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Nursing Care of the Acute Stroke Patient

Montana State Stroke Initiative Nursing Workgroup


Martha Allen, RN, (406) 237-7964 ( Karla Ruggiero, RN, (406) 657-4817 ( Polly Troutman, RN, (406) 543-7271 ( Anne Burnett, MN, APRN-BC, FNP (406) 455-5743 (


Great Falls:

Stroke Facts in America

Third leading cause of death in the United States 750,000 Americans suffer strokes each year 160,000 deaths each year 4,000,000 stroke survivors

Stroke Facts in America


A leading cause of adult disability Many strokes are preventable Every 45 seconds, someone suffers a stroke Twice as many women die from stroke every year than from breast cancer

Types of Stroke

Ischemic: embolic or thrombotic

blocked blood flow to the brain

Hemorrhagic: ICH, SAH, ruptured cerebral aneurysm TIA: This is a stroke, although symptoms resolve within an hour

Signs and Symptoms of Stroke


Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden dizziness, loss of balance or coordination or trouble walking Sudden severe headache with no known cause

Risk Factors

High blood pressure Carotid artery disease Physical inactivity Excess alcohol intake Atrial fibrillation Diabetes Heart disease Smoking Family history Prior stroke/TIA High cholesterol Obesity

Brain Anatomy

Treatment for Ischemic Stroke


tPA=Thrombolytic agent Document time of symptom onset. (If awoke with symptoms, must go by time when last seen normal) Immediate head CT (check for blood) Evaluate for tPA administration (review exclusion/inclusion criteria)

Treatment Cont

If not a tPA candidate, ASA in ED. Rectal ASA if fails swallow eval. or if swallow eval. not complete. Keep NPO, until a formal swallow eval. is done. Admit as Inpatient and perform diagnostic testing: Carotid US, Echo, TEE, ECG monitoring for a-fib, MRI, fasting Lipid, Clotting disorder blood work (Antiphospholipid, Factor V, Antithrombin III) Rehabilitation

tPA Administration Considerations


Must be started before 3 hours from onset No blood on head CT Review patient s history for other risk factors Accurate weight recorded Foley catheter prior to tPA

tPA Cont

Consent explained and signed (BP>185/110) treat with labetolol 10-20mg IV over 1-2 min. May repeat x1 or nitro paste 1-2 inches. If treatment does not lower BP, do not give tPA NIH stroke scale shows significant deficits to merit treatment.

tPA Contraindications



Any recent surgery<14 days/serious head trauma/recent IC surgery or previous stroke within 3 months History of ICH Uncontrolled HTN at time of treatment (BP>185/110) Seizure at the onset of stroke Active internal bleeding (<21 days)

Contraindications Cont..

Intracranial neoplasm, AV malformation, aneurysm Use of anticoagulants with PT>15 or INR >1.7 Platelet count <100,000/mm Administration of heparin within 48 hrs preceding the onset of stroke and an elevated PTT at presentation Lumbar puncture <7 days or recent arterial puncture

Calculation and Documentation of tPA



0.9 mg/kg Do not exceed the 90 mg max dose Mix 100 mg in 100 ml of sterile water, subtract pt dose from 100 ml and discard the difference. Final concentration 1mg/1ml Withdraw 10% and give IV bolus over 1 minute, followed by the remainder over 60 min. Double check for correct dose (MD, RN) Document bolus dose and drip dose over 1 hr

Example of tPA Calculation

Patient wt

80 kg



0800 tPA bolus 7.2 mg 0801 tPA infusion 64.8 mg in 64.8 ml given over 60 minutes

0.9mg/kg = 72 72mg in 72 ml (total dose) - 10% = 7.2 mg or ml (bolus dose) 72 -7.2 = 64.8mg (infusion dose)

During tPA Administration


Check BP every 15 min for 2 hours  Treat hypertension/hypotension as ordered Monitor Neuro status every 30 min x4 Watch for bleeding puncture sites, urine, stool etc. Know signs/symptoms of Intracerebral Hemorrhage: Any acute neurological deterioration, new HA, N/V, sudden HTN

Hemorrhage Suspected


STOP TPA INFUSION, call MD immediately Stat head CT without contrast Draw blood for PT, PTT, plt ct, fibrinogen, and type and hold Prepare for administration of cryo and or platelets

Post tPA

Continue to monitor for signs/symptoms of intracerebral hemorrhage Therapy/Rehab physician evaluation, if needed No unnecessary blood draws or invasive procedures for 12 hours after tPA Repeat CT scan 24 hours after tPA to evaluate for bleeding (STAT if suspect intracerebral hemorrhage) No aspirin, heparin, warfarin, or other antithrombotic or antiplatelet drugs 24 hours after tPA

Other Treatment Options for Ischemic Strokes

If symptom onset is greater than 3 hrs consider:

Other interventions (IA, corkscrew, stenting) Other trials (thrombolytics, neuroprotective, hyperglycemia)

Hemorrhagic Stroke Treatment


Do not give antithrombotics or anticoagulants Monitor and treat blood pressure greater than 150/105 (Table 6, 2005 Guidelines update) NPO, until swallow eval is completed Anticipate Neurosurgical consult Possible administration of blood products

In-patient Considerations

Nursing Issues

Started on stroke prevention medications? Clinical pathway followed? Blood pressure within appropriate parameters? Know signs of suspected Intracranial Hemorrhage and actions to take DVT prophylaxis addressed by day 2? IPC s/Lovenox/heparin SQ per orders Therapies seeing patient? Review PT/OT/ST recommendations

Inpatient Cont


IV fluids (Normal Saline or LR)? Nutrition? Dietary evaluation. Assistive devices for feeding. Calorie Counts as ordered. Fever? Treat if greater than 99 F with Tylenol Blood glucose within appropriate parameters? Obtain sliding scale if necessary. Positioning? Pillows under affected limbs. Turn Q2hours. Accommodate limitations Rehab consults as soon as possible, if needed

JCAHO Guidelines

Deep Vein Thrombosis (DVT) Prophylaxis Discharged on Antithrombotics Patients with Atrial Fibrillation Receiving Anticoagulation Therapy Tissue Plasminogen Activator (t-PA) Considered/Administered Antithrombotic Medication Within 48 Hours of Hospitalization


Lipid Profile During Hospitalization Screen for Dysphagia Stroke Education Smoking Cessation A Plan for Rehabilitation was Considered

From website Primary Stroke Center Standardized measures

JCAHO Expectations for ED


Stroke Team and written protocols to quickly evaluate and treat stroke patients Stroke education: 8 hours/year for Stroke Team Members Head CT within 25 min. of being ordered CT interpretation within 45 min. of order Lab and (ECG as needed) complete within 45 min. of order

Reference/Recommended Reading
(articles available online) (Stroke. 2003;34:1056.) 2003 American Heart Association, Inc. ASA Scientific Statement Guidelines for the Early Management of Patients With Ischemic Stroke : A Scientific Statement From the Stroke Council of the American Stroke Association Harold P. Adams, Jr, MD, Chair; Robert J. Adams, MD; Thomas Brott, MD; Gregory J. del Zoppo, MD; Anthony Furlan, MD; Larry B. Goldstein, MD; Robert L. Grubb, MD; Randall Higashida, MD; Chelsea Kidwell, MD; Thomas G. Kwiatkowski, MD; John R. Marler, MD George J. Hademenos, PhD, (ex-officio member) (Stroke. 2005;36:916-921) 2005 Guidelines Update, Adams, H; Adams, R; Del Zoppo, Goldstein, LB

Helpful Information

Montana Stroke Initiative:  State-wide protocols and guidelines  Evidence based practice  Stroke education for physicians, primary providers, nurses and EMS providers  Mission: To develop a state-wide stroke system of care that allows patients access to the best stroke care regardless of where they live in Montana