Assessment
What imaging is required for patients with S&S of stroke?
CT Head w/out contrast Per Stroke Protocol
Rule in/out hemorrhage stroke
CTA Head and Neck Per Stroke Protocol
MRI (Confirm or rule out CVA)
This does not mean they did not have a TIA or
aborted CVA post lytic
This Chronic Disease requires EDUCATION and should be monitored daily for control through diet, exercise, and medications.
What is Diabetes Mellitus
Hgb A1c >7 – Diabetic Educator Consult,
possible endocrinology referral and/or medication adjustment
Measures required on admission
What are
Yale Swallow Screen
This is required prior to anything taken by mouth (including meds)
Antithrombotic by day 2 (midnight)
ASA (rectal if NPO)
NIHSS on arrival
CT, CTA head and neck, MRI
VTE prophylaxis
Lipid profile within 48 hours
Admitted to unit with telemetry
The time sensitive window for treatment with IV thrombolytic for patients with ischemic stroke?
What is 4.5 hours from Last Known Normal
ED- Door to Needle Goal <45 minutes
Hemorrhagic stroke patients systolic blood pressure goal
Goal SBP <140 mmHg
(maintain between 130-150 mmHg)
Vertigo and disequilibrium may be a symptom of a CVA in what area of the brain?
What is a posterior circulation stroke
This controllable risk factor deals with the pressure of circulating blood on the walls of blood vessels.
What is Hypertension
Regardless of LDL, ischemic stroke/TIA patients should be discharged on what intensity statin or have a physician documented reason for not prescribing
What is high intensity statin
Pt’s >75 years of age moderate or high intensity
*LDL should still be measured within 48 hrs of arrival
Patients with LVO should be considered for what treatment(s)
What is IV Thrombolytic therapy and/or
endovascular thrombectomy
Patients with aneurysmal subarachnoid hemorrhage may be candidates for what procedure
What is endovascular coiling or clipping
Performed at HMCN or CSC
The most important assessment for thrombolytic and thrombectomy consideration
What is the ACCURATE time for
“Last Known Normal”
This controllable risk factor should be assessed on admission for use within the last year. Education is required and cessation should be taught.
What is tobacco use
Printed Tobacco Cessation ExitCare should be provided to patient.
The Hendrick Cancer Center takes referrals for one-on-one counseling for tobacco cessation with Linda Neill (requires physician referral)
Name 2 treatments acceptable for VTE prophylaxis in the stroke patient
Chemical Prophylaxis (Only ischemic/TIA)
(enoxaparin, warfarin, heparin, apixiban or rivaroxaban)
Mechanical Prophylaxis
(foot pumps or pneumatic compression device)
MUST FOLLOW ORDERS- Do not document “on approved chemical” in place of mechanical!
Ischemic Stroke patients with large vessel occlusion should be considered for endovascular thrombectomy (LVO Code) up to __ hours from last known normal
What is the 24 hour window for treatment
If last known normal 6-24 hours-
CT or MR perfusion required to determine eligibility
Patients diagnosed with an intracerebral hemorrhage (ICH) may require what intervention(s) by neurosurgery
What are
Craniotomy
EVD (external ventricular drain)
Ensure EVD Care Orders are entered by neurosurgeon
The NIHSS is performed in this manner
What is a systematic NIHSS assessment without skipping steps
Notify physician of any increase in NIHSS
Additional controllable
risk factors for stroke
What are
High cholesterol
Poor Diet
Obesity
Inactivity
Medication Noncompliance
Illicit Drug Use
Name three discharge measures for ischemic stroke/TIA
What is
Antithrombotic – ASA, clopidogrel, Aggrenox
High intensity statin
Anticoagulant for current/history of A.fib/flutter – warfarin, apixiban, etc.
PT/OT/ST referral addressed
Education – Remember HMC Stroke ExitCare and risk factor education (smoking cessation, DM, etc)
HMC Discharge summary questions related to stroke
NOTE- Hemorrhagic stroke patients should receive PT/OT/ST
and education related to diagnosis and risk factors
Ischemic Stroke blood pressure goal(s)
With or without lytic/thrombectomy
No thrombolytic or thrombectomy –
Permissive hypertension up to 220/120 mmHg
With IV thrombolytic or thrombectomy-
Permissive HTN-Keep BP <180/105
(Must be below 185/110 prior to lytic)
After the RRT team arrives, _____ activates the stroke code/alert
RRT-House supervisor or CCU Charge Nurse
A PHYSICIAN MAY ACTIVATE
STROKE CODE/ALERT without RRT
This is the acronym for identifying a possible stroke
What is BEFAST
B* Balance loss, trouble walking, dizziness
E* Eyes blurred or visual changes such as double vision or loss of vision in one or both eyes
F* Facial droop, severe headache
A* Arm weakness/drift or numbness in arm or leg (especially on one side of the body)
S* Speech slurring, trouble speaking, confusion
T* Time to call RRT!
Patients diagnosed with an ischemic stroke/TIA should be screened for these conditions as contributing factors and for secondary prevention
What are
Atrial Fibrillation/Flutter
Carotid artery disease
PFO (patent foramen ovale)
Diabetes Mellitus
Hyperlipidemia
What is the specific ExitCare that should be completed on all Stroke Patients and individualized risk factors/goals completed
HMC Stroke
(with risk factors and goals)
Per policy, nursing should assess/document the neurological assessment and vital signs
At minimum, on admission, discharge and with any neurological change
GCS must be assessed and documented for hemorrhagic stroke patients or ischemic stroke patients severely confused, not following commands or sedated
Post thrombolytic or thrombectomy assessments
every 15 min x 8, every 30 min x 12, every hour x 16 (VS timed with NIHSS)
Follow unit specific policy for additional requirements
Best practice- assess NIHSS together at shift change/nursing handoff
_____ is responsible for entering orders recommended during tele-neuro consult
Attending Physician
Tele-Neurologists are consultants only and make recommendations.
Nursing MUST facilitate communication between providers.