Acute Ischemic Stroke - 6 Nursing CEs

Author: Kristi Hudson RN MSN CCRN

Written: March 7, 2005

Updated: August 31, 2009

Course Objectives

Upon completion of this case study the student will be able to:

• Differentiate between ischemic and hemorrhagic stroke
• List 5 risk factors that contribute to Acute Ischemic Stroke
• Describe 5 common presenting symptoms of an Acute Stroke

• Describe the characteristics of the National Institute of Health Stroke Survey (NIHSS)
• Give the rationale and guidelines for the using the NIHSS
• Differentiate between mild, moderate and severe stroke using the NIHSS
• List the inclusion and exclusion criteria for administering IV Alteplase (t-PA)
• Have a better understanding of the different categories of the NIHSS
• Explain the proper dose of IV Alteplase (t-PA) administration
• State 3 post IV Alteplase (t-PA) administration considerations
• Describe the steps to take if Intracranial Hemorrhage is suspected during to IV Alteplase (t-PA) administration
• Discuss cardiovascular considerations for the Acute Ischemic Stroke patient
• Discuss blood pressure parameters and considerations for the Acute Ischemic Stroke patient
• Discuss measures to prevent PE/DVT for the Acute Ischemic Stroke patient
• Give the rationale for “patient focused education” as a prevention of further complications
• List 3 NANDA nursing diagnosis’ for the patient with an Acute Ischemic Stroke

What is the difference between an Ischemic and Hemorrhagic Stroke?

Ischemic Strokes: are caused by occlusions of the cerebral blood vessels. When this occurs; a focal brain infarction results. Cerebral angiography performed shortly after the onset of ischemic stroke reveals clots in large cerebral vessels in up to 80% of cases.

Hemorrhagic Strokes: also referred to as intracerebral hemorrhage (ICH), occurs when there is bleeding into the brain parenchyma.  The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension.

Risk Factors for Acute Ischemic Stroke Include:

• Age
• Male Sex
• Hypertension
• Diabetes
• Smoking
• Atrial Fibrillation
• Hypercholesterolemia
• Coronary Artery Disease

Common Presenting Symptoms of Acute Stroke:

• Ataxia
• Aphasia
• Facial or cranial nerve palsy
• Neglect
• Extremity weakness or paralysis
• Loss of sensation
• Numbness or tingling
• Change in LOC
• Alteration in behavior
• Visual field deficits
• Extra-ocular palsy
• Agnosia
• Deviated gaze
• Dysarthria
• ‘Locked In” syndrome

Characteristics of the NIHSS:

• There are 11 items of focus
• Score Ranges from 0-42, quantitative data
• A score of 0-8 is considered to be a mild stroke
• A score of 9-21 is considered to be a moderate stroke
• A score of 22 or greater is considered to be a severe stroke
• The NIHSS measure deficits commonly seen in stroke patients
• The NIHSS allows for standardized clinical terminology
• 1980 developed by NINDS neurologists and often used in clinical research

Rationale for use of the NIHSS:

• Quantify stroke severity
• Sensitive to subtle neurological changes
• Guide treatment options
• Predict outcome and prognosis
• Proven research tool
• Validity (accuracy)
• Reliability (intra & inter observer agreement)
• Consistency (variation within the scale)

Categories of the NIHSS:

• LOC (Arousal, Orientation Commands)
• Gaze abnormality
• Visual loss
• Facial weakness
• Motor weakness (Arm & Leg)
• Limb ataxia
• Sensory loss
• Language (Dysarthria Extinction and Inattention)

Guidelines for use of NIHSS (assessment should take 5-8 minutes):

• Test items in order
• Score what you see
• Score first attempt – minimal coaching
• Cuing can be used for aphasic, lethargic, uncooperative, inattentive patients
• Coma patient arbitrary scoring
• “9” scores to be described
• Check ataxia, facial weakness, language, sensory

 National Institute of Health Stroke Scale                                                          Score

Dysarthria Word List Includes:                                            

• Mama 
• Tip-Top
• Fifty-Fifty
• Thanks
• Huckleberry
• Baseball Player

Sentences to Repeat Include:

• You know how
• Down to earth
• I got home from work
• Near the table in the dining room
• They heard him speak on the radio last night

What is Tissue Plasminogen activator (t-PA) and how does it work?

Tissue plasminogen activator (t-PA) is produced endogenously by endothelial cells. It works by converting proenzyme plasminogen to activated enzyme plasmin. Activated plasmin in turn dissolves fibrin clots into LMW fibrin degradation products. It is produced by recombinant DNA techniques for clinical use. Serum half-life is 4-6 min but the half-life is lengthened when bound to the fibrin of a clot. Though  the criteria for the administration of a synthetic t-PA (Alteplase) is very stringent, it has been found to assist with dissolving clots that cause acute ischemic stroke. The following information lists the inclusion/exclusion criteria for the administration of IV or IA (intra-arterial) t-PA, as well as the risk factors that are to be considered:

Inclusion Criteria (all answers must be YES):

• Age 18 years or older
• Clinical diagnosis of ischemic stroke (causing measurable neuro deficit)
• Time of symptom onset < 3 hours for IV administration (well established)
• Time of symptom onset < 10 hours for IA administration (well established)

Exclusion Criteria (all answers must be NO):

• Evidence of ICH on CT
• Clinical suspicion of ICH with normal CT
• Minor or improving symptoms
• Known bleeding diathesis
• Platelet count <100,000/mm
• Heparin given within 48 hours and elevated PTT
• Recent use of anticoagulant and elevated PT >15 sec
• Intra-cranial surgery, TBI or Stroke within the past 3 months
• Any type of major surgery or trauma with in the past 14 days
• Evidence of an arterial puncture in a non-compressible site
• Lumbar puncture within the past 7 days
• Any history of ICH, AVM or aneurysm
• Witnessed seizure at onset of stroke symptoms
• Recent acute myocardial infarction
• SBP > 185 or DBP > 110 that requires aggressive treatment

Additional t-PA Critical Risk Assessment:

• Patients with severe neurological deficit
• NIHSS > 22
• Patients with major early infarction signs
  on CT
• Advanced age > 77

t-PA Administration for Acute Ischemic Stroke:

• IV 0.9 mg/kg, maximum dose = 90mg
• 10% of dose is given as a bolus
• Remaining dose infused over 60 min

Possible interactions to consider when administering t-PA:

Antiplatelet agents and anticoagulants increase risk of bleeding and should be avoided for 24 hours after the administration of t-PA. If these medications cannot be avoided, monitor for bleeding, especially at arterial puncture sites.

Post t-PA Considerations:

• Frequent vital signs - aggressive TX of BP
• Frequent Neuro checks
• ICH Protocol
• No ASA/heparin x 24 hours t-PA
• Bleeding Precautions
• Restrict vascular access and NGT during first
  24 hrs
• Restrict Foley Catheter insertion x 30 min after t-PA

Protocol for suspected ICH related to t-PA:

• Discontinue t-PA infusion
• Obtain blood for coagulation studies
• STAT CT
• Obtain Neurosurgical consult
• Prepare to transfuse PRBCs, cryoprecipitate, and platelets

Acute stroke nursing goals include:

• Monitor & Optimize cerebral circulation
• Monitor & Optimize cardiac and respiratory function
• Prevent complications
• Secondary stroke prevention
• Preparing patient and care givers for post-acute care
• Management based on ongoing assessment
• Evaluate patient’s response to treatment
• Early recognition of progressing neuro status
• Early recognition of cardiovascular and respiratory complications
• Safety and function issues
• Patient/caregiver emotional response to stroke

Nursing Assessment (Initial and On-going) for the acute stroke patient:

• Frequent monitoring of vital signs
• ABCs
• Temperature
• Baseline assessment
• Respiratory
• Cardiac
• Neuro
• Focused medical history
• Medications/allergies

Respiratory Considerations (monitor specifically for):

• Hypoxemia
• Respiratory Tract Infections
• Pneumonia is cause of 20-40% of all deaths post stroke

Respiratory Nursing Care:

• Ongoing assessment of airway and ventilation
• Monitor CXRs and cultures
• Positioning
• Pulmonary Toilet
• Pulse oximetry; maintain >PaO₂
• PaCO₂ at 30 mmHg for ventilator patient
• OOB when stable
• NPO until aspiration ruled out

Cardiovascular Considerations:

• Heart disease and cerbrovascular disease often coexist in same patients
• Common risk factors
• 12-17% of stroke related deaths due to cardiac disease
• Annual mortality due to MI 5-6% per year
• 40-70% of patients have clinical CAD
• 40% will have cardiac event during rehab

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