Although we observed Stroke Awareness Month in May, part of my job is to increase awareness of stroke signs and symptoms year-round. The time is always right to shine a light on advances in stroke care. Caring for a patient with stroke can be nuanced and complex.
Prehospital Care
Care of the patient with stroke begins in the prehospital setting, with quick recognition of potential stroke symptoms, activation of emergency systems, as needed, and rapid transportation to an appropriate emergency department (ED).
- Did you know that hospitals have different levels of stroke care? Many emergency medical services find the best way to triage these patients using different prehospital stroke scales. A patient experiencing a large vessel occlusion should be transported to a facility with emergent neuro interventional radiology capabilities.
- Some cities have mobile stroke units, which are ambulances equipped with a CT scanner, point-of-care laboratory technology and a neurology provider (either in person or via telemedicine), so IV thrombolysis can be administered before the patient arrives at an ED. These advances in stroke care have led to major improvements in patient outcomes.
Emergency Department
When a patient arrives at the ED, they are emergently evaluated by a provider with stroke expertise, a system that has also seen technological advancements. Many facilities that do not have an in-house neurovascular specialist use telestroke technology. Audio and visual technology is used to connect a neurovascular specialist to the care team to assist with rapid identification of a patient’s need for acute treatment. The American Heart Association (AHA) recently published a scientific statement discussing the most recent evidence-based recommendations for nursing care of patients with ischemic stroke in the prehospital setting and during an acute phase of care.
Nurses working in prehospital and emergency settings are likely familiar with their facility’s protocols for activating a stroke alert. However, patients can have strokes at any point in time, including during an unrelated hospitalization. My main advice to new nurses or nurses starting at a new facility is to:
- Know your patient’s baseline neurologic exam. That way if there is an acute change it can be recognized early.
- Know your facility’s protocol for activating a stroke alert, whether it involves calling a rapid response or if there is a dedicated stroke team.
Stroke Recognition
Acute stroke presentations vary drastically depending on the size and location of the stroke. At my hospital we use the mnemonic BEFAST to help with stroke recognition. If a patient has a sudden onset of:
- (B)alance problems
- (E)ye problems
- (F)ace drooping
- (A)rm weakness
- (S)peech changes
- (T)ime to call a stroke alert. Generally speaking, if your patient has a sudden neurologic change within the last 24 hours, my recommendation is to call the experts.
Stroke Treatments
Other advances in stroke treatment have occurred since the early 1990s when there was no option for acute treatment:
- 1996 – IV tPA or alteplase was first approved for use in patients presenting within three hours of their last known normal baseline and was later expanded to 4.5 hours.
- 2015 – Endovascular therapy for patients presenting within six hours of their last known normal baseline and a large vessel occlusion (internal carotid artery or middle cerebral artery) became a standard of care.
- 2018 – DAWN and DEFUSE3 were published, and the previous six-hour window expanded to 24 hours for certain patients.
Stroke Assessment
Patients who have received thrombolysis and/or endovascular therapy require frequent monitoring of vital signs, neurologic assessments and neurovascular assessments. A recent publication from the AHA discusses care of the patient who receives endovascular therapy, thrombolytic agents and/or requires ICU level of care. Topics include:
- Management of patients with potential complications such as intracranial hemorrhage
- Systemic hemorrhage or orolingual angioedema after thrombolytic therapy
- Postprocedural complications such as pseudoaneurysm or retroperitoneal hematoma
Other considerations for post-intervention management of a patient with stroke are frequent assessments of the airway, hemodynamic status and a neurologic exam. Using the NIH Stroke Scale to perform neurologic exams and focusing on the patient’s initial presenting symptoms (improving? getting worse?) are helpful monitoring tips. Patients with large strokes may require osmotic therapy to reduce cerebral edema. AACN’s Critical Care Nurse journal has a great article detailing this therapy: “Safety of Peripheral Administration of 3% Hypertonic Saline in Critically Ill Patients: A Literature Review.”
Not all patients with stroke experience ischemic stroke, but about 12%-15% of all strokes are hemorrhagic, including intracerebral hemorrhage and subarachnoid hemorrhage. Management of patients with intracerebral hemorrhage may require immediate reversal of anticoagulants.
Other helpful articles on the AACN website for managing patients with stroke include:
- “Acute Ischemic Stroke”
- “Aneurysmal Subarachnoid Hemorrhage and Vasospasm”
- “Management of Subarachnoid Hemorrhage”
- “Fundamentals in Neurocritical Care for the Non-Neurocritical Care Provider”
Discussions about brain injuries should include patients who do not have optimal outcomes and the challenges that come with caring for these patients and their family members. An NTI recorded session has more information.
Secondary Stroke Prevention and Management
After the patient is out of the hyperacute phase, the focus shifts to secondary stroke prevention and treatment of known stroke complications. A recent scientific statement released by the AHA discusses this phase in a patient’s stroke recovery. Since patients with stroke are at a high risk for recurrent strokes, they will likely undergo a thorough evaluation of the causes of the stroke and be placed on appropriate medications to reduce the risk of further strokes. Nurses play a key role in monitoring for and preventing other common stroke complications, including:
- Dysphagia and associated aspiration pneumonia
- Urinary retention and/or urinary tract infections
- Constipation
- Post-stroke cognitive impairment
- Depression
- Delirium
- Falls due to impaired mobility and/or impaired awareness of new neurologic deficits
- Post-stroke pain
- Pressure injuries
- Venous thromboembolism
Nurses also have a crucial role in patient safety and preventing these complications. For more information on your role, explore how an AACN Clinical Scene Investigator Academy team educated patients about stroke and read an article in Critical Care Nurse.
Challenge Yourself
The guidelines for care of a patient experiencing a stroke are typically updated annually. Whether you’re an experienced neuro ICU nurse, a novice neuro nurse or have minimal experience with neuro patients, you can help educate patients about modifiable risk factors to prevent stroke and know the signs or symptoms of stroke. With increased awareness, patients will be more apt to seek emergent treatment. I challenge you to refamiliarize yourself with the most recent publications and educational offerings on stroke, stroke treatment and the guidelines.
How will you refamiliarize yourself with the most recent guidelines for care of a patient with stroke?
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