Gen Ed
What is the most common type of stroke?
Ischemic Stroke
What is the treatment time window to receive TNK?
Within 4.5h of symptom onset.
After a Mechanical Thrombectomy, for how long are frequent vitals and assessments performed and documented on the post-procedure flowsheet?
24h
What are potential complications of post-Mechanical Thrombectomy?
Device-related: vasospasm, arterial perforation and dissection, and device detachment during the procedure.
Arterial Site Complications: Bleeding, pseudoaneurysm, localized infection, embolization of artery distal to puncture site, parasthesias, pain
Hemorrhage (Systemic and Intracranial): ICH, retroperitoneal/GI/GU bleeding. Oozing from gums/venipuncture sites, hemoptysis
What is the evidence-based screening tool used by nursing at RWJUH to assess the patient’s ability to safely and effectively swallow?
Yale Swallow Screen
What is the greatest risk factor for Ischemic Stroke?
Hypertension
Who administers TNK to patient at RWJUH?
Neurology LIP
In addition to the vitals, what other information needs to be documented on the patient that underwent a Mechanical Thrombectomy?
NIH Score, neurological assessment, procedural site assessment, and neurovascular assessment
What signs/symptoms can be an indicator of hemorrhagic conversion in the post-Mechanical Thrombectomy patient?
Headache, increased Lethargy, increase in NIH score of 2-4 points, change in hemodynamic status
Is the patient required to pass the Yale Swallow Screen prior to administration of medications by mouth?
Yes
What condition (whose symptoms last <24h) is a medical emergency and is a major warning that a stroke is likely to occur?
Transient Ischemic Stroke (TIA)
A patient met criteria to receive TNK (Tenecteplase) in the Emergency Room at 0817. What time should the next set of vitals be documented?
0832 OR 0830
What is the frequency of vital signs and performance of NIH Stroke Scale post Mechanical Thrombectomy?
Q15min for 2h; then Q30min for 6h; then Q1h for 16h
What assessments are included in neurovascular checks of affected extremity post-Mechanical Thrombectomy?
Assess pulses distal to arteriotomy site, capillary refill, skin color, temperature, sensation, and motor function.
If the patient fails the Yale Swallow Screen, what are appropriate subsequent actions?
Patient remains NPO, order formal Swallow Screen by SLP, insert NGT/OGT for medication administration and nutrition (once ordered)
What is the acronym used to identify the warning signs of a stroke?
B.E.F.A.S.T.
What is the most common potential complication after TNK administration?
Hemorrhage (Intracranial or Systemic)
What is the frequency of performing puncture site assessment and neurovascular checks post-Mechanical Thrombectomy?
Q15min for 1h; then Q30min for 1h; and then Q1h for 4h
What patient attributes increase risk of airway compromise post-procedure?
Decreased LOC, signs of increased ICP, seizures, cerebral and pulmonary edema;weakened oropharyngeal function, slurred/slow speech, and inability to manage secretions
Patient has a fingerstick reading of 162 post-Mechanical Thrombectomy and is NPO, what should you do next?
Medicate with insulin coverage as ordered and check fingersticks as ordered. Rationale: Extremes in glycemic control are associated with worse outcomes after stroke.
What does the acronym B.E.F.A.S.T stand for?
Balance: sudden loss of balance/coordination, difficulty walking
Eyes: sudden change in vision
Face: drooping or numbness to on one side of the face
Arm (and Leg): Weakness in a limb
Speech: Difficulty speaking or understanding others
Time: Call 911
Patient received TNK at 1700, then went to Interventional Radiology afterwards for Mechanical Thrombectomy. The nurse notes hemostasis time at 1850. When is the patient due for next set of vitals?
1905
You’ll be receiving a patient that underwent a Mechanical Thrombectomy in IR. The procedural nurse informs you that the hemostasis time is 20:00; and that he completed a set of vitals as ordered. The patient arrives to the unit at 20:20. When should you document next on the Post-Procedure Flowsheet?
20:30
While performing frequent assessments post-Mechanical Thrombectomy, patient noted to have NIH score of 7, patient was previously 3. What are expected next steps?
Inform provider of change in score (increase of >3), document in EHR score change and provider notification, repeat performance of NIH; possibly prepare for non-contrast head CT.
Patient is febrile post-Mechanical Thrombectomy, there is no order for antipyretic. What are possible next steps?
Obtain order for anti-pyretic from provider, obtain cultures (if ordered), perform nursing measures that promote cooling/normothermia.