Management of Stroke Patients

Initial Assessment and Management

• Comprehensive care for stroke patients should include dysphagia management, with formal swallowing assessment and consideration of alternative feeding routes if necessary, as recommended by the American Heart Association 1, 2
• Range of motion exercises are important for preventing complications of immobility, but not the priority when active bleeding is suspected, as stated by the American Heart Association, in patients with stroke 3
• Early mobilization when hemodynamically stable is recommended to prevent immobility complications in stroke patients, according to the American Heart Association and American College of Cardiology 3

Prevention of Immobility Complications

• DVT prophylaxis with anticoagulants or mechanical methods is recommended to prevent deep vein thrombosis in stroke patients, as stated by the American College of Cardiology 4, 1
• Early mobilization when hemodynamically stable is recommended to prevent immobility complications in stroke patients, according to the American Heart Association 3

Bowel and Bladder Management

• Addressing fecal incontinence and implementing a bladder training program are essential for bowel and bladder management in stroke patients, as recommended by the American Heart Association 5, 3

Infection Prevention

• Monitoring for pneumonia, especially with dysphagia, and preventing urinary tract infections are crucial for infection prevention in stroke patients, as stated by the American Heart Association 2, 3, 1
• Early mobilization to prevent complications, maintaining good oral hygiene, and administering antibiotics promptly if signs of infection develop, with a strength of evidence level of high, are recommended by the American Stroke Association 4

Dysphagia Management

• Formal swallowing assessment is necessary, even with absent gag reflex, to assess dysphagia in stroke patients, as recommended by the American Heart Association 1, 2
• Consideration of alternative feeding routes may be necessary for stroke patients with dysphagia, according to the American College of Cardiology 1, 2
• The American Heart Association recommends assessing airway patency and breathing effectiveness, and providing supplemental oxygen only if hypoxemia is detected, with a target oxygen saturation of ≥92% via pulse oximetry 2
• Elevating the head of the bed to 30° is essential to reduce the risk of further aspiration, and maintaining the neck in a neutral position facilitates airway patency, as recommended by the American Stroke Association 3
• Monitoring for signs of respiratory distress, such as fever, which may indicate aspiration pneumonia development, is crucial, with a strength of evidence level of high 2

• The following patients are at high risk for dysphagia and require closer monitoring:

  Patient Characteristics	Recommendation
  Impaired laryngeal sensation	Closer monitoring, with a strength of evidence level of high [6]
  Previous aspiration pneumonia	Closer monitoring, with a strength of evidence level of high [6]
  Poor performance status	Closer monitoring, with a strength of evidence level of high [6]
  Brain stem infarctions	Identification as being at greatest risk, with a strength of evidence level of moderate [4]
  Multiple strokes	Identification as being at greatest risk, with a strength of evidence level of moderate [4]
  Large hemispheric lesions	Identification as being at greatest risk, with a strength of evidence level of moderate [4]
  Depressed consciousness	Identification as being at greatest risk, with a strength of evidence level of moderate [4]

• The European Society for Clinical Nutrition and Metabolism recommends modifying food textures based on swallowing evaluation results, and using thickened liquids as recommended by the swallowing assessment, with a strength of evidence level of moderate 7
• The American Academy of Otolaryngology-Head and Neck Surgery suggests considering carbonated liquids for patients with pharyngeal residue, and referring for specialist nutritional assessment and counseling 7
• The American Heart Association recommends monitoring fluid balance and nutritional intake by trained professionals, and considering allowing free access to water in addition to thickened liquids on an individual basis with regular follow-up, with a strength of evidence level of low 7
• The American College of Chest Physicians suggests considering alternative feeding routes, such as nasogastric tube or percutaneous endoscopic gastrostomy (PEG), if necessary, with a strength of evidence level of moderate 1
• The European Society for Clinical Nutrition and Metabolism recommends repeating swallowing assessments at regular intervals until normal swallowing function is regained, and adjusting dietary modifications based on improvement or deterioration, with a strength of evidence level of high 7
• The American Heart Association suggests involving a multidisciplinary team, including physician, nurse, speech-language pathologist, dietitian, and physical/occupational therapists, to ensure consistent implementation of swallowing precautions across all care providers, with a strength of evidence level of moderate 8
• The American Academy of Otolaryngology-Head and Neck Surgery warns that relying solely on gag reflex is not sufficient to indicate safety from aspiration, and formal swallowing assessment is necessary even with intact gag reflex, with a strength of evidence level of high 4
• The American College of Chest Physicians emphasizes the importance of detecting silent aspiration through instrumental evaluation, and close monitoring of nutritional status and hydration to prevent reduced energy and fluid intake, with a strength of evidence level of moderate 8