Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Complications

 4.0 Nurses in all practice settings should assess (where feasible using a validated tool) the client’s risk for and/or presence of any of the following complications of stroke:

• fall risk:
- fractures secondary to falls,
- bone loss secondary to immobility;
• fatigue;
• painful hemiparetic shoulder;
• pneumonia secondary to immobility and dysphagia;
• pressure ulcers (e.g.: Braden Scale for Predicting Pressure Sore Risk);
• spasticity/contractures;
• urinary tract infection (UTI);
• venous thromboembolism.

 Advanced Care Planning
4.1
Nurses in collaboration with the interprofessional team will assess and support clients (family/substitute decision maker [SDM]) to make informed decisions that are consistent with their beliefs, values and preferences to ensure client wishes are known and incorporated into the plan of care (includes advanced, palliative and end of life care planning).