive aphasia, right sided weakness (arm weaker than leg) and right visual neglect.

Past medical history: hypertension, hypercholesteremia, osteoporosis, gastroesophageal reflux

No known allergies and does not drink or smoke

Case Study


Mrs. C’s vital signs are: BP 158/70 P-100 and irregular R-22 Temperature: 37.4’C

Mrs. C appears anxious and frustrated, especially when trying to communicate. She is restless and makes attempts to get out of bed

Case Study


4.2: Components of acute inpatient care

Risk for venous thromboembolism, temperature, mobilization, continence, nutrition and oral care should be addressed in all hospitalized stroke patients Appropriate management strategies should be implemented for

areas of concern identified during screening Discharge planning should be included as part of the initial

assessment and ongoing care of acute stroke patients


REVIEWREVIEW


4.2a Venous Thromboembolism Prophylaxis4.2a Venous Thromboembolism Prophylaxis

4.2a Venous thromboembolism prophylaxis

All stroke patients should be assessed for their risk of developing venous thromboembolism High risk patients include patients with inability to move one or both

lower limbs and those patients unable to mobilize independently

Patients who are identified as high risk for venous thromboembolism should be considered for prophylaxis provided there are no contraindications Early mobilization and adequate hydration should be encouraged

with all acute stroke patients to help prevent venous thromboembolism


REVIEWREVIEW


4.2a Venous thromboembolism prophylaxis

In addition to secondary stroke prevention, antiplatelet therapy should be used for people with ischemic stroke to prevent VTE;

The following interventions may be used with caution for selected people with acute ischemic stroke at high risk of VTE: Heparin in prophylactic doses (5000 units BID) or low molecular

weight heparin (with appropriate prophylactic doses per agent) External compression stockings


REVIEWREVIEW


Hot Off the Press!Hot Off the Press!Lancet May 27, 2009Lancet May 27, 2009

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Clots in Legs Or sTockings after StrokeClots in Legs Or sTockings after Stroke

Trial 1: Trial 1: Do graduated compression Do graduated compression stockings reduce the risk of stockings reduce the risk of DVT in stroke patients?DVT in stroke patients?

Trial 2: Trial 2: Are full length graduated Are full length graduated compression stockings compression stockings more effective than below more effective than below knee stockings in reducing knee stockings in reducing the risk of DVT? (QEII ) the risk of DVT? (QEII )

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ConclusionsConclusions

DVT occurred equally in patients with and DVT occurred equally in patients with and without stockings.without stockings.

Alteration in skin integrity was seen more often Alteration in skin integrity was seen more often in the stocking group.in the stocking group.

Data does not support use of (thigh length) Data does not support use of (thigh length) stockings in patients admitted to hospital with stockings in patients admitted to hospital with acute stroke.acute stroke.

Guidelines will be revised!Guidelines will be revised!

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4.2b Temperature Management



4.2b Temperature Management

Should be monitored as part of routine vital sign assessments (every 4 hours for first 48 hours and then as per ward routine or based on clinical judgment) For temperature more than 37.5°C, increase frequency of

monitoring and initiate temperature reducing measures For temperature more than 38°C, iidentify and treat source (site and

etiology) of fever in order to start tailored antibiotic treatment and antipyretics



REVIEWREVIEW

Let’s take a break…Let’s take a break…15 min

4.2c Mobilization



4.2c: Mobilization

Acute stroke patients should be mobilized as early and as frequently as possible preferably within 24 hours of stroke symptom onset, unless contraindicated Assessment of patients’ ability in activities of daily

living should be completed and reassessed regularly Within the first 3 days after stroke, blood pressure,

oxygen saturation and heart rate should be monitored before each mobilization

Acute stroke patients should be assessed by rehabilitation professionals as soon as possible after admission preferably within the first 24 to 48 hours



REVIEWREVIEW

Mobilization is defined as

the act of getting a patient to

move in the bed, sit up, stand, and eventually

walk.

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AVERT Trial AVERT Trial

Within the first 3 days after stroke, blood pressure, oxygen saturation, Within the first 3 days after stroke, blood pressure, oxygen saturation, and heart rate should be monitored before each mobilizationand heart rate should be monitored before each mobilization

If during mobilization, there is a drop in blood pressure of greater than If during mobilization, there is a drop in blood pressure of greater than 30 mmHg this mobilization attempt should cease. If a drop of greater 30 mmHg this mobilization attempt should cease. If a drop of greater than 30 mmHg occurs on 3 consecutive attempts, further medical than 30 mmHg occurs on 3 consecutive attempts, further medical assessment is required. assessment is required.

Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). A Julie Bernhardt PhD*; Helen Dewey PhD; Amanda Thrift PhD; Janice Collier PhD; and Geoffrey Donnan MD. (2008). A Very Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before Very Early Rehabilitation Trial for Stroke (AVERT) Phase II Safety and Feasibility. Stroke. Published online before print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363print January 3, 2008, doi: 10.1161/STROKEAHA.107.492363

Mobilization: Physiological Monitoring

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REVIEWREVIEW

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Deterioration in the person’s condition in the first Deterioration in the person’s condition in the first hour of admission that: hour of admission that: resulting in direct admission to ICU, resulting in direct admission to ICU, a documented clinical decision for palliative a documented clinical decision for palliative

treatment (e.g. those with devastating stroke)treatment (e.g. those with devastating stroke) immediate surgery. immediate surgery.

Unstable coronary or other medical condition.Unstable coronary or other medical condition. A suspected or confirmed lower limb fracture at A suspected or confirmed lower limb fracture at

the time of stroke preventing mobilizationthe time of stroke preventing mobilization Systolic blood pressure less than 110, or greater Systolic blood pressure less than 110, or greater

than 220mmHg. than 220mmHg.

*Contraindications to Mobilization

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*AVERT Trial recommendations

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Oxygen saturation of less than 92% with Oxygen saturation of less than 92% with supplementation. supplementation.

Resting heart rate of less than 40 or greater than Resting heart rate of less than 40 or greater than 110 beats per minute. 110 beats per minute.

Temperature of greater than 38.5°C. Temperature of greater than 38.5°C.

Persons who have received rt-PA can be Persons who have received rt-PA can be mobilized if the attending physician permits.mobilized if the attending physician permits.

*Contraindications to Mobilization



*AVERT Trial recommendations

4.2d Continence



4.2d Continence

All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence and constipation Stroke patients with urinary incontinence should be assessed by

trained personnel using a structured functional assessment A bladder training program should be implemented in patients who

are incontinent of urine A bowel management program should be implemented in stroke

patients with persistent constipation or bowel incontinence



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Incontinence



40-60% of stroke patients have urinary incontinence

25% of incontinent patients will have urinary incontinence at discharge

15% will have incontinence at 1 year post stroke

Urinary incontinence within 24 hours of a stroke is a predictor of functional disability

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Bladder Incontinence



All stroke patients should be screened for urinary incontinence and retention (with or without overflow)

Urinary incontinence should be assessed by trained personnel using a structured functional assessment

The use of indwelling catheters should be avoided. If used, indwelling catheters should be assessed daily and removed as soon as possible

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Bladder Incontinence



The use of a portable ultrasound (bladder scanner) is recommended as the preferred non-invasive painless method for assessing post void residual and eliminates the risk of introducing urinary infection or causing urethral trauma by catheterization


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Assessment of Incontinence

Post residual volume

Urine culture

Vaginal examination

Rectal examination

Incontinence history

Fluid intake

Medical history

Medications

Functional ability

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Strategies for Urinary Incontinence



Ensure adequate fluid intake (1500-2000 mls)

Assess post void residuals (normal is 50-100 mls)

Review medications (?diuretics)

Introduce a regular toileting routine

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Strategies for Urinary Incontinence



Encourage bladder retraining (urge incontinence)

Pelvic muscle exercises – Kegal’s

Double voiding, Crede maneuver and intermittent catheterization (overflow incontinence)

Limit use of dietary bladder irritants ( caffeine, etoh, spicy foods)

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Bowel Incontinence



Bowel incontinence occurs in 30% of stroke patients and 97% regain control within one year.

Incontinence may result due to the following: Altered consciousness Cognitive deficits Impaired communication Neurogenic bowel without sensation

or control

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Bowel Incontinence



Bowel function risk factor assessment should include: mobility, inactivity, adequate fluid and food intake, polypharmacy,

etc.

All stroke patients should be screened for fecal incontinence

A bowel management program should be implemented in stroke patients with persistent constipation or bowel incontinence

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Establishing a Bowel Program



Encourage appropriate fluids, diet, and activity.

Choose an appropriate rectal stimulant.

Provide rectal stimulation initially to trigger defecation daily.

Select optimal scheduling and positioning.

Select appropriate assistive techniques.

Evaluate medications that promote or inhibit bowel function

Source: www.guideline.gov/

4.2e Nutrition



4.2e Nutrition

The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool Results from the screening process should guide appropriate

referral to a dietitian for further assessment and the need for ongoing management of nutritional and hydration status



REVIEWREVIEW

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Nursing Interventions for Dysphagia/Nutrition



Maintain all patients with stroke NPO (including oral medications) until a swallowing screen has been administered and interpreted, within 24 hours of patient being awake and alert

Screening results should guide appropriate referral to a Dietician for further assessment and the need for ongoing management of nutritional and hydration status

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Dysphagia/Nutrition



Consideration of enteral nutrition support within 7 days of admission for patients who are unable to meet their nutrient and fluid requirements orally

This decision should be made collaboratively with the multidisciplinary team, patient and their caregivers/family

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Nursing Interventions for Dysphagia



Assess for signs & symptoms of dysphagia Choking on food Stifled, suppressed or overt coughing during meals Nasal regurgitation Moist, wet voice Complaints of food sticking in the throat Drooling or loss of food &/or fluid from the mouth Pocketing of food in cheeks Slow, effortful eating Delay in initiating swallow (i.e. > 5 seconds)

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Dysphagia – Points to Remember



All stroke patients should have a nutritional screen within 48 hours of admission

Many dysphagic patients aspirate without any external sign that food or liquid is entering the airway – instead ‘silent aspiration’

Although many stroke patients will recover from dysphagia spontaneously, all stroke patients should have a SLP/RD assessment

The presence of a gag reflex does not exclude The presence of a gag reflex does not exclude the possibility of dysphagiathe possibility of dysphagia

4.2f Oral Care



4.2f Oral care

All stroke patients should have an oral/dental assessment, which includes screening for obvious signs of dental disease, level of oral care and appliances, upon or soon after admission For patients wearing a full or partial denture it must be determined if

they have the neuromotor skills to safely wear and use the appliance(s)

An oral care protocol should be established and include: Frequency Types of oral care products Strategies for patients with dysphagia Consultation with dentistry



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Oral Care



Consider consulting dentistry, occupational therapy, speech language pathologists, and/or a dental hygienist to develop an oral care protocol

A referral to dentistry for consultation and management of oral health and/or appliances should be made as soon as possible

4.2g Discharge planning

Discharge planning should be initiated as soon as possible after patient admission to hospital (emergency department or inpatient care) A process should be established to ensure involvement of patients

and caregivers in the development of the care plan, management and discharge planning

Discharge planning discussions should be ongoing throughout hospitalization to support a smooth transition from acute care

Information about discharge issues and possible needs of patients following discharge should be provided to patients and caregivers soon after admission



REVIEWREVIEW

Check Up QuizCheck Up Quiz

QUIZQUIZ


Check Up

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In one clinical study, stroke unit care reduced the odds of what

three outcomes?

1. Death at final follow up 2. Death or institutionalized care 3. Death or dependency

Check Up

04/11/23 57


Name two common complications related to stroke.

Aspiration Pneumonia 40%Urinary tract infection 40%

Check Up

04/11/23 58


In what type of unit should In what type of unit should patients admitted to hospital patients admitted to hospital with acute stroke or TIA be with acute stroke or TIA be

treated? treated?

In an interdisciplinary stroke unitIn an interdisciplinary stroke unit

Check Up

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What type of planning should be included as part of the initial

assessment and ongoing care of acute stroke patients?

Discharge planningDischarge planning

Check Up

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What type of treatment should patients who are identified as high

risk for venous thromboembolism be considered for?

Prophylaxis provided there are no contraindications

Check Up

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In addition to secondary stroke prevention, what type of therapy should be used for people with

ischemic stroke to prevent VTE?

Antiplatelet therapy

Check Up

04/11/23 62


What action should be taken if a patient’s temperature rises to more than 38°C?

Identify and treat source (site and Identify and treat source (site and etiology) of fever in order to start etiology) of fever in order to start tailored antibiotic treatment and tailored antibiotic treatment and

antipyreticsantipyretics

Check Up

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How often should the temperature of a stroke patient be monitored?

As part of routine vital sign assessments (every 4 hours for first

48 hours and then as per ward routine or based on clinical

judgment)

Check Up

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When should acute stroke patients be mobilized?

As early and as frequently as possible preferably within 24 hours of

stroke symptom onset, unless

contraindicated

Check Up

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Mobilization of stroke patients is Mobilization of stroke patients is contraindicated when systolic blood contraindicated when systolic blood pressure is less than or greater than pressure is less than or greater than

what values?what values?

Systolic blood pressure less than Systolic blood pressure less than 110mm Hg or greater than 220mm 110mm Hg or greater than 220mm

Hg.Hg.

Check Up

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What percentage of stroke patients What percentage of stroke patients have urinary incontinence?have urinary incontinence?

40-60% of stroke patients have 40-60% of stroke patients have urinary incontinenceurinary incontinence

Check Up

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What does the use of a portable What does the use of a portable ultrasound (bladder scanner) to ultrasound (bladder scanner) to

access bladder function eliminate? access bladder function eliminate?

Risk of introducing urinary infection Risk of introducing urinary infection or causing urethral trauma by or causing urethral trauma by

catheterizationcatheterization

Check Up

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What are three strategies for treating What are three strategies for treating overflow incontinence?overflow incontinence?

1.1. Double voiding Double voiding

2.2. Crede maneuver Crede maneuver

3.3. Intermittent catheterizationIntermittent catheterization

Check Up

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Bowel incontinence occurs in what Bowel incontinence occurs in what percentage of stroke patients and percentage of stroke patients and

what percentage regain control within what percentage regain control within one year?one year?

Bowel incontinence occurs in 30% of Bowel incontinence occurs in 30% of stroke patients and 97% regain stroke patients and 97% regain

control within one yearcontrol within one year

Check Up

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What should a bowel function risk What should a bowel function risk factor assessment include?factor assessment include?

Mobility, inactivity, adequate fluid and Mobility, inactivity, adequate fluid and food intake, polypharmacyfood intake, polypharmacy

Check Up

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Identify four things you can do to Identify four things you can do to manage bowel incontinence.manage bowel incontinence.

1.1. Increase dietary fibre and fluidsIncrease dietary fibre and fluids2.2. Increase mobilityIncrease mobility3.3. Maintain a bowel recordMaintain a bowel record4.4. Establish a regular toileting Establish a regular toileting

routineroutine

Check Up

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The nutritional and hydration status of stroke patients should be screened

within what period of time after admission and using what tool?

Within Within the first 48 hours of admission using a valid screening tool

Check Up

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Maintain all patients with stroke NPO Maintain all patients with stroke NPO (including oral medications) within 24 (including oral medications) within 24

hours of patient being awake and hours of patient being awake and alertalert

What should be done with all What should be done with all patients with stroke until a patients with stroke until a

swallowing screen has been swallowing screen has been administered and interpreted?administered and interpreted?

Check Up

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The presence of a gag reflex does not exclude the possibility of dysphagia

The presence of a gag reflex does not exclude the possibility of

what?

Early Assessment &Early Assessment &Stroke RehabilitationStroke Rehabilitation15 min


When should stroke rehabilitation start?

When Should Stroke Rehabilitation Start


Priorities are : Manage stroke sequelae to optimize recovery Prevent post-stroke complications that may interfere with recovery

process

Acute stroke accounts for the longest length of stay in Canadian hospitals and places a significant burden on inpatient resources, which increases further when complications are experienced.

When Should Stroke Rehabilitation Start


Consider that rehabilitation is a process, not a place.

Rehabilitation and discharge planning begins at the time of admission to acute care


What are the benefits of early assessment and rehabilitation?

Benefits of Early Assessment & Rehabilitation


Assessment should start as early as possible in the ER and continue through the inpatient and community reintegration phases

Benefits of Early Assessment & Rehabilitation


Early consultation with rehab professionals: Contributes to reductions in complications from immobility such as

joint contracture, falls, aspiration pneumonia and deep vein thrombosis

Contributes to early discharge planning for transition from acute care to specialized rehabilitation units or to the community

Should reduce the overall cost of care through improved outcomes and reduced time to discharge (BPG 5.1)

Examples of Assessment Tools


Clinicians should use standardized, valid assessment tools to evaluate stroke-related impairments and functional status

Domain Selected Measure

Measures of stroke severity

Orpington Prognostic Scale (OPS) National Institute of Health Stroke Scale

Upper/lower extremity structure and function

Chedoke-McMaster Stroke Assessment (CMSA)

Language Screening in acute care and follow-up, with Frenchay Aphasia Screening Test (FAST)

Boston Diagnostic Aphasia Examination (BDAE) Cognition Montreal Cognitive Assessment (new addition

by Canadian Stroke Strategy cognitive working group, January 2008)

Self-care activities of daily living

Functional Independence Measure (FIM)

Your Role in Early Assessment &Stroke Rehabilitation



When done, we'll review

some of your pearls of wisdom!

At your tables discuss What are the benefits of early assessment and

stroke rehabilitation at your institution? Where can you make a difference in realizing

these benefits? What is the role of the nurse in stroke

rehabilitation? What barriers and enablers do you see?

Family & Patient EducationFamily & Patient Education15 min

From the Patient and Family’s Perspective:From the Patient and Family’s Perspective:

Where You Can Make a Difference!

Did you know that skills training of

caregivers makes a huge difference

in patient outcomes in areas

of functionality and depression!


1. At your tables, discuss What would be your role in educating

and supporting patients and caregivers about acute inpatient stroke care?

2. When done, we'll debrief the whole group to identify some best practices

Patient and Family Education


Content should be specific to; The phase of care Patient/caregiver readiness Patient/caregiver needs Education should be timely, interactive, up to date and provided in a

variety of formats, languages including aphasia friendly

Processes should be established by clinical teams for education including designating team members for provision and documentation of education

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Education content should include: The nature of the stroke and its manifestations Signs and symptoms of stroke Impairments and their impact on the person Caregiver training to manage Risk factors Post-stroke depression Cognitive impairment Discharge planning and decision making Community resources Home adaptations



www.heartandstroke.ca

Putting It All TogetherPutting It All Together30 min

Case Study


1. Review the case study in your PW

2. With your team, answer the questions on the worksheet at the end of the study

3. We’ll review when done to share some best practices and get ready to create a Stroke Care Action Plan


Case Study


Mrs. C is a 76 year old right handed woman who was admitted to the Stroke Unit post thrombolysis. She lives with her 80 year old husband who requires some assistance with ADL’s due to his Parkinsons’ disease.

They live in a 2 bedroom condominium and have the support of 2 adult children nearby.

On admission Mrs. C is found to have expressive aphasia, right sided weakness (arm weaker than leg) and right visual neglect.

Past medical history: hypertension, hypercholesteremia, osteoporosis, gastroesophageal reflux

No known allergies and does not drink or smoke

Case Study Questions


What would be the priority areas for Mrs. C’s care plan development?

What education would you provide for the family?

What complications would you be monitoring for with Mrs. C?

Case Study Questions


1. With the case study we just reviewed in mind, create a stroke care action plan Identify 1-2 key learnings from today that you could take back to

help kick start your change initiatives

2. Use the Stroke Care Action Plan worksheet in your PW to record your plan

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Best Practice Nursing Care Across Best Practice Nursing Care Across the Acute Stroke Continuumthe Acute Stroke ContinuumThank you for your participation!

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