Stroke Basics
What does BEFAST stand for?
Balance
Eyes
Face
Arms
Speech
Time
What is the timeframe for being a candidate for TNK?
LKW≤ 24 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
Who can call a code BART?
Any caregiver
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 BART?
Yes- if patient c/o the room spinning/shaking, sudden onset (≤ 24 hr), or dizziness is not related to position.
What are the vital sign and neuro check requirements post TNK admin?
q15min x2hr
q30min x6hr
q1hr x16hr
What are the BP parameters for an Intracerebral hemorrhage?
SBP 130-150
How do you activate a code BART?
Dial x3000
Remember to leave a correct call-back #
What are some risk factors for aspiration?
- Inability to remain alert for the test
-Eats a modified diet
- Existing external feeding tube
- HOB restriction requiring HOB<30 degrees
- Strict NPO orders
If the patient is having a difficult time participating in an NIHSS exam due to LOC what resource can be utilized?
Comatose NIHSS scale located in all ICU rooms in stroke packet
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
What is the activation criteria for a code BART?
+BE FAST
Or if patient has a known stroke and has a new symptom (new number being scored on NIHSS)
LKW within 24 hours
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
According to stroke quality measures, eligible patients with ischemic strokes should receive VTE prophylaxis by this hospital day.
Hospital day 2--Aspirin and Plavix do not count. SCDs must be documented as on if no chemoprophylaxis is ordered. If patients refuses document patient refused and follow up with MD regarding chemoprophylaxis orders.
What needs to be done prior to TNK admin?
1. Weight - actual weight
2. NIH/VS within 15 min of giving TNK
3. BP control
4. Nurse Dual sign
While in the ICU, how often should an NIHSS/SNAP be documented on bleed patients?
Q1 hour and PRN decompensation
What is our time goal from activation to CT start for code BART patients?
10 minutes
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 and made NPO until then. Even if they were screened at sending facility.
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 who receive TNK?
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 blood pressure medications are typically utilized for hemorrhagic stroke patients?
As the primary RN, what are your priorities for a Code 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. Must be 1 min prior to PO intake.