Disease
headache, nausea, dizziness, difficulty walking, hand/foot weakness, numbness/tingling, hiccups, clumsiness of hands
What are examples of atypical stroke symptoms
what to do when a patient c/o any sudden vision change/disturbance occurring within 24 hours from arrival.
Call a code stroke "E" in BEFAST
What does a stroke neuro assessment entail?
what do you do when oral Aspirin is ordered for a stroke/TIA patient with a "failed" bedside dysphagia screening OR not appropriate to be screened?
Notify provider and request order is changed to most appropriate route (suppository)
Process to follow when code stroke is called to alert staff and facilitate a timely MD assessment (time).
Walkin Triage RN notifies charge RN with code stroke/patient name. Confirms with MD, then assigns pt.
This specific informaiton/time-frame is important when speaking with a person with stroke-like symptoms. It helps us determine if they are a candidate for neuro intervention. (e.g. IV Tenecteplase), thrombectomy)
What is the person's last known well (LKW)?
altered mental status, dizziness, BEFAST, numbness, atraumatic headache requiring CT scan
What are triggers/symptoms prompting a dysphagia screening, PRIOR to oral intake
2 clinician verification. "time out" attesting that 8-rights of medication were followed/confirmed PRIOR to administration. (co-signed on EMAR or written out in a note). Mark as done by other. 2. co-sign/verify with 2nd nurse, pharmacist, or non-ordering MD. (verify 8 rights, b/p, and weight)
What is a required on EMAR, as per NH policy, when documenting administration on Tenecteplase.
When drawing code stroke labs HOW much they be sent to lab
Make sure specimens are in GREEN bag and lab is aware they are a CODE and time sensitive. (must be resulted within 45 minutes)
Can a stroke neuro assessment (FULL NIHSS &pupils) be completed on a comatose or confused patient.
The stroke neuro assessment (FULL NIHSS &pupils) must be completed by using the standardized tool located on unit and by accessing QR code that nursing should have attached to badge as a on-hand reference for standardization.
Occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain.
What is Intracerebral Hemorrhage (ICH)
What are commons signs of patient with dysphagia prompting a "failed" screening outcome.
wet/gurgling voice after swallowing, throat clearing, spitting out food/liquid, tearing eyes, labored breathing, coughing
An irregular and often rapid heart rate that can increase your risk of strokes, heart failure and other heart-related complications. A major concern is the potential to develop blood clots within the upper chambers of the heart that may circulate to other organs and lead to blocked blood flow (ischemia).
What is atrial fibrillation (afib)
The nurse has a patient who just received IV Tenecteplase. Upon re-assessment they complain of a new headache and the NIHSS score has increased from the previous score. what should the nurse do next?
Contact provider IMMEDIATELY and anticipate bringing the patient for a stat CTH.
CTH negative
What is noted when imaging shows no head bleed
A brief interruption of blood flow to part of the brain, spinal cord or retina, which may cause temporary stroke-like symptoms but does not damage brain cells or cause permanent disability. An incomplete stroke
What is a transient ischemic attack (TIA)
Full NIHSS and PERRL/pupils with atypical symptoms(if applicable) as per provider order.
What is a stroke neuro check/assessment
What is the maximum blood pressure where Tenecteplase can be administered
What are common signs of a posterior stroke
Dizziness, unsteady gait, vision loss, confusion, LOC
What should the nurse complete PRIOR to acute stroke patient (ischemic OR hemorrhagic) transferring to ICU.
Complete a FULL set vitals and Stroke neuro assessment prior to transfer (even if not due yet) on ED STROKE flowsheet.
A rim of mild to moderately ischemic tissue lying between tissue that is normally perfused and the area in which infarction is evolving, may remain viable for several hours.
What is brain cells within the penumbra?
What are the 5 D's commonly associated with posterior stroke
The nurse must FIRST administer bedside dysphagia screening, if not already completed/passed, and ensure patient can safely swallow/"passes" BEFORE administering any Oral medications.
An advanced neurological procedure for removal of a cerebral occlusion using a mechanical device, also known as a clot retrieval device or stent retriever, and/or aspiration technique.
What is mechanical endovascular reperfusion (MER) therapy or thrombectomy. ** A code Biplane is called.
When people have this condition/type of stroke, they commonly state they suddenly developed the "worst headache of my life" often accompanied with n/v.
What is a subarachnoid hemorrhage.