Call It Stroke
B
E
F
A
S
T
Balance: Loss of balance/coordination
Eyes: Sudden vision changes
Face: facial droop or numbness
Arm: new or increasing weakness/numbness of arm, or leg, especially on one side of the body
Speech: garbled/slurred speech or an inability to speak or confusion/disorientation.
Time: call RRT (using extension “222”) and note the time last known well (LKW) and time of symptom onset/identification.
How/ when does MSM RN do Neuro checks?
With NKE (e.g., nursing shift change; patient transfer from another unit/ department)
Upon a change in condition
At Discharge
As ordered by the Physician
Review patients’ chart and document Neuro Assessment
If the patient is a known or suspected Hemorrhagic Stroke admission, Complete the Glasgow Coma Scale (GCS), Basic Neurological assessment, and Complex Neurological assessment per unit standards.
Unit Standards:
Telemetry: Every 4hrs
What does the Primary RN report to the RRT using the SBAR format?
-The time the patient was last seen without stroke symptoms (i.e., time last known well)
-the time symptoms were identified.
When do you do a swallow evaluation?
The Registered Nurse is to perform a swallow screen before the patient takes anything by mouth, including oral medications.
A stroke patient who was transferred from a non-KP hospital, directly admitted to us, and who already has a soft diet in place because another facility might have different screening tools or any changes during the transport.
If the patient passes the initial screen, the nurse may start the diet as ordered by the physician. If no order is present, the nurse is to contact the physician and request a diet order.
If the patient fails the swallow screen, or if the patient has been fed enterally due to dysphagia, nursing will place an order for a Speech Therapy (ST) consult for a swallow evaluation.
If the patient passes the initial screen, the nurse may start the diet as ordered by the physician. If no order is present, the nurse is to contact the physician and request a diet order.
If the patient fails the swallow screen, or if the patient has been fed enterally due to dysphagia, nursing will place an order for a Speech Therapy (ST) consult for a swallow evaluation.
Speech Therapy referrals are NOT indicated under the following conditions: patients exhibiting signs and symptoms of a stroke but who are unresponsive, unable to follow commands, or who are uncooperative.
Speech Therapy referrals are NOT indicated under the following conditions: patients exhibiting signs and symptoms of a stroke but who are unresponsive, unable to follow commands, or who are uncooperative.
Primary RN/ Charge RN to obtain POCT or blood glucose immediately. Y/ N?
Yes
Hyperglycemia is common in the early phase of stroke. Hyperglycemia mimicking a left MCA syndrome without evidence of seizure reversed with medical management, (Shah et al., 2023).
Hypoglycemia can trigger a sequence of events that may induce stroke.
The AHA/ ASA recommends maintaining the blood glucose level in the range 140-180 mg/dl
When do you initiate a stroke plan of care/ patient care plan?
Upon admission
Education should be individualized for each patient
Smartphrase
Individualized patient care plan must be updated every shift and as needed
Who can activate Code Stroke?
RRT RN, MOD, Neurologist, ICU RN
Where to find stroke resources?
San Diego Stroke Program - Sharepoint
SD link--> San Diego Intranet--> Quick links--> Stroke Program
Unit Binder
DAILY DOUBLE (1000)
Blood Pressure Targets During Acute Stroke
KP Thrombolytic of Choice
Blood Pressure Targets During Acute Stroke
Treatment
Goal (mm Hg)
IV thrombolysis
< 185/110
Thrombectomy
≤ 185/110
Both IV thrombolysis and thrombectomy
< 185/110
Neither IV thrombolysis nor thrombectomy
<220/120
Hemorrhagic Stroke
Goal: 140 systolic. Target range is 130-150 systolic.
TNK= Tenecteplase
Bolus no IV gtt needed, cost-effective, and safe.
RRT RN to infuse.
The stroke admission/ discharge tool includes the pink sheet, Stroke Support Group List (in the Packet)
Member Education after Discharge – Positive Choice Program, and the patient satisfaction survey with the QR code. Y/N
Yes