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
Can dizziness be a reason to activate a Code BART?
Yes- if patient
c/o the room spinning/shaking,
Persistent and sudden onset (≤ 4.5hr)
Dizziness is not related to position.
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)
When admitted to a telemetry unit, how often are neuro checks completed?
Every 4 hours - initial assessment is an NIH, following assessments can be an NIH or SNAP
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
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 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
When documenting a full NIH do you have document pupils?
No, pupil assessment is only required with a SNAP assessment
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
As the primary RN, what are your priorities for a Code BART patient?
1. Symptom discovery - BE FAST symptoms or sudden sever HA
2. Determine LKW
3. Vital Signs/ Neuro assessment
4. POCT glucose
5. Actual weight (bed/standing scale) - or delegate
5. Transport to CT/help place the patient on monitor
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 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
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)
Why are BP parameters for stroke patients so important?
Hemorrhage: prevent further bleeding.
Post‑TNK: prevent bleeding complications.
LVO without thrombolytic therapy: support and optimize cerebral perfusion.
How do you activate a Code BART?
Dial x3000
(campus, unit, room number, patient name, caller’s name, and call back number.)
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 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 needs to be done prior to giving TNK?
1. Weight - actual weight
2. NIH within 15 min of giving TNK
3. BP control
4. Nurse Dual sign
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.
For a Code BART 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
When should you complete and document a swallow screen?
Document at least 1 minute prior to giving anything PO- including dissolvable meds.