BEFAST
Jeff was outside walking and all of a sudden fell in his driveway, Jeff did not have a mechanical fall. As the triage nurse what symptom is Jeff displaying and what is the appropriate next step?
What is Balance ?
What is establish LKW?
What is activate a stroke alert if less than 24 hours of symptom onset?
What is obtain blood glucose and weight?
Atrial fibrillation increases risk of stroke due to blood pooling in this area.
What is the left atrial appendage?
Who eligible for TNK ?
What is :
- Patients 18 y/o and older
-LKW up to 4.5 hours
-Not on AC
-No bleeding on CT scan
You ask the patient to perform heel to shin testing and finger to nose. You are testing for ____.
What is ataxia?
Ataxia test's for coordination of movement's. If ataxia is noted it would indicate the thought process of an issue in the cerebellum.
What is the goal time for door to TNK ?
What is less than 60 min with goal of less than 45min.
** AS nurse always document reasons for delays : example patient needing sedation/intubation prior to imaging, difficult IV access, difficulty obtaining consent ect.
You have a 88 year old female whom presents to the triage desk reporting she was reading the newspaper and all of a sudden experienced visual loss in her right eye 30 min PTA. What should be the next step as the triage nurse?
What is activate a stroke alert for stroke symptoms?
This brain lobe is responsible for reasoning, memory, impulsivity, and voluntary eye movements.
What is the frontal lobe?
What is the blood pressure goal prior to TNK administration?
What is the TNK goal during and after administration of TNK?
-What is: 185/110
-What is 180/105
You are performing an NIHSS on Mrs. Curtis. You enter her room and she appears to be sleeping. You call her name out loud and she does not answer. You then rub her chest to have her awaken and she responds with "what?!" . What should her LOC score be?
LOC: 2
LOC 2- Not alert, requires repeated stimulation to arouse.
Your patient is in CT and the neurologist reports to you that the patient has a hemorrhagic bleed. What is your primary focus at this time?
What is: Obtain blood pressure reading ASAP, obtain blood pressure goal from provider/communicate on handoff, manage and monitor blood pressure closely.
AHA Guidelines recommend blood pressure systolic goal 130-150.
Penny is a 62 year old female whom presented to the ED with a left facial droop. Penny is asking for some water for her dry throat. What should the nurse do prior to administering water.
What is perform a stroke swallow screen?
What is fail Penny on the stroke swallow screen?
What is not give PO medications if swallow screen if failed?
A patient presents with a visual field deficit and may have a stroke in this area of the brain.
What is the occipital lobe?
What is the max dose for TNK ?
What is 25 mg/5ml.
You are doing the visual field testing on Mr. Brown. You notice that Mr. Brown cannot count fingers in the right upper and right lower quadrants. His NIH for visual field testing is :
What is 2 - partial hemianopsia
Describe stroke alert process when EMS activates stroke alert?
What is:
-EMS brings patient to CT scan
-Obtain blood glucose and weight
-Move patient to CT scan
You have a 52 year old male who presents to the ED with right arm weakness. Patient reports symptoms started 20 min PTA. You are the nurse start the thought process of TNK. What is the time window for TNK for this patient?
What is up to 4.5 hours from symptom onset?
Your patient comes into the emergency department with sudden onset of dizziness and ataxic gait. What part of the brain is being effected in this patient?
What is the cerebellum?
You are administering TNK to a patient whom reports sudden onset of headache and then starts to vomit. The next step you should take is :
What is stop the TNK and notify the doctor immediately and obtain order for STAT CT head.
Your patient is receiving TNK; what is the TNK protocol for obtaining NIH assessments and VS?
What is :
NIHSS+ VS documented prior to TNK.
NIHSS + VS every 15 min x 2 hours.
NIHSS + VS every 30 min x 6 hours.
NIHSS + VS every 1 hour up to 24 hour mark of TNK.
Describe how to perform stroke swallow screen?
What is :
-Perform on every suspected stroke patient
-Follow exact prompts in stroke swallow screen
-If patient does not pass swallow screen patient should be strictly NPO including medications.
-Swallow screen needs to be documented prior to PO administration.
A 72 year old woman with history of AFIB on Xarelto with last dose today at 9AM, presented with sudden onset of word finding difficulties. The son reported she was speaking but her sentences were not making sense, her symptoms have not improved and symptom onset was 1.5 ours PTA. Is this patient a TNK candidate?
What is no?
Patient on AC cannot receive TNK
Describe the difference between an ischemic stroke and hemorrhagic stroke along with the risk factors associated with each.
What is: an ischemic stroke involves a blockage of blood flow to brain tissue where hemorrhagic stroke involves rupture of blood vessel and bleeding.
Ischemic stroke risk factors: HTN, DM, Chol., Smoking, Substance Abuse, AFIB, ETOH, Obesity, OSA
Hemorrhagic Stroke Risk factors : Smoking, HTN, Alcohol use, Drug use
Patient is receiving TNK and patient is on Lisinopril at home, the patient starts to develop angioedema. What is the next step?
What is : Stop TNK and treat anaphylaxis.
Your stroke patient is intubated and sedated at this time, they cannot participate in answering questions from the NIH assessment and cannot follow commands at this time for NIHSS assessment. How should you document a score for this patient?
What is : NIHSS assessment is to focus on scoring what patients are able to to do, if patient cannot perform task or assessment is not able to be obtained you must score 0 and note that you are unable to obtain assessment and why. *NEVER LEAVE BLANK*
Explain the difference between Code neuroendovascular and stroke alert.
What is :
Code Neuro Endovascular is called when a Large Vessel Occlusion is noted on CTA- Patient may be eligible for EVT / clot retrieval with neuro surgery team .
Stroke Alert - An alert called for patient experiencing stroke symptoms up to 24 hours from onset and patient may be eligible for TNK if LKW is less than 4.5 hours.