Assessment Framework for the Stroke Cohort

Applying the framework to assess patients who have had a stroke

During my specialist training I built templates for imaginary patients and added to it as I learnt more. Unfortunately, they were paper based and disappeared into my archives somewhere!

To give you an idea of how I use the framework, below is an evidence-based approach to the new patient being admitted with stroke to your rehabilitation ward. It is not complete (they never are) so feel free to copy and add your own knowledge to it.

Medical

  • Haemorrhagic: acute blood pressure lowering
  • Ischemic Stroke: The Holy Triad – long-term anti-platelet/ ACE inhibitor/anti-hypertensives (longer term)/ anti-cholesterol (statin)
  • Comorbidity medical management: Atrial fibrillation (AF), HT and diabetes especially
  • Medication management: in-hospital BP medication titration
  • Primary prevention
    • Deconditioning (use deconditioning framework)
    • Related to current conditions – enoxaparin to prevent thromboembolism (if no warfarin/ NOAC), pressure injuries if bed bound / sensory loss
  • Secondary prevention: for AF – long term ECG monitoring and carotid artery assessment both strongly recommended, Transoesophageal echocardiography
  • Nutrition: especially if dysphagia
  • Toxins: smoking, drugs, alcohol
  • Lifestyle: sleep (sleep apnoea is common), exercise

Physical

  • Hemiplegia assessment
  • Spasticity Assessment
  • Shoulder assessment
  • Visual assessment (visual loss affects 30% survivors and is often missed)
  • Prognosis (sitting balance/ wrist and finger extension, gait)
  • Cardiovascular (pulse, blood pressure, O2 sats and presence of cardiac failure important for exercise)
  • Gait assessment (if walking)

Function

  • pADLs – what can people generally achieve with a single functioning upper limb (e.g. can they open lids, containers and feed themselves)
  • Cognition: Knowledge of a person’s orientation to Place and Time is mandatory, (you should also do a more thorough assessment), can they learn and therefore participate? Nearly all people will have some cognitive impairment, especially executive, early on
  • Speech and communication assessment
  • Swallow Assessment – should be done within 6 hours of arrival to hospital.
  • Bladder (take out indwelling catheter as soon as possible), manage urinary incontinence
  • Sexuality – likely to be impacted in stroke

Psychological

  • Stress/ Anxiety/ Depression (high rates of depression)
  • Adjustment to disability can impact significantly on performance
  • Understanding of condition

Social

  • Housing
  • Relationships
  • Finances: who pays the bills?
  • Insurance: is there any local support for people with disability e.g. the National Disability Insurance Scheme in Australia, income protection scheme, sickness or disability benefits
  • Supports: emotional/ financial/ physical
  • Transport: driving (mandatory exclusions, local rules apply)

Recreational

  • What do they like to do? What aren’t they able to do?
  • What might occupy them in hospital that could also be functional retraining (e.g. knitting)

Vocational

  • School or other education: Do they need a certificate?
  • Work: paid or volunteer (do they need medical certificates to support them?)
  • Caring for others (if they care for others, who is now caring for the others?)
  • Aspirations/  life goals