Practice Recommendations: Complications

Recommendation	Level of Evidence
4.0 Nurses in all practice settings should assess the client’s risk for pressure ulcer development, which is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability (such as the Braden Scale for Predicting Pressure Sore Risk (See appendix D of the Stroke Assessment Nursing BPG) is recommended.	IV
4.1 Nurses in all practice settings should assess the stroke client’s fall risk on admission and after a fall using a validated tool (such as the STRATIFY or timed "Up and Go").	IV
4.2 Nurses in all practice settings should assess stroke clients for the following stroke complications: painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis in order to facilitate appropriate prevention and management strategies.	IV