9/18/13

Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

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Activating a Stroke Alert: A Neurological Emergency CE591 :: 1.00 Hours

Author: Anna Ver Hage, RN, BSN, CCRN, CNRN Anna Ver Hage, RN, BSN, CCRN, CNRN, is a staff nurse in the neurosurgical ICU at University of Colorado Hospitals in Aurora, a comprehensive stroke center. Objectives The goal of this program is to provide nurses with knowledge about how to quickly recognize and manage adult patients with signs and symptoms of acute stroke. After studying the information presented here, you will able to: State the benchmark treatment times for acute stroke Describe the differences in management of ischemic stroke and hemorrhagic strokes Discuss nursing interventions in the care of a patient presenting with an acute stroke

You are the nurse caring for a 76-year-old African-American man with an admitting diagnosis of heart failure. He has a past medical history of atrial fibrillation, previous transient ischemic attacks, hypertension and hyperlipidemia. Entering the room, you note right-sided weakness, expressive aphasia and right-sided facial droop. He is able to follow commands. When you saw the patient five minutes ago, he did not have any of these neuro deficits. He is not on a cardiac monitor. His vital signs are pulse 110 irregular, blood pressure 210/114, respirations 16 and O2 saturation 93% on room air. As the nurse taking care of this patient, what do you suspect is wrong? What are your nursing priorities? What do you need to focus your assessment on? What types of diagnostic tests do you anticipate? Being able to recognize the symptoms of an acute stroke and intervening appropriately will help to improve your patients outcomes. The public is more aware of stroke than ever before. The American Stroke Association uses the slogan Time lost is brain lost to emphasize the need to recognize stroke symptoms immediately and seek medical help quickly. Early assessment and rapid medical interventions save lives.1 Stroke is a leading cause of long-term disability and death in the U.S.2 Stroke is the result of a blocked or ruptured blood vessel that deprives brain cells of oxygen, resulting in tissue death in minutes.2 Brain cells die every minute during a stroke, which places the patient at risk for permanent brain damage or death.2 There are two types of strokes. An acute ischemic stroke is a neurological deficit of sudden onset caused by vessel blockage. An acute hemorrhagic stroke occurs when a blood vessel or aneurysm in the brain ruptures, causing blood to accumulate in the brain. Around 85% of all strokes are ischemic and 15% are hemorrhagic.3 But hemorrhagic
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

strokes account for more than 30% of all stroke-related deaths.2 Clinical Presentation of Hemorrhagic Strokes2 Intracerebral Decrease in level of consciousness Nausea or vomiting Sudden numbness and weakness of face, arm or leg, usually unilateral Sudden, severe headache with unknown cause Subarachnoid Loss of consciousness Nausea or vomiting Stiff neck

Sudden, severe headache. The worst headache of my life.

About 80% of strokes are preventable, and patient education can help reduce the risk.2 Major risk factors that patients can control or modify are alcohol and tobacco use, hypertension, high cholesterol, inactivity, obesity or overweight, atrial fibrillation and diabetes. Patient education includes counseling on smoking cessation, regular exercise, healthy eating and limiting alcohol intake.2 In addition, patients should know their health histories and have regular checkups with their physician to monitor for conditions such as high BP, high cholesterol, heart disease, atrial fibrillation and carotid artery disease.2 Nurses must know these five classic warning signs of a stroke: Sudden Sudden Sudden Sudden Sudden numbness or weakness of the face, arm or leg, especially unilateral confusion; trouble speaking or understanding trouble seeing in one or both eyes trouble walking, dizziness, loss of balance or coordination severe headache with no known cause1,2

The National Stroke Association recommends using the FAST method for recognizing and responding to stroke symptoms.2 F (FACE) Ask the person to smile. Does one side of the face droop? A (ARMS) Ask the person to raise both arms. Does one arm drift downward? S (SPEECH) Ask the person to repeat a simple sentence. Does the speech sound slurred or strange? T (TIME) If you observe any of these signs, call 911 or get to the nearest stroke center or hospital. If a patient presents with one or more of the signs or symptoms consistent with a stroke even if they have resolved the nurse must react quickly. Patients must undergo diagnostic tests promptly to determine whether they are having symptoms concurrent with an ischemic or hemorrhagic stroke. The information from these tests helps guide treatment. Depending on your institutions policy and the patients location (in the hospital or in a clinic), notify the physician and activate a stroke alert, or call 911. If a patient calls the clinic with these symptoms, immediately call or tell the patient or significant other to call 911. EMS is key in the chain of survival.4 The 911 call will alert the dispatcher of a potential stroke, and EMS will provide emergency transport to the hospital (preferably an accredited stroke center) so the patient will be triaged quickly and given priority for treatment.4
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

Much is being done in terms of treatment for acute stroke. Joint Commission-accredited primary stroke centers have a process in place to alert the stroke (or rapid response) team of a patient with stroke-like symptoms. The team should consist of a minimum of a physician trained in treating stroke, preferably a neurologist.5 This allows for quick recognition and treatment to reduce permanent deficits. Nurses play a pivotal role in the care of the stroke patient. They should gather information, including when symptoms began or when the patient was last seen without neurological deficits. If someone was with the patient when symptoms started, ask that person what the patient was doing. Was the patient exhibiting signs of a seizure, which could mimic a stroke? Think of the risk factors for a stroke and ask whether the patient has a history of atrial fibrillation, TIAs or hypertension. This is vital information when thinking about treatment with thrombolytic therapy, such as rtPA (alteplase). Nurses are often responsible for coordinating diagnostic tests and ensuring that the patient undergoes tests within the benchmark times while paying close attention to the patients airway, breathing and circulation.6 Nurses must handle a possible stroke quickly, as if the patient were having a cardiac arrest. This patient is the main priority. Nursing management includes delegating tasks, keeping the patient and family informed, and eliciting the help of other team members, all with the primary goal of getting the patient to CT in the benchmark time of 25 minutes.4,6 While waiting for the team to respond, the nurse anticipates the need for a blood sugar test to rule out hypoglycemia, as signs of hypoglycemia can mimic signs of acute stroke.4,6 Plan for cardiac monitoring with monitoring of oxygen saturation and drawing of a panel of labs: complete blood count, basic metabolic panel, coagulation panel (PT/INR, PTT) and troponin. Complete a pregnancy test if a female patient is of childbearing age. These labs must be drawn and processed STAT. Prepare the patient for emergent transport to CT. CT imaging is the main priority so that appropriate treatment can be planned. Imaging of the brain is recommended before initiating any specific therapy to treat an ischemic stroke.4 (Level A) If the patient is on oxygen, notify respiratory therapy as needed and obtain an oxygen tank. A power injector is used to deliver IV contrast dye for a CT angiogram and CT perfusion studies; this requires that the patient have a large-bore antecubital IV or power-injectable central line. If the patient doesnt have this type of access and requires IV contrast, place at least one IV. Because of the critical nature of this patient, a nurse or physician should help transport the patient to CT to enable continuous neurological monitoring. Crucial Benchmarks Benchmark times have been set to maximize patient outcomes related to stroke symptoms. Nurses are essential in coordinating tests and interventions promptly. As mentioned, the benchmark time is 25 minutes from symptom onset or arrival to the ED to CT scan.4 CT interpretation should be completed in 20 minutes.4 The goal for rtPA candidates is door to CT interpretation in 45 minutes with thrombolytic treatment starting in 60 minutes.4 (Level A) rtPA should be administered within three to 4.5 hours of the onset of symptoms.4,7 A delay can result in further neurological damage. The FDA has approved IVrtPA only for eligible patients up to three hours of symptom onset. But the American Stroke Association in 2009 recommended that the time for administering IV-rtPA be extended to 4.5 hours of symptom onset for patients who meet eligibility.7 (Level A) For patients who present after the window for IV rtPA, other interventions may be performed. Interventional radiology procedures include intra-arterial thrombolysis, in which rtPA is administered directly into the clot, or mechanical embolectomy, which involves removal of
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

the clot.4,6 Diagnostic imaging varies by hospital. At a minimum, patients require a CT scan of the brain without contrast. Some hospitals use MRIs; many have moved to CT angiogram and CT perfusion studies. The noncontrast CT of the brain is the gold standard.6 For rtPA to be administered, the clinician must rule out a hemorrhagic stroke or a nonvascular cause of the symptoms, e.g., a brain tumor.6 The radiologist determines whether blood is evident on the scan. A CT angiogram shows the vessel formation and gives additional information on a patient with a suspected cerebral aneurysm.6,8 A CT perfusion study shows cerebral blood flow and blood volume and takes into account the transit time of contrast to areas in the brain.4 Both CT angiogram and CT perfusion studies focus on the ischemic area and surrounding tissue. Because of time constraints, MRIs are usually ordered in the acute phase of a stroke only when the CT angiogram and CT perfusion study are negative and rtPA is still a consideration. Timing is critical. The nurse must continuously monitor the patient for changes in condition. Close Care Nursing management of an ischemic stroke or hemorrhagic stroke involves close monitoring, focusing on neurological exams and BP management. This patient requires critical care monitoring in the ICU. Use oxygen as needed, place the patient on seizure precautions and promote proper positioning with the head of the bed at 30 degrees to avoid aspiration. This is also thought to help decrease the elevated intracranial pressures that may be developing.6 Patients should remain NPO, including medications or sips of water by mouth, until a swallow evaluation is done.4 (Level A) Nurses in stroke centers should be trained to perform a bedside swallow evaluation. If the patient requires medications but fails the swallow evaluation, consider a NG tube. Nursing management also includes monitoring body temperature with a goal of maintaining a normal temperature, maintaining a normal fluid balance and stabilizing blood sugars.8 If the patient is a candidate for rtPA, consider placing at least two IVs.4 (Level A) One IV site can be dedicated to infusing rtPA, and the other can be used for infusing IV medications and fluids as needed. Invasive devices, such as an indwelling urinary catheter or NG tube, should also be placed before giving the thrombolytic. Do not delay rtPA; use every moment when dealing with an ischemic event.6 The initial nursing neurological assessment is the baseline assessment, with the nurse paying close attention to further changes. Neurological exams, performed as often as hourly, are important in the initial stages of a stroke and include level of consciousness, pupil reactivity and movement of extremities. Neurological exams help determine signs of further stroke, hemorrhagic conversion of an ischemic stroke, hydrocephalus and the development or worsening of cerebral edema. The nurse needs to assess for subtle changes and report them to the physician. The preferred stroke assessment scale is the National Institutes of Health Stroke Scale.4,6 It is a reliable indicator of a patients condition after a stroke and helps predict outcomes after treatment.4,6 Training and certification in the use of the scale are available. BP management is vital to improving outcomes in acute ischemic stroke. If the patient is a rtPA candidate, the nurse must take measures to keep systolic BP less than 185 mmHg and diastolic BP less than 110 mmHg.4,6 The patient may receive antihypertensive medications, such as beta-blocking agents e.g., labetalol (Trandate), or calcium channel-blocking agents; e.g., nicardipine (Cardene). If the patient cannot maintain BP less than 185/110 even with aggressive use of medications, the patient is not a candidate for rtPA.4,6 If the
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

patient is not a candidate, the American Heart Association recommends not treating elevated BP unless systolic BP is greater than 220 or diastolic BP is greater than 120.4 (Level A) Allowing BP to remain elevated gives the brain a chance to try to reperfuse ischemic areas through collateral circulation.4,6 Rapidly lowering BP may worsen the neurological assessment by reducing perfusion to ischemic areas.6 Association guidelines recommend BPgoals of less than 180/105 mmHg for the first 24 hours in patients who have received thrombolytic therapy.4,6(Level A) With ischemic stroke, the focus is on saving the viable tissue surrounding the stroke, the penumbra. Nursing management of a hemorrhagic stroke has the same priorities as in an ischemic stroke, but the interventions are different. But a hemorrhagic stroke is also a medical emergency. If blood is present on the CT scan, whether in the intracerebral or subarachnoid space, this excludes the use of thrombolytic therapy.6 The nurse needs to process the test results, evaluate signs and symptoms, and perform appropriate nursing interventions to decrease further damage to brain tissue. The main priority is to carry out interventions to reduce the risk of rebleeding, which include careful BP management. Because of the high acuity of acute stroke patients, most will require critical care monitoring in an ICU, preferably by a nurse trained in neurosurgical emergencies. There are different types of hemorrhagic strokes, depending on where in the brain blood is located. Subarachnoid hemorrhage usually presents with an abrupt onset of headache, altered level of consciousness and nausea and vomiting.8 Patients with a subarachnoid hemorrhage often say they are having the worst headache of their lives. The CT scan may show blood in the subarachnoid space, or a lumbar puncture may be positive for RBCs in the cerebrospinal fluid. A subarachnoid hemorrhage is caused by a ruptured aneurysm on a large artery in the brain.2 An intracerebral hemorrhage usually presents with altered level of consciousness and/or focal neurological deficit that presents on CT imaging as a collection of blood within the surrounding brain tissue, usually caused by hypertension.2 BP management is a main priority for a nurse taking care of a patient with a hemorrhagic stroke. There are no absolutes where blood pressure ranges are concerned.9 Medical management involves trying to keep an adequate balance between perfusing the stroke area and trying not to cause further cerebral edema or hemorrhage. In patients with cerebral hemorrhage, a typical goal is to keep the systolic blood pressure less than 160, with some physicians preferring less than 140.8 This is particularly important if the blood is from an aneurysm that has not yet been treated. If the CT scan shows subarachnoid blood, permissive hypertension is not acceptable with hemorrhagic stroke. This is important to remember if you are transferring a patient with hemorrhagic stroke to a neurosurgical center for treatment. To reduce the risk of rebleeding during transfer, carefully manage BP and intervene if the systolic BP becomes elevated.9 Once the aneurysm is surgically managed or coiled in interventional radiology, BP parameters allow for a higher BP. The patient now is at risk for spasming of the blood vessels in the brain, known as vasospasms. Nursing interventions to help with BP control can include turning the lights down in the patients room, maintaining a calm presence, keeping the patient informed of treatment and administering BP and IV pain medications as needed. When using narcotics to help with pain and blood pressure control, give a dose that helps with the pain but does not mask any neurological changes that could predict a worsening clinical picture. Patients presenting with hemorrhagic strokes can have intense nausea and vomiting. Avoid giving PO medications, specifically narcotics, to a person with nausea. PO medications may cause vomiting, and the increased intracranial pressure associated with vomiting may cause the patients condition to deteriorate. Use IV antiemetics for any sign of nausea. Depending on the severity of the bleed and patients level of consciousness and ability to protect their airway, many patients require intubation and mechanical ventilation.
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

With an intracerebral hemorrhage, BP parameters are less restrictive than with a subarachnoid hemorrhage, but concrete evidence has yet to show whether more aggressive BP control during the initial phase of an intracerebral hemorrhage helps improve patient prognosis.9 (Level A) Remember that with hemorrhagic strokes, the goal is to prevent expansion of the hemorrhage into the surrounding tissues and reduce further ischemia to the brain. That said, the American Heart Association guidelines for intracerebral hemorrhage take into account the patients clinical presentation:9 If systolic BP is greater than 200 mmHg or mean arterial pressure greater than 150, use continuous IV antihypertensive medications, such as labetalol, nicardipine or esmolol (Brevibloc), to aggressively reduce BP. If systolic BP is greater than 180 mmHg or mean arterial pressure is greater than 130 with probable increased intracranial pressure, recommend monitoring the intracranial pressure and using IV push or continuous infusion antihypertensives to maintain a cerebral perfusion pressure of about 60 to 80. If systolic BP is greater than 180 mmHg or mean arterial pressure is greater than 130 mmHg and intracranial pressure is normal, consider a blood pressure goal of around 160/90 with a mean arterial pressure around 110. Expert Centers Joint Commission-accredited stroke centers help improve patient outcomes with programs and protocols to rapidly diagnose stroke and provide onsite emergency treatment.6 Accredited centers have Joint Commission performance measures in place to help guide the care of patients throughout their admission.5 Nurses are often responsible for seeing that these measures are evident in patients plans of care. Some of the nursing-centered performance measures focus on deep vein thrombosis prophylaxis, drawing of a lipid panel, smoking cessation education and stroke education. Because of the stroke patients high risk for aspiration, which can lead to pneumonia, nurses should perform and document a swallow screening evaluation to test for dysphagia before the patient takes anything by mouth. Patients need to be NPO until they complete this evaluation.4 The main cause of pneumonia in stroke patients is aspiration due to dysphagia. Pneumonia is a potentially fatal complication that occurs 48 to 72 hours after an ischemic stroke.6 It accounts for 15% to 25% of stroke-related deaths.6 Many swallow screens are available to assess for dysphagia. Basic bedside swallow assessments may use water and crackers. More extensive tests include barium swallow, video fluoroscopy, esophagoscopy, radio nucleotide studies, esophageal manometry or endoscopy.4 These tests take longer and are not always available on nights and weekends. The nurse must prescreen the patient for risk factors, such as lethargy, unresponsiveness or an inability to hold the head up, to assess whether the patient is even a candidate for evaluation. If the patient is not a candidate, make the patient NPO, including medications with sips of water, and reassess as needed or contact speechlanguage pathology. The nurse is vital in maximizing successful outcomes for a patient presenting with a stroke. The nurse must know the benchmark treatment times for acute stroke, know the differences in management and nursing interventions between ischemic and hemorrhagic stroke and collaborate with other team members to get the patient timely, appropriate care. Collective, timely interventions may preserve your patients life and minimize the permanent deficits possible after a stroke. Remember the patient who was having signs and symptoms consistent with a stroke? The nurse activated a stroke alert, and the stroke team responded to assess him. The nurse sent off a panel of labs and checked the patients blood sugar, which was 164; this ruled out a hypoglycemic event. Given the patients risk factors and hypertensive episode, the
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Print Course | Activating a Stroke Alert: A Neurological Emergency > CE591

nurse expected an acute ischemic stroke. Anticipating the need for a CT scan and possibly rtPA, the nurse placed two 18g IVs, one in the antecubital area. The nurse went with the patient to CT scan, doing frequent neurological assessments for deterioration. The imaging confirmed an ischemic stroke, and the patient received rtPA within 60 minutes of symptom onset. He was transferred to the ICU. With quick assessment and interventions, the patient suffered no permanent neurological deficits. Gannett Education guarantees this educational activity is free from bias.

References 1. Warning signs of a stroke. American Stroke Association Web site. http://www.strokeassociation.org/STROKEORG/WarningSigns/WarningSigns_UCM_308528_SubHomePage.jsp. Accessed January 30, 2012. 2. Stroke symptoms: act FAST. National Stroke Association Web site. http://www.stroke.org/site/PageServer?pagename=SYMP. Accessed January 30, 2012. 3. Am I at risk for stroke? National Stroke Association Web site. http://www.stroke.org/site/PageServer?pagename=RISK. Accessed January 30, 2012. 4. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. JAMA. 2009;40:2911-2944. 5. Stroke core measure set. Joint Commission Web site. http://www.jointcommission.org/stroke. Accessed January 30, 2012. 6. Adams H, del Zoppo G, Alberts M, et al. Guidelines for the early management of adults with ischemic stroke. Circulation: JAHA. 2007;115(20):478-534. 7. Lansberg M, Bluhmki E, Thijs V. Efficacy and safety of tissue plasminogen activator 3 to 4.5 hours after acute ischemic stroke. Stroke: JAHA. 2009;40:2438-2441 8. Bederson J, Connolly E, Batjer H, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke: JAHA. 2009;40: 994-1025. 9. Broderick J, Connolly S, Feldman E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. Stroke: JAHA. 2007;38:2001-2023

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