Stroke

Stroke

Welcome back to the Nursing School Week by Week Podcast. I’m your host, Melanie, and today we are focusing on Strokes, or Brain attacks. This is one of those conditions that is so important for us nurses to know the signs and symptoms of, because your patient could have a stroke at any point. They could come into the ER with a suspected stroke, or they could be recovering on the med-surg unit, about to be discharged, and then have a stroke. So it can happen at any time, and we want to make sure we know what to look for. We also want to make sure we know what their baseline looks like, so we have something to compare any changes to. This is one reason why, when you’re in clinicals, your instructors will stress that you do a bedside shift report, or at least that you go into the patient’s room and do the physical assessment within the first hour of your shift starting. Because if you don’t go in there for four hours, and then when you finally do, they have slurred speech and limited arm movement, you’re not going to know if that’s what they were like before your shift, or if those are new changes. 

Alright, so what is a stroke, or brain attack? A stroke is when there’s damage to the brain, either because the blood flow has been blocked, or there is bleeding in the brain. So if the blood flow has been blocked, we call that an ischemic stroke; if we’re dealing with intracranial bleeding, like a blood vessel in the brain has ruptured, we call that a hemorrhagic stroke. And usually when I hear the word “hemorrhage”, I picture like massive amounts of blood, like the patient is just bleeding out, but this isn’t the case when it comes to a hemorrhagic stroke. It’s usually just a small amount of blood, but because there is a limited amount of space in the cranial cavity, even a small amount of extra blood creates an increased pressure in the brain. Also, blood is just very irritating to the soft tissues of the brain. 

So there’s ischemic stroke and hemorrhagic stroke, but the signs and symptoms can look very similar no matter what type of stroke the patient is having, so it’s important to figure out the type using diagnostic tests, before treating it, since the treatment to clear a blocked vessel in the brain is obviously very different than the treatment to stop a vessel in the brain from bleeding. 87% of strokes will be ischemic, and 13% are hemorrhagic, so most of what you see will be ischemic strokes.

Alright, let’s talk about risk factors. People who are most likely to have a stroke are people with Atherosclerosis, so people with arteries that have hardened and have a buildup of plaque inside them. Also, people with hypertension. Chronic high blood pressure is the main cause of hemorrhagic strokes. Other risk factors include Diabetes, obesity, smoking, and oral contraceptives. 

Another thing I want to touch on are TIA’s or Transient Ischemic Attacks. These are like mini-strokes, because the symptoms are short-lived, lasting just minutes to maybe a couple hours. A good way to remember this one is that the word “transient” means “lasting only for a short time”, like a transient worker, would be a non-permanent worker, like someone who is just passing through town. And if a patient has had a TIA, they are much more likely to have a stroke in the future. So a transient ischemic attack is a short, mini-stroke. I got that easy way to remember TIA’s through my Picmonic app. And Picmonic also has some really good videos to help you remember the types of strokes, as well as what to look for as far as signs and symptoms that let you know if the stroke affected the right side of the brain, or the left side. Picmonic is an interactive audio-visual learning system that helps students memorize information faster and remember it longer. I highly recommend it, and right now they are having an incredible deal. If you sign up during the month of August, you can get 30% off your subscription. Just click on my link in the show notes, and you’ll get 30% off of Picmonic. 

Alright, so what are some signs and symptoms of a stroke? What are we, as the nurse, going to be on the lookout for? The acronym that most people remember is F.A.S.T. This stands for: F for Facial drooping, A for Arm Weakness, S for Speech difficulty, and T for “time to call 911”. If we’re in the hospital, we won’t call 911, but we definitely want to be on the lookout for the other three. So we’re asking, “does one side of the face droop, or is it numb? We could ask them to smile, and see if the smile is uneven. We’re asking, “is one arm weak, or numb?” We can ask them to raise both arms, and see if one arm drifts down over 10 seconds. Do they have slurred speech? Another symptom is if the patient is complaining of a severe headache. If the patient states, they are having “the worst headache of their life,” then alarm bells should go off in your head, and you should be assessing them for a stroke. Other indicators include sudden confusion, trouble walking, and vision problems. We also sometimes think of the T in F.A.S.T. as the time when symptoms started, because it’s very important to try to figure out when the patient was last seen normal, or last known well, since this can dictate what medications are available to them, or not. And if the patient woke up with stroke symptoms, then we assume their last known well time was when they would have gone to bed the night before. 

You may see some questions on the NCLEX about right vs left sided strokes. We want to remember that damage to the brain manifests contralaterally, meaning if we are seeing arm drooping of the right arm, we know the stroke is on the left side of the brain. If we are seeing facial drooping on the left side of the face, we know the stroke is on the right side of the brain. It’s opposite. Cause the left side of the brain controls movement on the right side of the body, and vice versa. This is called hemiplegia. So a left hemisphere stroke would cause right side paralysis. Beyond that, I want you to remember that a left-sided stroke can cause language difficulties, and a right-sided stroke can cause recklessness, meaning they can have poor impulse control and think they can physically do more than they actually can now since the stroke. So I want you to think, Left = Language, and Right = Reckless. 

Alright, so let’s walk through what we’re going to do for these patients. And we’re gonna think about this in 5 steps. Step one is to recognize the stroke, step 2 activate a stroke code, step 3 get a CT scan, Step 4 give the treatment, and Step 5 monitor the patient. Alright, so Step one, recognition. Remember I said that a patient can have a stroke anywhere, at any time, right? So we could be recognizing the signs and symptoms of a stroke on a patient who’s already in the hospital for something else, or we could be getting a suspected stroke patient via EMS. If they are coming via EMS, this gives us a little bit of time to prepare. The EMTs will call the ER while they’re driving to the hospital, and then we can call a code stroke and when the patient gets to the ER, the nurses and doc will be all ready to assess the patient. Alright, so we have a whole team working on this patient when they arrive, so many things will be getting done simultaneously. So we want to check the patient’s ABCs, the airway, breathing, and circulation. We will also check the patient’s blood sugar level with a quick fingerstick, since hypoglycemia can often look like stroke symptoms. And fixing a low blood sugar level is way simpler than treating a stroke. So definitely rule out hypoglycemia first. We also want to get a set of vitals, especially the Blood pressure, cause this is so important to know with stroke patients. While we are getting all these things, someone is calling CT, or Computed Tomography, to make sure they are ready to scan this patient. Someone is also getting an NIH stroke scale. The NIH grades the patient on 11 different things, like level of consciousness, vision, facial droop, arm drift, leg drift, skin sensation, and language difficulties. 42 is the highest number someone can get, but the higher the number, the more severe the deficits are. So closer to 0 is good, closer to 42 is bad. We're also, if we have time, getting blood for labs and putting at least one large bore IV in them, so a 20 gauge or larger. We also want to ask the patient, or their family or friends that are with them when the patient was last seen normal. This is really important to know because TPA, or tissue plasminogen activator, can only be given within the first 4 and a half hours of when the symptoms started. And we are asking about any medications they take and any allergies they have. We especially want to know if they have an allergy to contrast dye. 

Alright, next we are going to head to CT with the patient; and we may still be finishing up the NIH stroke scale on our way to get the CT scan. We really want the door to CT time to be less than 25 minutes. So once the patient gets to CT, they will first get a Head CT without contrast, and this tells us if the patient has an ischemic, or a hemorrhagic stroke. So ischemic, if it’s a blood clot that’s blocking a blood vessel in the brain. Hemorrhagic if a vessel has ruptured, and the scan shows blood pooling in the brain. If we’re dealing with an ischemic stroke, the patient will then get a CT angiogram. This is when contrast dye is inserted into the blood vessels of the brain to kind of light them up, so we can see where the clot or obstruction is. This will let them know if the patient is a candidate for a mechanical thrombectomy, where they can go in through the groin and physically remove the clot. But this can only be done if the obstruction is in a large vessel.

Alright, so let’s talk treatment. If the patient is not a candidate for a mechanical thrombectomy alone, what can be done? The main treatment that will be given, as long as we are within that 4 and a half hour window, is TPA, or tissue plasminogen activator. TPA works by dissolving blood clots that block blood flow to the brain. There is a high risk of bleeding that comes with TPA, so we want to make sure we check their background and don’t give it if they’ve had serious head trauma in the past 3 months, if they have a low platelet count, or if they have any kind of clotting disorder. TPA is given through the patient’s IV, and once it starts, they will be at risk for bleeding, so we want to actually get 2 IVs in the patient before we start the TPA. And if they will need a Foley catheter, we want to insert that before starting the TPA. Basically, we don’t want to poke or insert anything that we don’t absolutely have to once we’ve started the TPA. Once they start it, that patient will be a 1:1 ratio. So you will need to get someone else to take care of your other patients, because this patient will take all your time, just monitoring them. You are monitoring them for bleeding, monitor their neurological status and their blood pressure every 15 minutes. If you notice severe bleeding, or if they start complaining of a headache, stop the TPA, and get help. They may now have bleeding in the brain. It’s a delicate balance.

If the patient is outside of the window for TPA, like it’s been more than 4 and a half hours since their symptoms started, and they are not a candidate for a mechanical thrombectomy, the docs will often order permissive hypertension. This is when we don't give them blood pressure medications, and we allow their blood pressure to get really high, up to 220/120, in the hopes that this will better perfuse the area around the blood clot. 

The treatment for a hemorrhagic stroke looks a little different. I’m not going to go into too much detail on this, since the majority of strokes are ischemic, but hemorrhagic strokes are treated by locating the source of the bleeding and then surgically “clipping” it, and then draining the skull to decrease the intracranial pressure. We will also give the patient blood pressure medications, usually beta blockers, to lower their blood pressure to keep it at a safe level. 

Alright, you guys. I hope that was helpful to you in remembering what you need to know to identify when someone is having a stroke, and to have a general idea of what will need to be done for this patient. I know we’re all gearing up for the start of a new semester of nursing school. There’s so much to learn, and it’s so exciting! Make sure you tune in next week for the next case study verbal simulation that I’m going to do. Alright, have a good week, and I’ll talk to you next time.