Stroke Identification, Treatment, Risk Factors
4 hours after TNK administration, a pt develops headache, nausea and vomiting.
What is the priority concern?
Intercranial hemorrhage
Following TNK, these symptoms may indicate hemorrhage and require immediate provider notification
A pt experiences sudden aphasia that resolves completely after 15 minutes, MRI is normal.
Which statement is most accurate?
A TIA carries the same mechanism as ischemic stroke and requires full evaluation
TIAs require a complete stroke evaluation despite absence of imaging abnormalities
A patient's abbreviated NIHSS increases by 2 pts. The nurse does a full NIHSS which reveals a 4 pt increase from baseline. What is appropriate action?
Notify provider ASAP
Providers must be notified for any NIHSS change verified by a full NIHSS showing a change greater than 3 pts
A Patient arrives to the ED at 1000 with left sided weakness. LKW is 0730. TNK administered at 1017. Patient transferred to IR for thrombectomy.
Which documentation element is most important when transferring to IR?
Name of IR RN receiving report and NIHSS done together
This disease can damage blood vessels and increase stroke risks?
Diabetes
Following thrombectomy, a pt develops a cool lower extremity with an absent distal pulse. What is the nurse's immediate priority?
Notify the provider immediately
Loss of pulse following access procedures required immediate notification
Which of the following NIHSS items are included in the abbreviated NIHSS used after carotid procedures?
LOC (1a-1c) and motor arm/leg assessments (5a, 5b, 6a, 6b)
A thrombectomy procedure is delayed after the initial timeout. What must occur before the procedure starts?
Repeat timeout
A timeout must be repeated if there is a delay before procedure initiation.
Patient presents with left MCA occlusion. Which deficit would most likely be expected?
Aphasia
Left hemispheric MCA strokes commonly produce aphasia
The RN must immediately notify the provider after TNK for which findings?
Change in any vital sign, LOC, new headaches, bleeding
What is the fundamental rule regarding scoring patient responses on NIHSS?
Score what the patient actually does not what you think they can do
An RN documented a vascular puncture site as an incision in Epic. What potential problem can occur?
Vascular site assessments may not populate in the thrombectomy flowsheet
The puncture site must be entered as vascular puncture to populate correctly
Which hemorrhagic stroke subtype primarily requires aneurysm occlusion to prevent rebleeding?
Subarachnoid hemorrhage
SAH treatment focuses on securing the ruptured aneurysm via coiling or clipping
Notify provider immediately and prepare for hemorrhage workup
How many seconds must the RN instruct the pt to hold his arm up if tested in the supine position?
10 seconds
Before giving oral food, fluids or medications to many acute stroke patients this should be addressed?
Dysphagia/swallow screening
Which symptom cluster should raise concern for basilar artery occlusion?
Dizziness, diplopia, dysarthria, dysphagia
These are classic posterior circulation findings
This medication history is especially important because it can effect ineligibility for certain acute stroke treatments?
Anticoagulants/antiplatelet use
How many seconds must the leg be help up in the supine position during the evaluation?
5 seconds
When documenting a stroke patient's change in condition, the RN should record the time of the change and this additional information?
Objective neurological findings