STROKE:

WHAT SHOULD NURSES NEED TO KNOW ABOUT STROKE?

DR. ELMER CATANGUI

RN, RM, MBA, PGCERT ( NURSE PRESCRIBER), MSC IN NURSING (UK), PHD IN NURSING SCIENCE
DIRECTOR CLINICAL NURSING, MEDICAL CARE AND STROKE PROGRAM
MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS, KING ABDULAZIZ MEDICAL CITY RIYADH
Selamat Siang Indonesia
Greetings from the Kingdom of Saudi Arabia
 LEARNING OBJECTIVES
• Stroke epidemiology
• Stroke classifications
• Signs and symptoms of stroke
• Investigations
• Thrombolysis treatment for acute ischemic stroke
• Multidisciplinary team in stroke
• Stroke management during covid -19 pandemic
 Richard Nixon, President
Sharon Stone, actress

Charles Dickens Winston Churchill, Prime MinisterElizabeth Taylor

actress
Why bothered in stroke ?

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9
 In Indonesia

2nd leading cause of

mortality

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In Global Scale,
For every

seconds

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12
In stroke, time is brain!

Every minute counts

When stroke strikes, act FAST

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 STROKE:

a sudden neurological deficit of

..
cerebrovascular cause that persists
beyond 24 hours or is interrupted by death tissues
( brain) within 24
hours.

World Health Organization, 2017

Is this a stroke or TIA?
• 70 year old, hypertensive, with history of
diabetes.

• On admission to the hospital, she

claimed that last night she had a sudden
onset of right sided weakness which
lasted for 12 hours and resolved
completely this morning.

• Vital signs were stable.

• She went for CT scan and it emerged:

 Stroke is a global health burden
• It is costly

• Stroke occurs at any age level.

• Stroke is the leading cause of

physical disability and
2nd cause of mortality rate
What are two main types of stroke?
Ischaemic ( 80%) Hemorrhagic ( 20%)

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Why is so important to determine the types of stroke?

1. Monitoring frequency differs

2. Treatment choice differs

Ischaemic stroke : Thrombus ( Clot busting medication or antiplatelets)
Embolus ( anticoagulant)

Hemorrhagic stroke: Hemorrhagic protocol

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What are the signs and symptoms of stroke?

Circle of willis
19
Thinking
Occlusion in the
carotid/MCA can cause
anterior circulation
stroke symptoms

Occlusion in the
basilar/vetebral arteries
can cause posterior
circulation stroke
symptoms.
 Therefore,
Posterior stroke symptoms Anterior stroke symptoms

Balance problem Eye disturbance

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BE- FAST Tool
 LEARNING OBJECTIVES

• Stroke epidemiology
• Stroke classifications
• Signs and symptoms of stroke
• Risk factors
• Investigations
• Treatments
 WHO ARE RISKS FOR STROKE ?
A. Non-Modifiable Risk Factors
Age?

Gender?
Ethnicity?

Family history?
B. Modifiable Risk Factors
 WHAT ARE THE INVESTIGATIONS FOR
STROKE?

1. CT scan
2. MRI
3. Carotid doppler
4. Echocardiogram
5. 24 hour tape / holter
 LEARNING OBJECTIVES
• Stroke epidemiology
• Stroke classifications
• Signs and symptoms of stroke
• Investigations
• Thrombolysis treatment
• Multidisciplinary team in stroke
• Stroke management during covid -19 pandemic
 Case study
Mr. A

-Having breakfast with his wife

10:04 am:
Developed sudden onset of right sided weakness
and speech disturbance

10:20
Taken by a car and transferred to the nearest hospital
10:30 Patient arrived in the ER
10:37 Stroke team came and assessed Mr. A
10:40 CT scan was done
10:50 Thrombolyzed
11:00 Transferred to the stroke unit
11:30 Showed remarkable improvement

Went home after 3 days with no stroke symptoms

 THROMBOLYSIS TREATMENT
• Thrombo – clot
• Lysis – destruction
 The Ischaemic Penumbra and Underlying
Core Infarct

The objective is to avoid lesion enlargement

Nurses should ACT promptly when you recognize stroke

Within 4.5 hours

After 6 hours

After 24 hours

When stroke strikes, ACT FAST

 Do you know that?
• 1. 1.9 million of neurons are lost each
minute.

• 1.2 billion of neurons die in full blown

stroke

• TIME IS BRAIN. Time is lost. Brain is lost!

Thrombolysis administration
Figure 1 Figure 2

Reperfusion

Key point for nurses:

Nurses involved in thrombolysis treatment should administer the medication as soon as possible.
“The sooner, the better”
Bottom Line

• Patients presenting with

symptoms of a stroke
within 4.5 hours of onset
may benefit from
thrombolysis.
 Without thrombolysis
treatment?

26 people
survive with minimal or no disability
 With
thrombolysis treatment?

40 people
will survive with minimal
disability
Risk vs Benefit
Benefit
Key point for nurses:
Remind the stroke team (doctors)
to highlight the risk and benefit of
this treatment to patient/family.

Risk
 Who are suitable?
ACT NOW
• A – age from 18-80
• C – clear clinical diagnosis of stroke
• T – time onset of stroke is clear
• NO contraindications
• Where patient is not bed ridden

(NINDS 1995, Hacke etal 2008; Catangui, 2015)

 Nursing Role : Before Thrombolysis

A IRWAY D O NOT

BREATHING E VER

B
CIRCULATION/CT SCAN
F ORGET

c
G LUCOSE

“When stroke strikes, ACT now – the sooner the better patients will get recovered.” 41
 Administer Thrombolytic Medication
Alteplase (Actilyse)
Total tPA = 0.9 mg /kg
10% of the tPA via bolus for 1 minute
90% of the tPA via infusion pump for 60 mins

Estimate patient’s weight

70 kg
Total tPA= 63mg
10% is 6 ml
90% is 57 ml

Key note for nurses:

It is expensive, therefore, prepare or administer if the team is certain with their
decision.
 Monitoring
Neuro observations: ( GCS, Pupil size/ reaction, limb power and vital signs)

– Every 15 mins during hours 1 -2

– Every 30 mins during hours 3 - 9
– Every 1 hour during hours 10 - 24

Monitor patient and observe for any signs of complications.

Complication 1: Intracerebral hemorrhage

 Nursing role:

 If a patient has episode of high BP,

headache and bradycardia

 Ask the doctor to arrange for urgent

CT scan.
 Cushing reflex
• High blood pressure
• Headache
• Low pulse rate

Nursing role: Check for any signs and symptoms of raised intracranial pressure.
Complication 2: Orolingual edema
Nursing role: Check the mouth (for any swelling) at least
every 1 hour.
Complication 3: Gum bleeding

Nursing role : check the status of the gum ( assess for any bleeding) at lea
every 1 hour.
Complication 4: Bruises
Nursing role: Check the skin before and after giving medication.
 Post thrombolysis Nursing Role
1. Stop Alteplase infusion if:

a. Anaphylaxis
b. Marked hypotension
c. Neurological deterioration ,decreased consciousness level ( 2 points
GCS eye or motor score ) NIHHS_> 4 points
d. Increased BP > 185/110 mgHg if sustained ( 2 readings 5 minutes
apart) or if associated with neurological deterioration

2. Complete bed rest.

3. Do not give Antiplatelets / Anticoagulant for 24 hours
4. Avoid NG tube insertion for 24 hours
5. Do not catheterise for 24 hours post Thrombolysis (unless
clinically indicated)
6. Continue to monitor patients based on recommended protocol.
 Stroke epidemiology
 Stroke classifications
 Signs and symptoms of stroke
 Investigations
 Thrombolysis treatment for acute ischemic stroke
 Stroke management during covid -19 pandemic
 Multidisciplinary team in stroke
 1.3% reported incidence of stroke among covid -19 patients
 Corona virus ( Covid 19) can trigger stroke due to multifactorial reasons
 Activation of coagulation, inflammatory pathways
 Multiple co –morbidity ( elderly, ischemic heart disease, hypertension,
diabetes, hyperlipidemia, smoking and Atrial fibrillation)
 Triage
Triage patient
patient

Screen
Screen for
for covid
covid 19
19

Activate
Activate stroke
stroke code
code
team
team

Imaging
Imaging

Treatment
Treatment

Hyperacute
Hyperacute Stroke
Stroke
Unit
Unit

Acute
Acute Stroke
Stroke Unit
Unit
 g
u sin
e Scr
g tim e en
n
di PPEs ing
en pa
Sp tie
nts
i tin g
a wa
and s
ing ult
b b res
a
Sw
Nurses are getting covid 19 Nurses are tired and experienced
‘stigma’ from other staff

Change of patient ratio Nurses are feeling demoralized

 Despite of Covid -19, stroke care is vital
( 24 to 72 hour care as per American Heart and Stroke Association, Royal College of Physicians,
UK)

 Physiological monitoring
 Swallowing screening/NPO/NGT
 Aspirin/ clopidogrel/ statin
 Physio/OT / SLP/ Dietician Hydration
 Blood Pressure management
 Blood sugar control
 Prevention of deep vein thrombosis and other complications
• Temperature: Commence paracetamol if 37.5C
• Blood pressure:
 Maintain 130/85mm.hg for ischemic stroke
 Prior thrombolysis, treat hypertension if BP is >185/110
 Hemorrhagic stroke, treat hypertension if BP is >220/110
• Oxygen saturation : Maintain > 94%
• Temperature: Commence paracetamol if 37.5C
• Blood pressure:
 Maintain 130/85mm.hg for ischemic stroke
 Prior thrombolysis, treat hypertension if BP is >185/110
 Hemorrhagic stroke, treat hypertension if BP is >220/110
• Oxygen saturation : Maintain > 94%
• Swallowing screening must
be done within 4 hours of
admission from the
emergency room.

• Technique:
Water Swallow Test
 Physiotherapists Social worker

Physicians

Speech
Language
Nurses pathologists

Occupational
therapists
 Maintain blood sugar between 8 to 11 mmol.
 Commence insulin if requires
Key:
A = ACE inhibitor (e.g. perindopril, ramipril) B= Betablocker ( e.g. atenolol,
metoprolol) C = Calcium-channel blockers (e.g. amlodipine) D = Diuretics (e.g.
indapamide, bendroflumethiazide)
 Summary
S udden onset
T reatable and manageable
R isk factors
O rganized stroke unit
K ey: TIME is brain.
E xpert multidisciplinary team
Act FAST!

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Terima kasih banyak!