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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 750.000.000 stroke survivors .000 deaths each year 4.000 Americans suffer strokes each year 160.

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 .

ruptured cerebral aneurysm TIA: This is a stroke.Types of Stroke  Ischemic: embolic or thrombotic  blocked blood flow to the brain   Hemorrhagic: ICH. SAH. although symptoms resolve within an hour .

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

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 .

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

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

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 .

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

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) .

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 . aneurysm Use of anticoagulants with PT>15 or INR >1.Contraindications Cont.. AV malformation.      Intracranial neoplasm.

RN) Document bolus dose and drip dose over 1 hr . followed by the remainder over 60 min.Calculation and Documentation of tPA      0. Double check for correct dose (MD. subtract pt dose from 100 ml and discard the difference. Final concentration 1mg/1ml Withdraw 10% and give IV bolus over 1 minute.9 mg/kg Do not exceed the 90 mg max dose Mix 100 mg in 100 ml of sterile water.

8 ml given over 60 minutes  0.8mg (infusion dose) .8 mg in 64.2 mg 0801 tPA infusion 64.2 mg or ml (bolus dose) 72 -7.Example of tPA Calculation  Patient wt 80 kg    Chart:    0800 tPA bolus 7.10% = 7.9mg/kg = 72 72mg in 72 ml (total dose) .2 = 64.

N/V. sudden HTN . stool etc. Know signs/symptoms of Intracerebral Hemorrhage: Any acute neurological deterioration. urine. new HA.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.

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

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.Post tPA      Continue to monitor for signs/symptoms of intracerebral hemorrhage Therapy/Rehab physician evaluation. or other antithrombotic or antiplatelet drugs 24 hours after tPA . heparin. warfarin.

hyperglycemia) . stenting) Other trials (thrombolytics.Other Treatment Options for Ischemic Strokes  If symptom onset is greater than 3 hrs consider:   Other interventions (IA. corkscrew. neuroprotective.

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

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 .

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

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 .

org website Primary Stroke Center Standardized measures .JCAHO Cont      Lipid Profile During Hospitalization Screen for Dysphagia Stroke Education Smoking Cessation A Plan for Rehabilitation was Considered From JCAHO.

of order . of order Lab and (ECG as needed) complete within 45 min. of being ordered CT interpretation within 45 min.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.

2003. Del Zoppo. Adams. Adams. Hademenos. Robert J. Thomas Brott. 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. Goldstein. 2005. MD.americanheart. MD George J. MD. (Stroke. Adams. Marler. Anthony Furlan. Goldstein. Grubb. MD. MD. MD. John R. (ex-officio member) http://www. MD. Chelsea Kidwell.34:1056. Randall Higashida. MD. Thomas G. H. Gregory J. Jr.ahajournals. Adams. MD. Chair. Robert L. Larry B.) © 2003 American Heart Association.36:916-921) 2005 Guidelines Update. LB .org/presenter. PhD. Kwiatkowski. Inc. MD. MD.jhtml?identifier=3023366 (Stroke.Reference/Recommended Reading (articles available online)     http://stroke. del Zoppo.

Helpful Information  Montana Stroke Initiative: http://montanastroke. primary  State-wide protocols and guidelines  Evidence based practice  Stroke education for physicians. 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 .