Recognize a stroke

Sudden neurologic deficits are a stroke until proven otherwise.

BalanceSuddenlossEyesVisionchangeFaceDroopArmWeakness,driftSpeechSlurred orabsentTimeCall; notetime
BE FAST. Activate the stroke team per protocol and note the time the client was last known well.
Ischemic (most strokes)Clot blocks an arteryAtrial fibrillation, atherosclerosisThrombolysis and thrombectomy may helpAntiplatelet or anticoagulant laterHemorrhagicBleeding into or around the brainHypertension, aneurysm, anticoagulantsSudden severe headache, vomitingNo thrombolytics; reverseanticoagulants; control BPvs
Ischemic vs hemorrhagic. Imaging distinguishes them; the clinical picture alone cannot.

Acute treatment timeline

Every minute of delay loses brain tissue.

Time from last known well (selected windows)0 h3 h4.5 h6 h12 h24 hIV thrombolysisUp to 4.5 hThrombectomySelected clients up to 24 h
Treatment windows. Eligibility depends on imaging and clinical criteria set by the stroke team.
StepNursing action
ArrivalAirway, breathing, circulation; neuro assessment (for example, NIH Stroke Scale)
GlucoseCheck early; treat hypoglycemia
ImagingTransport for noncontrast CT promptly
ThrombolysisTwo IV sites; BP below 185/110 before; frequent neuro and BP checks after; bleeding precautions
After thrombolysisReport new headache, worsening neuro status, nausea or vomiting (possible bleeding); avoid invasive procedures per protocol

Clients who do not receive thrombolytics often have higher blood pressures tolerated early (permissive hypertension) unless very high, per the provider.

Ongoing care and complications

Nursing care prevents the complications that often follow a stroke.

ProblemNursing care
Dysphagia and aspirationNPO until swallow screen passed; upright for meals; thickened liquids if ordered; speech-language pathology referral
ImmobilityTurn and position, range of motion, early mobilization when stable, DVT prevention
Neglect (right-hemisphere stroke)Approach and teach the client to scan toward the affected side; arrange the environment for safety
Aphasia (left-hemisphere stroke)Simple yes/no questions, picture boards, allow time, do not finish sentences
Homonymous hemianopsiaPlace items within the intact visual field; teach head turning to scan
FallsFall precautions; assistive devices; supervised transfers

Expressive (Broca) aphasia: understands but cannot speak fluently. Receptive (Wernicke) aphasia: speaks fluently but with impaired understanding.

Left vs right hemisphere

Questions often ask which behavior or safety risk to expect.

Left hemisphereRight-sided weaknessAphasia (language)Slow, cautious behaviorAware of deficits; may be depressedSafety: communicationRight hemisphereLeft-sided weaknessLeft neglect, spatial problemsImpulsive, poor judgmentDenies or minimizes deficitsSafety: fallsvs
Side matters. The weakness is on the opposite side of the body from the affected hemisphere.

NGN-style case

Time and safety come first.

functions Clinical judgment case — sudden weakness

At 0930 a client on a medical unit cannot lift the left arm and has slurred speech. The client was talking normally at 0900. BP 196/108, glucose 112 mg/dL. Which actions are appropriate? (1) Activate the stroke team; (2) record 0900 as last known well; (3) give oral aspirin now; (4) keep the client NPO; (5) prepare for CT.

  1. Recognize cues: sudden left arm weakness and slurred speech; normal glucose.
  2. Analyze: acute stroke, possibly eligible for thrombolysis (within 4.5 hours).
  3. Aspirin is not given before imaging, and nothing is given by mouth before a swallow screen.
  4. BP above 185/110 must be lowered before thrombolysis if it is given.

Answer. Appropriate: 1, 2, 4, and 5. Not appropriate: 3.