NIHSS Mastery
Which NIH item tests visual fields?
3
What is the most common type of stroke?
Ischemic
What is the current window for TNK?
4.5 hours or less
What is the earliest sign of increased intracranial pressure (ICP)?
Change in level of consciousness
What is the first line imaging for stroke?
Non contrast head CT per stroke alert
What is meant by Last Known Well or Last Known Well Time?
The last time the patient was at baseline/ seen normal
What common mistake should nurses avoid when performing the NIH?
Coaching or helping the patient
How should the NIH be performed/assessed?
At handoff with the oncoming RN
What is the primary pathophysiological problem in an ischemic stroke?
Lack of blood flow and oxygen - cell death
Name 1 major contraindication for TNK
Active bleeding or recent hemorrhage
Why must stroke patients be kept NPO until a passed BSS?
What are we looking for with the first CT?
Bleeding/Hemorrhage
What is our Stroke Alert to CT Goal?
10 minutes or less
What type of evaluation must be performed prior to discharge?
PT, OT, and/or SLP
How do you score ataxia in an intubated & sedated patient?
Absent or Zero
What is the penumbra?
Tissue that is not yet permanently damage, still viable
What is the maximum dose of TNK for a CVA?
25mg
What is the neurocheck frequency after receiving TNK?
Q15 mins for 2 hrs, Q30 mins for 6 hrs, Q1 hr for 24 hours, use TNK timer
What can show up on a CTA that is a medical emergency?
LVO (Large vessel occlusion)
Why must a POC glucose be obtained prior to administering TNK?
Because hypoglycemia mimics stroke
What is a precursor for Stroke, where 1 out of 3 will have a stroke within 90 days?
TIA
When performing the NIH, the patient's arm drifts, but does not hit the bed, what is the score?
1
What is the most common artery a stroke occurs in?
MCA
What nursing intervention is needed if the patient has a BP of 185/115 and you are about to administer TNK?
Lower BP with medications - Labetalol and/or nicardipine.
BP must be less than 185/110
Why is blood pressure sometimes kept higher in ischemic stroke patients?
To maintain cerebral perfusion
What is CTP imaging looking for?
Assess brain tissue viability and ischemic penumbra
What mandatory item must be used if the patient received TNK?
TNK Timer
What medication route should be used for oral medication if the patient has a OGT?
OGT
High suspicion of LVO is determined by an NIH score of what or greater?
6
How many brain cells are lost every minute during a stroke?
2 million
When can antiplatelets/antithrombotics be started after receiving TNK?
24 hours from the time of TNK and they must have a head CT negative for a bleed
What position is recommended for a patient with increased ICP after a stroke?
HOB elevated 30 degrees, neutral head/neck alignment
What should the nurse do if stroke symptoms resolve before imaging?
Continue process; possible TIA still requires eval & treatment
What is the biggest cause of delay in stroke treatment?
Stroke recognition
What type of education must be completed prior to discharge on stroke and TIA patients?
Stroke Education, Diabetic Education and Social Habits Education
How often does the NIH need to be performed?
On admission, at shift change throughout entire hospitalization, as needed with any neurological change and at discharge
In a hemorrhagic stroke, bleeding most commonly occurs in which two areas?
Intracerebral & Subarachnoid space
What is a major complication to monitor for after thrombolytic therapy?
Bleeding, especially intracranial hemorrhage
What do you anticipate if your patient develops sudden unequal pupils?
Treat as a neurological emergency, prepare for STAT head CT, possibly call stroke alert
What diagnostic test is done after a stroke is determined, to find the source of emboli?
ECHO
You are caring for a post-op CABG who was clearly speaking and alert and oriented during 0900 med pass. You go back in to evaluate your patient and he has slurred speech, facial droop, and he is confused. What do you do?
1)Call a stroke alert
2)Call and speak with CTS (surgeon ONLY) to verify if the patient may be transported to CT
What is the most common cause of fever post-stroke, and how does it affect neurologic outcomes?
Aspiration pneumonia & it worsens neurological outcomes