Stroke Basics
What does BEFAST stand for?
Balance/unsteady gait
Eyes
Face
Arms
Speech
Time
What is the timeframe for being a candidate for TNK?
LKW≤4.5 hours
What are some common symptoms of hemorrhagic strokes?
HA (mild to severe) - not relieved by medications or different than their normal HA
Nausea/vomiting
LOC/confusion, pupil changes, neck pain/stiffness, numbness/weakness on one side, etc
What is the difference between a Code Stroke and Code BART?
Code Stroke - ED only, non-admitted patients. Uses Telestroke at Noc
Code BART - Inpatient/admitted patients only. Uses NHT 24/7
What types of patients require a nurse bedside swallow screen?
- Stroke or TIA-like symptoms
- Any neuro change and/or Code BART
- Potential or identified swallow/feeding deficit
- Patients extubated following prolonged intubation (>48hr)
Can dizziness be a reason to activate a Code Stroke?
Yes- if patient
c/o the room spinning/shaking,
Persistent and sudden onset (≤ 4.5hr)
Dizziness is not related to position.
How often should VS and Neuro Checks be done after giving TNK?
q15min x2hr
q30min x6hr
q1hr x16hr
What are the BP parameters for an Intracerebral hemorrhage?
SBP 130-150
How do you activate a Code Stroke?
1. Dial x3000 (campus, unit, room number, patient name, caller’s name, and call back number.)
2. Pulsara
3. Call DAC Telestroke Hotline if 19:00 - 7am
What are some of the Severe Risk Factors that would prevent you from doing a swallow screen?
- Inability to remain alert for the test
-Eats a modified diet
- Existing external feeding tube
- HOB restriction requiring HOB<30 degrees
- Strict NPO orders
For a patient with a Large Vessel Occlusion identified on imaging, what interventions are necessary?
-HOB flat, as tolerated
-Perfusion- maintain SBP≤220/120 prior to IR
You patient has a stated weight in Epic of 58.3kg, how much TNK should the patient receive?
Cannot use a stated weight for TNK must be an actual weight.
15 mg - 3ml (if actual weight)
While in the ED, how often should an NIHSS/SNAP be documented on bleed patients?
At least q2 hours
When would you use the Thunderclap Headache Algorithm in the ED?
Sudden onset of severe HA and BEFAST negative (no neuro deficits). Concern for SAH.
True or False:
If a patient fails a swallow screen, but their neuro exam improves later on, we can rescreen them at the bedside.
False:
If the patient fails, you MAY NOT rescreen them. They have to be seen by SLP. Even if they were screened at an OSH.
What assesments are part of the LAMS score?
Is controlling blood pressure an appropriate reason to delay giving TNK?
What are the BP parameters for a patient that receives TNK?
Yes, prior to giving TNK please ensure that the BP ≤ 180/105.
What are the BP parameters for a Subarachnoid Hemorrhage?
SBP ≤140
Can you activate a Code Stroke when the LKW is over 4.5hr? Explain
If BEFAST positive, LKW ≤24hr, and LAMS 4-5. For inpatient: if patient has severe stroke/like symptoms and LKW ≤24hr
What are some symptoms that would 'fail' the patient before and/or during the swallow screening?
- Difficulty keeping food/liquid in mouth
- Difficulty managing secretions
- Fever w/ abnormal lung sounds and congestion
- Reports difficulty swallowing
- Requires frequent suctioning
- Wet/gurgly voice
What is included in a SNAP assessement?
- GCS, or parts 1a,1b,1c of NIHSS
- Extremity Movements- part 5a,5b,6a,6b of NIHSS
- Pupil reactivity
- Trending of original symptoms (i.e. facial droop, dysarthria, etc)
What BP meds are used for stroke patients?
What and how much is given?
1. Labetalol 10mg, recheck BP in 10min. Then 20mg and recheck in 10min.
2. Nicardipine gtt start at 5mg/hr, titrate by 2.5mg q5min
What is the "Say Yes to the Bed" protocol and what type of patients might it be used for?
This applies to SAH patients only, especially those with a known aneurysm and/or clinical instability. Such patients may require urgent intervention in the OR or IR, or CSF drain placement by Neurosurgery.
As the primary or triage RN, what are your priorities for a Code Stroke patient?
1. Determine LKW
2. Vital Signs/ Neuro assessment
3. POCT glucose
4. Actual weight (bed/standing scale)
5. Transport to CT
When should you complete and document a swallow screen?
Document at least 1 minute prior to giving anything PO- including dissolvable meds.