Stroke Alert! Know Your Role

Maggie Aime, BSN, RN

Every 40 seconds, a person has a stroke in the United States; and every 3 to 4 minutes, a person dies of a stroke. This translates to about 795,000 people having a stroke every year in the United States and 137,000 deaths from stroke. Today, over 4 million people are living with some type of deficit or lasting damage from a stroke, making stroke a leading cause of significant long-term disability nationwide. Early recognition of the signs and symptoms of stroke and the prompt initiation of treatment increase the chances of survival exponentially while decreasing permanent brain damage and reducing deficits. In the acute care setting, nurses play a pivotal role in every aspect of stroke patients' care throughout their inpatient stay.

About stroke

Just like every organ in the body, the brain needs blood to function properly. A stroke occurs when blood flow to the brain is blocked because of either a ruptured blood vessel or a clot. This lack of blood flow causes brain cells to start dying very quickly. A stroke is also known as a "cerebrovascular accident (CVA)” or a "brain attack".

3 Common Types of Stroke

Hemorrhagic Stroke

When a blood vessel ruptures causing an interruption of blood supply to the brain and pressure on brain cells. Uncontrolled blood pressure and aneurysms are the leading causes of hemorrhagic strokes.

Ischemic Stroke

Occurs when there is disruption of blood flow to the brain due to blockage of a blood vessel by either plaque or a clot. It is the most common type of stroke. An ischemic stroke can also turn into a hemorrhagic stroke.

Transient ischemic Attack (TIA)

Known as a mini-stroke, is a temporary blockage of blood flow to the brain that resolves on its own before there is any permanent damage to the brain. TIAs tend to be of short duration, lasting a few minutes to one hour, but they are an important warning sign of a possible future and more serious stroke; and it is crucial to seek medical care immediately.

Is it a Stroke? BE-FAST

The American Stroke Association (ASA) reports that for every minute that stroke treatment is delayed, 1.9 million brain cells die. Use the acronym BE-FAST to recall the warning signs of a stroke:

B – Balance
Is there sudden unsteady gait, lack of balance, or dizziness?

E – Eyes
Are there sudden visual disturbances, loss of or blurred vision, either in one or both eyes?

F – Face
Is there sudden numbness, or weakness of the face? Is the face drooping on one side or is uneven when the person smiles?

A – Arms
Is there sudden numbness, weakness, and/or drifting of one arm when the person holds his or her arms outstretched with palms up and eyes closed (the pronator drift test)?

S - Speech
Is there sudden confusion, difficulty speaking, slurred speech, or trouble understanding speech?

T - Time
If any of the above signs are present, it's time! Call 9-1-1 immediately.

Another warning sign of stroke is a sudden onset of intense headache that comes out of nowhere.

Who's at risk of a stroke?

According to Mayo Clinic, any of the following modifiable risk factors (factors that can be changed or treated) increase a person's risk of having a stroke:

Having high blood pressure.
Being overweight or obese.
Leading a sedentary lifestyle.
Using birth control pills or hormone replacement therapy.
Having diabetes.
Having heart disease, especially those that can form blood clots like atrial fibrillation.
Having an elevated low-density lipoproteins (LDL) cholesterol, known as the bad cholesterol.
Being under high levels of stress or anxiety.
Having obstructive sleep apnea.
Being a smoker or having exposure to second-hand smoking.
Having a brain aneurysm or arteriovenous malformations (AVMs).
Having a viral infection, like COVID-19, or an illness that causes inflammation.
Using illicit drugs such as cocaine.
Drinking alcohol excessively.
Having a suboptimal diet.

The following risk factors for stroke are non-modifiable risk factors (factors that can't be changed):

Being age 55 or older (the risk of stroke increases with age).
Being of African American, Hispanic, or American Indian descent.
Being a male (men are more likely to have a stroke than women).
Having sickle cell disease.
Having a family history of stroke, TIA, and/or heart disease.
Having had a previous stroke or TIA.

The ASA reports that 80% of strokes are preventable. The modifiable risk factors listed above can be managed and treated through lifestyle changes, medical treatments, stroke risk screenings, and education. Stroke care begins with prevention!

The Nurse's Role in Stroke Care: A Brief Overview

Stroke is an emergency and stroke care is complex. Nurses and healthcare providers have a key responsibility to improve outcomes and decrease disability and mortality in stroke patients by timely recognition of the signs and symptoms of stroke and early intervention. In the acute care setting, competent nursing management in all phases of care, from arrival to the emergency room through discharge, is vital; and nurses must have a full understanding of their role:

Please note that the succession of events, steps, and responsibilities listed below are not all-inclusive and will vary based on the facility. It is strongly recommended that institutional policies and protocols are reviewed and adhered to.

In the Emergency Room

When a stroke is suspected at presentation to the emergency room, remember the principle "Time is Brain". The triage nurse's role is to promptly screen the patient using an institution-designated stroke screening tool. The National Institutes of Health Stroke Scale (NIHSS) is a commonly used tool that uses a scoring system to determine the severity of strokes.
Many institutions have established a Stroke Alert process – which mimics the concept of a Code Blue – that is used to notify a pre-designated team of providers of an acute stroke and to quickly activate the stroke response system. Usually, the triage/emergency room nurse will activate the Stroke Alert.
A 60-minute or less protocol, developed by the ASA, lists specific medical interventions that must be performed at set intervals within the first 60 minutes of the patient's arrival in the emergency room to optimize outcomes. In most facilities, the emergency room nurse is responsible to document the arrival time of a stroke patient and, if possible, document the patient's last known normal (LKN). This is used to mark the start of the 60-minute timer for tracking of time-sensitive interventions.
A non-contrast CT scan of the head must be performed within 25 minutes of the patient's arrival. In most facilities, the emergency room nurse accompanies the patient to the CT scan department and ensures patient safety.
Based on the CT scan results – and if an ischemic stroke – treatment with tissue plasminogen activator (tPA), also known as alteplase or Activase, is initiated. This intravenous medication is usually given within 3 hours of the onset of symptoms and can be given up to 4.5 hours in certain cases. This is done to dissolve the clot and restore blood supply to the brain. Among other duties, the nurse administers the treatment and closely monitors the patient for complications.
In the case of a hemorrhagic stroke, the primary focus of care is to control the bleeding and blood pressure, as needed, using medication. Surgery to repair the ruptured blood vessel may be indicated. The nurse closely monitors the patient for any concerns or changes in status.

In the ICU

At this point, the patient may be transferred to the intensive care unit (ICU), and the emergency department nurse accompanies the patient to the ICU and ensures a safe transition of care.
For eligible patients with an ischemic stroke, a mechanical thrombectomy may be indicated. This surgical procedure is done to remove the clot via catheterization and is typically performed within 6 hours of the onset of stroke symptoms and can be done up to 24 hours from onset. Among many other responsibilities, the ICU nurse's role is to monitor for postoperative complications, condition deterioration, perform neurologic assessments, titration of medications, and other system monitoring per practice guidelines and institution protocol.
In some severe stroke cases, the patient may need to be intubated. The ICU nurse is responsible to monitor for airway patency per hospital guidelines.

On the Floor

When the patient is stable and ready for transfer, the floor nurse's responsibilities include, among countless others:

Continuing to closely monitor for and prevent complications, including the possibility of a second stroke.
Helping with improvement of patient's mobility.
Assisting the patient with managing and coping with disability such as sensory and/or communication deficits.
Collaborating with the multidisciplinary team to include Physical Therapy, Speech Therapy, Occupational Therapy.
Assessing the patient for depression, as needed, and addressing accordingly.
Preparing the patient for discharge whether to home or to a rehabilitation facility.
Providing education on the risk of recurrent strokes and prevention methods.

A stroke is a life-threatening and life-changing event. Early action is vital during stroke care. The nurse's role, as the patient transitions across care environments, is very diverse and complex and includes effectively meeting the patient's various care needs, collaborating, providing education and support, promoting recovery, contributing to positive patient and family outcomes, and more. It is of utmost importance for nurses to stay abreast of proper stroke care and advancements in treatment modalities, become familiar with their facilities' stroke protocols, and take an active role in advocating for and educating the public about stroke signs and symptoms, prevention methods and the management of risk factors.

References

About Stroke | American Stroke Association

Characteristics of the stroke alert process in a general Hospital - PMC (nih.gov)

Prevention | American Stroke Association

Role of the nurse in acute stroke care - PubMed (nih.gov)

Stroke - Symptoms and causes - Mayo Clinic

Stroke Facts | CDC.gov

Update: Stroke guidelines: Nursing Management (lww.com)

Updated guidance confirms crucial role of nurses for patients with acute ischemic stroke | American Heart Association