Stroke Cheat Sheet
Stroke Cheat Sheet
Stroke Cheat Sheet
Stroke
Neurologic
t 1. Pathophysiology & Assessment
Cerebrovascular accident (CVA) (stroke) is a lack of Risk factors for stroke are associated with increased risk
cerebral perfusion from either ischemia or hemorrhage for vascular damage or clot formation:
(FIGURE 1): #1 risk factor = hypertension (SBP >140).
y Ischemic: Clot forms (thrombosis) or breaks off y Diabetes mellitus
(embolism) in a cerebral artery cerebral perfusion y Obesity
y Hemorrhagic: Bleed in the brain (typically from y Smoking
ruptured aneurysm) intracranial pressure (ICP) y Atherosclerosis
cerebral perfusion y Atrial fibrillation
y Carotid stenosis
Transient ischemic attack (TIA) = temporary lack of
cerebral perfusion (resolves within 24 hours).
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1. Pathophysiology & Assessment, Continued
Left-sided stroke (Language):
TABLE 1. WARNING SIGNS OF STROKE
y Causes speech and language deficits
y Implement interventions for aphasia (see TABLE 3).
F Facial drooping
y Types of aphasia:
y Expressive (Broca): Understands language but
A Arm weakness or drift
has difficulty speaking (Broca = “broken” speech)
y Receptive (Wernicke): Can speak but has
S Speech difficulties difficulty understanding language
y Mixed aphasia: Both expressive and receptive
T Time: seek immediate treatment
Right-sided stroke (Recklessness):
y Causes behavior changes and spatial awareness
Assessment findings indicate neurologic changes: deficits (left-sided neglect)
y Unilateral weakness or paralysis (hemiparesis)
Neurologic
Implement fall precautions due to impulsivity and
y Weakness is opposite from the affected side impaired balance.
(right-sided stroke left-sided weakness).
y Motor deficits (ataxia) 2. Acute Interventions
y Clients with hemorrhagic stroke may also Priority interventions for stroke include:
experience: 1. Protecting the airway
Severe headache or “worst headache of 2. Assessing type of stroke and time of onset
my life” 3. Restoring cerebral perfusion
y LOC
1. Protect the airway:
Other symptoms vary based on which region of the brain y Assess for airway compromise related to
is affected: dysphagia (choking, coughing, gurgling).
NPO until swallow evaluation to prevent
FIGURE 2. LEFT-SIDED VS. RIGHT-SIDED STROKE aspiration
2. Assess stroke type and time of onset:
If onset <4.5 hours ago, a client with an
ischemic stroke may be a candidate for
fibrinolytic therapy (tPA).
Immediately perform a head CT to determine
whether stroke is hemorrhagic or ischemic.
y Other assessments:
y Measure blood glucose to rule out
hypoglycemia, which mimics stroke
symptoms.
y Frequent neuro assessments using the NIH
stroke scale (measures stroke severity)
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2. Acute Interventions, Continued
3. Restore cerebral perfusion: TABLE 2. ABSOLUTE CONTRAINDICATIONS FOR
y Intervention depends on whether a stroke is FIBRINOLYTIC THERAPY (tPA)
ischemic (give tPA) or hemorrhagic (surgery).
y Active bleeding
Ischemic stroke:
y Current or prior intracranial hemorrhage (ICH)
y Administer fibrinolytic (i.e., “clot buster”) as prescribed
y Aortic dissection or cerebral vascular malformation
if symptom onset <4.5 hrs ago
(e.g., AV malformation)
(see FIBRINOLYTIC THERAPY).
y Head trauma, cranial surgery, or ischemic stroke in
y Prepare for possible embolectomy (clot retrieval
past 3 months
procedure).
y Maintain SBP 160-180 mmHg for first 48 hours to
increase cerebral perfusion (permissive hypertension). 4. Post-Acute Interventions
Post-acute interventions for stroke focus on:
Hemorrhagic stroke:
y Preventing complications (falls, aspiration)
Neurologic
y Implement interventions toICP (elevate HOB,
y Supporting communication and sensory impairment
minimize stimulation).
y Maintaining adequate nutrition
y Maintain SBP <160 mmHg to keep ICPand
prevent rebleeding. Fall prevention:
y Implement seizure precautions (at risk due toICP). y Use assistive devices (walker, transfer belt).
No blood thinners, which can worsen bleeding When ambulating a client with hemiparesis, stand on
y Prepare for surgical repair of ruptured aneurysm. the client’s weak side so the client can lead with the
strong side.
3. Fibrinolytic Therapy
Aspiration prevention:
y Tissue plasminogen activator (tPA) using IV alteplase
y High-Fowler position when eating
dissolves clots to treat ischemic stroke, MI, or PE.
y Place food on the unaffected side to prevent food trapping.
y Before tPA infusion:
Clients with dysphagia require thickened liquids and
y Assess for contraindications that increase risk for a soft or pureed diet.
hemorrhage (TABLE 2).
Interventions to support communication:
y Establish at least 2 VAD lines.
y Complete all other invasive procedures before
TABLE 3. COMMUNICATING WITH CLIENTS WHO HAVE APHASIA
starting tPA torisk of bleeding (including
NG tube, urinary catheter).
y Ask yes or no questions instead of open-ended
y During tPA infusion:
questions.
#1 priority = monitor for intracranial Speak at a normal volume because raising your
hemorrhage (ICH). voice does not improve understanding.
Stop infusion and notify HCP if client develops y Use simple instructions, giving one step at a
signs of ICH: time.
y LOC y Use picture and communication boards.
y Hypotension y Give extra time for the client to understand
y Nausea and vomiting instructions and complete tasks.
y Frequent VS and neuro assessments y Repeat yourself as needed.
y Administer IV labetalol for SBP >180 mmHg
(HTNrisk of ICH).
Fall precautions and aspiration precautions Decreased LOC during tPA administration
should be implemented for a client having a is a warning sign of life-threatening
stroke. The client should remain NPO until a intracranial hemorrhage.
swallow evaluation is performed.
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4. Post-Acute Interventions, Continued
Vision impairment interventions: Preventing future strokes:
Dress affected side first. y Carotid angioplasty: Catheter is inserted through
Have client scan surroundings for safety by turning the the femoral or radial artery to place a stent, opening a
head from side to side. narrowed carotid artery.
y Approach client from unaffected side. y After carotid angioplasty:
y Rotate meal tray to improve food visibility, especially y Frequently monitor VS and neurologic status.
for clients with left-sided neglect. Immediately report any change in LOC to the
Interdisciplinary referrals: HCP (could indicate stent occlusion).
y Registered dietician to support nutrition y Affected extremity should be kept straight and
y Speech-language pathologist to support swallowing monitored for impaired perfusion (pulses).
and communication
y Physical and occupational therapy to support mobility
Neurologic
The #1 risk factor for stroke is _____. A client with a stroke should remain NPO until
which evaluation can be performed?
A client reporting “the worst headache of my
life” is most likely experiencing a(n) (ischemic or Decreased LOC during tPA administration is a
hemorrhagic?) stroke. warning sign that may indicate _____.
Answers: 1. hypertension 2. hemorrhagic 3. head CT, 4.5 hours 4. swallow evaluation 5. intracranial hemorrhage
References:
Attributions:
Callahan, B., Hand, M., & Steele, N. (Eds.). (2023). Nursing: A y Types of stroke: Created with BioRender.com
concept-based approach to learning (4th ed., Vol 1). Pearson.
y Left-sided vs. Right-sided stroke: Created with BioRender.com
Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (Eds.).
(2023). Lewis’s medical-surgical nursing: Assessment and
management of clinical problems (12th ed.). Elsevier.
Tyerman, J., Cobbett, S., Harding, M. M., Kwong, J., Roberts, D.,
Hagler, D., Reinisch, C. (Eds.). (2023). Lewis’s medical-
surgical nursing in Canada: Assessment and management
of clinical problems (5th ed.). Elsevier.
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