Section 7: Acute Stroke Management

NUR 433: Adult Health II; MCUSON; Mrs. Cooper

The single most important fact in the history is the _____ _____ _____: the exact date and time the patient was last seen without symptoms

last know normal (LKN)

last known normal decides eligibility for _____ and _____

thrombolytics; thrombectomy

***If a patient wakes up with symptoms, last known normal is when they went to sleep.

what does BE-FAST stand for

B: balance - sudden loss or balance or coordination

E: eyes - sudden blurred, double, or lost vision

F: face - one-sided facial droop

A: arms - arm drift or weakness

S: speech - slurred, confused, or absent speech

T: time - call 911 now and note the time (time=brain)

***Also teach: sudden confusion, sudden trouble walking or dizziness, and a sudden severe headache with no known cause

_____ is a standardized exam that scores stroke severity from 0 to 42 (higher = worse). Do it on admission, at any change in status, at transfer and at discharge

NIH stroke scale (NIHSS)

***NIH stroke scale (NIHSS) assesses

1. Level of consciousness (1a–1c)

2. Best gaze

3. Visual fields

4. Facial palsy

5. Motor arms

6. Motor legs

7. Limb ataxia

8. Sensory

9. Language (aphasia)

10. Dysarthria

11. Extinction and inattention (neglect)

***Think about it: the NIHSS does not test pupils, the gag or corneal reflexes, or vital signs. A full neuro assessment still includes them

Testing for stroke must quickly (1) separate _____ from _____ stroke, (2) find the cause and location, (3) decide treatment eligibility, and (4) map the tissue that can still be saved.

ischemic; hemorrhagic

_____-_____ _____ first. It shows hemorrhage immediately. Ischemic changes may not appear for 6–8 hours

non-contrast CT

Blood glucose right away: _____ can mimic stroke

hypoglycemia

CT angiography, MRI/MRA, cerebral angiography: locate the occlusion. These use _____: check allergies and kidney function

contrast

Transcranial Doppler: blood flow _____

velocity

Lp-PLA₂ (PLAC) test: a blood _____ of vascular inflammation linked to stroke risk

marker

_____ ______: not routine because of herniation risk. Used only when SAH is suspected and CT is negative

lumbar puncture

***Also: CBC, coags (PT/INR, aPTT), electrolytes, ECG (look for A-fib)

Door-to-needle goals (60 minutes)

list some nursing priorities during the workup for stroke

• activate the stroke alert

• protect the airway

• monitor BP and neuro status

• keep the patient NPO

• get the patient to CT fast and communicate the LKN

what is the drug class that alteplase (tPA) IV and tenecteplase (single IV bolus)

thrombolytic (fibrinolytic)

***for thrombolytics - within 4.5 h of LKN; CT must rule out bleeding; BP < 185/110 before and ≤ 180/105 for 24 h after. Watch for bleeding and neuro decline. No invasive procedures and no antithrombotics for 24 h

what drug class does aspirin and clopidogrel belong to

antiplatelet

***antiplatelet - Start within 24–48 h (wait 24 h after tPA). Pass the swallow screen before oral aspirin

what drug class does heparin, warfarin, apixaban, and dabigatran belong to

anticoagulant

***anticoagulant - Not in the acute phase. Used for secondary prevention, especially A-fib

what drug class does atorvastatin and simvastatin belong to

statin

***statin - Lower LDL and stabilize plaque

what drug class does labetalol and nicardipine belong to

antihypertensive

***antihypertensive - Treat only above the BP limits below

_____ reduce fibrin formation

anticoagulants

_____ stop platelets from clumping

antiplatelets

anticoagulants and antiplatelets prevent clots from forming and growing. Neither dissolves an existing clot; _____ do

thrombolytics

Neuroprotection: no drug is approved. Protect the _____ by keeping normal temperature, glucose and perfusion

penumbra

_____ disable stroke symptoms, even if improving (your facility may use an NIHSS threshold)

thrombolytics

thrombolytic treatment can start within ___ hours of last known normal

4.5

thrombolytics eligibility are for patients aged ___ or older

18

thrombolytic eligibility exclusion: _____ on CT

hemorrhage

thrombolytic eligibility exclusion: BP that can’t be lowered below ___/___

185/110

thrombolytic eligibility exclusion: glucose <___ or >___ mg/dL (may treat once corrected if deficits persist)

50; 400

***thrombolytic eligibility exclusion: Labs: INR > 1.7, platelets < 100,000, PT > 15 sec, aPTT > 40 sec

***thrombolytic eligibility (alteplase): Full-dose LMWH within 24 h; DOAC (apixaban, rivaroxaban, dabigatran, edoxaban) within 48 h

thrombolytic eligibility (alteplase): Head trauma or ischemic stroke within ___ months; MI within ___ months

3; 3

thrombolytic eligibility (alteplase): Major surgery or trauma within ___ days

14

thrombolytic eligibility (alteplase): Arterial puncture at a noncompressible site or LP within __ days

7

***thrombolytic eligibility (alteplase): Active internal bleeding, bleeding disorder, or intracranial AVM, aneurysm or tumor

thrombolytic eligibility (alteplase): _____; seizure at onset

pregnancy

what procedure for ischemic stroke and prevention uses a catheter to retrieve a clot from a large vessel; up to 24 h from LKN in selected patients

mechanical thrombectomy

list some nursing roles for mechanical thrombectomy

• Neuro checks

• puncture-site and distal pulse checks

• BP per protocol

what procedure for ischemic stroke and prevention removes carotid plaque to prevent stroke

carotid endarterectomy (CEA)

list some nursing roles for carotid endarterectomy (CEA)

• Bleeding

• airway

• cranial nerve injury (facial droop, hoarseness, tongue deviation

what procedure for ischemic stroke and prevention opens a narrowed carotid with a balloon and stent

carotid angioplasty and stenting

list some nursing roles for a carotid angioplasty and stenting

• Groin site

• hematoma

• distal pulses

• keep leg straight as ordered

***These procedures serve 3 purposes: prevent a stroke, restore blood flow after a stroke, and repair vascular damage or malformations

list the goals for hemorrhagic stroke

• stop the bleeding

• control BP

• lower ICP

• prevent rebleeding and vasospasm

***Priority: never give thrombolytics, anticoagulants or antiplatelets for a hemorrhagic stroke. Reverse anticoagulants if the patient was taking them.

***exact parameters vary by facility. always follow your protocol and orders