Stroke: Time-Critical Care
Ischemic vs. hemorrhagic, thrombolytics, and nursing priorities
Recognize: BE FAST
| Balance | Sudden loss of balance or coordination |
| Eyes | Sudden vision loss or double vision |
| Face | Facial droop |
| Arm | Arm (or leg) weakness |
| Speech | Slurred or confused speech |
| Time | Note last known well; call emergency services |
First steps
- ABCs; check blood glucose (hypoglycemia mimics stroke).
- Non-contrast CT immediately: rules out bleeding before any clot-busting drug.
- NIH Stroke Scale; time of last known well.
- NPO until a swallow screen is passed (aspiration risk), including oral meds.
Ischemic stroke: reperfusion
IV thrombolytic within 4.5 hours of last known well (the standard window ends at 4.5 h; it does not start at 3 h). 2026 AHA/ASA: selected patients up to 9 h, or wake-up stroke, if advanced imaging shows salvageable brain. Updated
- Alteplase 0.9 mg/kg (max 90 mg): 10% as a bolus over 1 min, rest over 60 min; or
- Tenecteplase 0.25 mg/kg (max 25 mg) single IV bolus. Updated
Streptokinase and reteplase are not used for stroke.
Mechanical thrombectomy for large-vessel occlusion: up to 24 h in selected patients.
BP before thrombolytic: <185/110. Keep ≤180/105 for 24 h after.
Exclusions (examples): any bleeding on CT, active internal bleeding, recent major surgery, head trauma or stroke, BP that can't be lowered below 185/110, low platelets or anticoagulation (check labs/history).
After: neuro checks and VS every 15 min × 2 h, every 30 min × 6 h, hourly × 16 h; no antithrombotics for 24 h; avoid invasive procedures. New headache, worse neuro status, nausea/vomiting, or sudden BP rise → stop the infusion, call, urgent CT.
Hemorrhagic stroke
- Usually sudden severe headache ("worst of my life"), vomiting, ↓ LOC.
- Lower systolic BP (commonly to ~140); reverse anticoagulants.
- ICP care: HOB 30°, head midline, avoid straining, coughing and hip flexion; seizure precautions.
- No thrombolytics, antiplatelets or anticoagulants.
Right vs. left hemisphere
Right brain (left-side weakness)
- Impulsive, poor judgment, safety risk
- Left-sided neglect; spatial problems
- Denies deficits
Left brain (right-side weakness)
- Aphasia (speech, language)
- Slow, cautious, anxious
- Aware of deficits; may be depressed
Rehab nursing
- Homonymous hemianopia: place food and items in the intact visual field; teach head-turning to scan the blind side.
- Dysphagia: upright 90°, chin tuck, thickened liquids as ordered by IDDSI level.
- Approach and speak from the unaffected side early on; encourage use of the affected side over time.