Stroke Basics
What does BEFAST stand for?
Balance
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), Nausea, vomitting, LOC, confusion, pupil changes, neck pain/stiffness, numbness/weakness on one side, etc
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 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)
Can dizziness be a reason to activate a Code Stroke/BART?
Yes- if patient c/o the room spinning/shaking, sudden onset (≤ 4.5hr), or dizziness is not related to position.
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
How do you activate a Code Stroke/BART?
Dial x3000
Remember to leave a correct call-back #
What are some of the Severe Risk Factors for dysphagia?
- Inability to remain alert for the test
-Eats a modified diet
- Existing external feeding tube
- HOB restriction requiring HOB<30 degrees
- Strict NPO orders
What assesments are part of the LAMS score?
What are the BP parameters for a patient that receives TNK?
BP ≤ 180/105
What are the BP parameters for a Subarachnoid Hemorrhage?
SBP ≤140
Can you activate a Code Stroke when the LKW is over 4.5hr? Explain
If BEFAST positive, LKW ≤24hr, and LAMS 4-5. For inpatient: if patient has severe stroke/like symptoms and LKW ≤24hr
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
For a patient with a Large Vessel Occlusion identified on imaging, what interventions are necessary?
-HOB flat, as tolerated
-Perfusion- maintain SBP≤180/105 prior to IR
What is a Wake-up stroke?
Patients that wake up w/ stroke symptoms or unknown time of onset and present to ED within 4.5hr of symptom discovery.
Ischemic stroke visible on MRI Brain DWI and NO corresponding FLAIR changes can receive TNK.
While in the ED, how often should an NIHSS/SNAP be documented on bleed patients?
At least q2 hours
When would you use the Thunderclap Headache Algorithm in the ED?
Sudden onset of severe HA and BEFAST negative (no neuro deficits). Concern for SAH.
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 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 q5min
What is the "Say Yes to the Bed" protocol and what type of patients might it be used for?
SAH patients only, especially if there is a known aneurysm, and/or the patient is unstable. These patients may need to go the OR/IR or get a drain placed by NSGY.
As the primary or triage RN, what are your priorities for a Code Stroke/BART patient?
1. Determine LKW
2. Vital Signs/ Neuro assessment
3. POCT glucose
4. Actual weight (bed/standing scale)
5. Transport to CT
When should you document a swallow screen?
Before documenting anything PO- including dissolvable meds.