Before We Start
Stroke — when brain tissue dies, and why every minute matters
A stroke is the sudden death of brain cells from loss of blood supply. The brain is the most metabolically demanding organ in the body — it consumes 20% of the body's oxygen while representing only 2% of its weight. Brain cells begin dying within 4–6 minutes of oxygen deprivation. After that, the damage accumulates at a staggering rate.
The phrase that defines stroke care is: "Time is brain." For every minute a large vessel stroke goes untreated, approximately 1.9 million neurons die. The nurse who recognizes stroke immediately, activates the stroke response system without delay, and ensures tPA is given within the treatment window directly determines how much brain the patient keeps.
💡 Ischemic vs Hemorrhagic Stroke
Ischemic stroke (87% of strokes): A blood clot blocks a cerebral artery, cutting off blood supply to the brain tissue downstream. Subtypes: thrombotic (clot forms in a cerebral artery, often from atherosclerosis) and embolic (clot travels from elsewhere — most commonly the heart in A-fib — and lodges in a cerebral artery).
Hemorrhagic stroke (13%): A blood vessel in the brain ruptures, flooding brain tissue with blood. The blood itself is toxic to neurons and the hematoma causes mass effect (pressure on surrounding tissue). Types: intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH — often from a ruptured aneurysm, presenting with "worst headache of my life").
Critical distinction: tPA (clot-busting drug) is used for ischemic stroke. tPA is absolutely contraindicated in hemorrhagic stroke — giving it to a bleeding brain patient would be fatal. CT scan without contrast is the first test because it identifies hemorrhage. Treatment cannot proceed safely without it.
Recognition — FAST and BE-FAST
The stroke recognition tools every nurse and layperson should know
F — Face drooping
Facial asymmetry — one side droops or cannot move normally
Ask the patient to smile. In stroke, one side of the face droops — the smile is asymmetric, one corner of the mouth pulls downward, one eye may not close fully. This is caused by damage to the motor cortex or its connections to the facial nerve on the affected hemisphere.
Clinical assessment: "Show me your teeth." "Raise your eyebrows." Observe both sides simultaneously. Any asymmetry is abnormal and concerning for stroke until proven otherwise.
Bell's palsy distinction: Bell's palsy (peripheral facial nerve palsy) causes the ENTIRE side of the face to be weak — including the forehead. In a stroke (central lesion), the forehead is typically spared because it has bilateral cortical representation. Forehead sparing = think stroke. Entire face affected including forehead = consider Bell's palsy. This distinction matters because the treatments differ entirely.
💊 "Smile test — one corner droops = call the stroke team." This is something nurses do at the bedside in seconds. Any facial asymmetry in a patient with sudden onset symptoms requires immediate stroke assessment activation.
A — Arm weakness
Unilateral arm drift — one arm cannot stay up
Ask the patient to hold both arms outstretched in front with palms up and eyes closed. Hold for 10 seconds. In stroke, the affected arm drifts downward and pronates (palm turns downward) — called pronator drift. This is caused by damage to the motor cortex or corticospinal tract.
Why it's unilateral: The motor cortex controls the opposite side of the body. A left hemisphere stroke causes right-sided weakness. A right hemisphere stroke causes left-sided weakness. Bilateral weakness suggests other causes (hypoglycemia, seizure, metabolic encephalopathy).
Leg weakness: Also common in stroke. Ask the patient to lift each leg while lying supine. The affected leg drifts downward. Weakness of the arm AND leg on the same side = hemiplegia/hemiparesis = classic stroke presentation.
S — Speech difficulty
Slurred, wrong words, or no speech — three very different aphasia patterns
Speech abnormalities in stroke come in three main forms, and understanding which type is present helps localize the stroke:
Dysarthria: Speech is slurred or garbled but the patient uses the RIGHT words — a motor problem, not a language problem. The muscles of speech are weak. Ask: "You can't teach an old dog new tricks." Slurring without word-finding difficulty.
Expressive (Broca's) aphasia: The patient knows what they want to say but cannot get the words out — frustrating, telegraphic speech ("yes... no... water... home"). Left hemisphere, frontal lobe. The patient understands you.
Receptive (Wernicke's) aphasia: The patient speaks fluently but produces nonsense ("word salad") — and cannot understand what you are saying to them. Left hemisphere, temporal lobe. Profoundly disorienting for the patient.
Bedside test: Ask the patient to name an object ("What is this?"), repeat a phrase ("No ifs, ands, or buts"), and follow a command ("Close your eyes"). These three tasks test naming, repetition, and comprehension.
💊 "Sudden speech change = stroke until proven otherwise." Any acute change in speech — slurring that wasn't there an hour ago, struggling for words, saying the wrong words — requires immediate stroke assessment. Do not attribute it to tiredness, medication, or alcohol without ruling out stroke first.
T — Time to call 911 / Time last known well
The most important piece of information in stroke care
Time is the defining variable in stroke treatment eligibility. The tPA treatment window is 3–4.5 hours from symptom onset (or last known well time). Mechanical thrombectomy can be performed up to 24 hours in selected patients.
Last known well (LKW): The last time the patient was observed to be at their neurological baseline — speaking normally, moving normally, no stroke symptoms. This is not when symptoms were discovered. It is when the patient was last NORMAL.
Wake-up stroke: A patient who wakes up with stroke symptoms — the LKW is the last time they were seen normal before sleep. The treatment window calculation starts from that time. Many wake-up strokes are excluded from tPA because the window cannot be established — though advanced imaging (DWI-FLAIR mismatch on MRI) can sometimes identify treatment-eligible patients.
BE-FAST: An expanded version adding Balance and Eyes:
• B — Balance suddenly lost
• E — Eyes: sudden vision change, double vision, loss of half the visual field (hemianopia)
• F — Face drooping
• A — Arm weakness
• S — Speech difficulty
• T — Time to call 911
💊 "The LKW is when they were last NORMAL, not when you found them." A patient found by their spouse at 7am with stroke symptoms, last seen normal when they went to bed at 11pm — their LKW is 11pm, not 7am. The 8-hour gap may exclude them from tPA. This is why it matters to ask precisely: "When was the LAST TIME you saw them acting completely normally?"
Treatment
tPA — the clot buster, its window, and its dangers
tPA — Tissue Plasminogen Activator
The only FDA-approved drug for ischemic stroke — and its strict criteria
Alteplase (tPA) dissolves blood clots by activating plasminogen — converting it to plasmin, which breaks down fibrin (the structural component of clots). Given IV, it can reopen occluded cerebral arteries and restore blood flow to ischemic but not yet dead brain tissue — the ischemic penumbra.
tPA eligibility criteria (must meet ALL):
• Ischemic stroke confirmed (no hemorrhage on CT)
• Symptom onset within 3 hours (or up to 4.5 hours in selected patients)
• Age 18 or older
• Disabling neurological deficit
tPA absolute contraindications:
• Hemorrhagic stroke (bleeds the brain further)
• Blood pressure above 185/110 — must be lowered before tPA
• Recent surgery within 14 days (major bleeding risk)
• Recent intracranial surgery, head trauma, or stroke within 3 months
• Active internal bleeding
• Anticoagulation with INR above 1.7
• Platelet count below 100,000
• Blood glucose below 50 or above 400 mg/dL (glucose extremes mimic stroke — must be corrected first)
Door-to-needle time goal: 60 minutes from ED arrival to tPA administration. Every minute counts.
💊 "Blood pressure must be below 185/110 BEFORE giving tPA." This is non-negotiable. Giving tPA with uncontrolled hypertension dramatically increases the risk of hemorrhagic transformation — turning an ischemic stroke into a fatal hemorrhagic one. If BP is above 185/110, labetalol or nicardipine IV is given first.
tPA Nursing Monitoring
The 24 hours after tPA — what to watch and what to never give
Once tPA is administered, the nursing role shifts to aggressive monitoring for the most feared complication: hemorrhagic transformation — the ischemic stroke converting to a bleed from the reopened, fragile blood vessels.
Monitoring protocol during and after tPA:
• BP every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then every hour × 16 hours
• Neurological assessment (NIHSS or simplified neuro checks) every 15 minutes during infusion, then hourly
• Target BP below 180/105 during and for 24 hours after tPA
Signs of hemorrhagic transformation — stop tPA immediately:
• Sudden worsening of neurological deficits
• Severe headache ("worst of my life")
• Nausea and vomiting
• Rapidly rising blood pressure
• Decreasing level of consciousness
Post-tPA restrictions for 24 hours:
• NO anticoagulants (heparin, warfarin, DOACs)
• NO antiplatelet agents (aspirin, clopidogrel)
• NO arterial punctures (femoral, radial, brachial) — use AC fossa only
• NO Foley catheter (unless necessary — increased bleeding risk with instrumentation)
• NO NG tube (unless essential)
• Avoid all invasive procedures
💊 "No aspirin for 24 hours after tPA." Antiplatelet agents after tPA increase hemorrhagic transformation risk. Aspirin is typically started 24 hours after tPA once a repeat CT confirms no bleeding. Until then — no antiplatelet, no anticoagulant, no unnecessary invasive procedures.
Mechanical Thrombectomy
Retrieving the clot directly — for large vessel occlusions
Mechanical thrombectomy (MT) uses a catheter inserted through the femoral artery, navigated to the occluded cerebral artery, and a stent retriever or aspiration device to physically remove the clot. It is the most effective treatment for large vessel occlusion (LVO) stroke.
Extended treatment window: MT can be performed up to 24 hours from symptom onset in selected patients — much longer than the tPA window. Advanced imaging (CT perfusion or MRI) identifies patients with viable penumbra (salvageable brain tissue) who benefit from late thrombectomy.
MT + tPA: Eligible patients receive both — tPA given first (bridge therapy) while the patient is being prepared for thrombectomy.
Stroke Nursing Priorities
Post-stroke nursing care — the complications that kill after the clot
Post-Stroke Nursing Care
Swallowing, positioning, pressure injuries, DVT, and rehabilitation
Dysphagia screening before ANY oral intake: Stroke commonly affects swallowing — aspiration pneumonia is a leading cause of post-stroke death. Dysphagia screening must be completed before giving the patient anything by mouth — including medications, water, or food. Use a validated screening tool (e.g., 3-ounce water swallow test). If screening fails, speech therapy consult is required.
Positioning: Head of bed flat (0–30 degrees) for the first 24 hours in most ischemic stroke patients — promotes cerebral perfusion. Exception: if aspiration risk is high or increased ICP is present, HOB may be elevated. This is provider-directed.
Blood pressure management: Permissive hypertension — in acute ischemic stroke, elevated BP is often allowed (up to 220/120 before tPA, up to 180/105 after) because hypertension helps perfuse the ischemic penumbra. Aggressively lowering BP in acute stroke can expand the infarct.
Blood glucose control: Hyperglycemia worsens stroke outcomes — target 140–180 mg/dL. Hypoglycemia mimics stroke and must be corrected immediately.
Temperature: Fever worsens neurological outcomes after stroke. Treat fever aggressively with antipyretics. Target normothermia.
DVT prevention: Hemiplegia increases DVT risk. Sequential compression devices immediately. Heparin typically held for 24 hours post-tPA; timing of anticoagulation prophylaxis depends on stroke type and size.
💊 "Nothing by mouth until swallowing is assessed." This is one of the most important post-stroke nursing orders. Aspiration of food, water, or saliva into the lungs from stroke-related dysphagia causes aspiration pneumonia — a preventable, frequently fatal complication. The nurse who gives a stroke patient a cup of water without dysphagia screening has contributed to a preventable harm.
🏥 Clinical Scenario — Acute Ischemic Stroke Response
Mrs. Petersen, 72 years old, is visiting her husband in Room 412 when she suddenly slumps in the chair. Her husband says "She was fine two minutes ago." You are called to the room at 2:14pm.
FAST
Rapid BE-FAST assessment: Face — right facial droop confirmed. Arm — right arm drifts and pronates immediately when raised. Speech — slurred, struggling for words, repeating "I... I... can't..." Eyes — denies vision changes. Balance — cannot stand. All FAST criteria met. Stroke alert called at 2:16pm. LKW: 2:12pm per husband.
2:20
Stroke team arrives. Simultaneous actions: 12-lead ECG (A-fib detected — embolic source). Blood glucose: 148 (within range). IV access × 2. Blood drawn: CBC, BMP, PT/INR, type and screen. BP: 196/108 — above tPA threshold. Labetalol 10mg IV given. Repeat BP in 15 minutes: 178/96 — now below 185/110. Patient to CT scanner.
2:38
CT head without contrast: No hemorrhage confirmed. Large left MCA territory hypodensity beginning to appear. Neurology: "NIHSS 14, within tPA window, no contraindications. Give tPA." tPA initiated at 2:44pm — door-to-needle: 30 minutes. Well within 60-minute goal.
Post-tPA
Nursing priorities: BP monitoring q15 min. Neuro checks q15 min — NIHSS score trending. No anticoagulants, no aspirin, no invasive procedures for 24 hours. HOB flat (30 degrees per neurology). NPO until dysphagia screening by speech therapy in morning. SCDs applied. Repeat CT at 24 hours — no hemorrhage. Aspirin started day 2. Anticoagulation for A-fib discussed — to be started 2 weeks post-stroke per neurology.
📌 NCLEX Application
Stroke is one of the most tested Med-Surg topics on NCLEX:
tPA contraindication: "A patient with ischemic stroke has a BP of 192/106. What does the nurse do before administering tPA?" → Lower the BP to below 185/110 first — tPA with uncontrolled hypertension causes hemorrhagic transformation. Labetalol or nicardipine IV as ordered.
Post-tPA restrictions: "Which order does the nurse question for a patient 12 hours after receiving tPA?" → Heparin infusion — anticoagulants are held for 24 hours after tPA due to hemorrhagic transformation risk.
Dysphagia: "A patient had a stroke 4 hours ago and is asking for water. What does the nurse do?" → Complete dysphagia screening before giving any oral intake — stroke causes aspiration risk from dysphagia, and aspiration pneumonia is a leading post-stroke complication.
LKW importance: "A patient is found at 8am with stroke symptoms. His wife last saw him normal at 11pm. What is the last known well time?" → 11pm — not 8am when found. tPA eligibility is calculated from 11pm, placing the patient outside the 3-hour window.
⚠️ The Trap — Lowering Blood Pressure Aggressively in Acute Ischemic Stroke
A patient arrives with an ischemic stroke. BP is 188/102. The nurse, trained to treat hypertension, prepares to aggressively lower the blood pressure to normal range — 120/80.
Why this is wrong: In acute ischemic stroke, the brain tissue around the infarcted core (the penumbra) is alive but barely perfused. It survives because elevated blood pressure is forcing blood through collateral vessels into the hypoperfused area. If you lower the BP aggressively, you eliminate the driving pressure keeping the penumbra alive — and the infarct expands.
Permissive hypertension in acute ischemic stroke: BP is allowed to remain elevated — up to 220/120 — in patients who are NOT receiving tPA. The only reason to lower BP before tPA is to reach the 185/110 threshold required for safe tPA administration. After tPA, the target is below 180/105.
The paradox: The same blood pressure that would be an emergency in a cardiac patient is therapeutic in an acute stroke patient. Context determines treatment — always assess the clinical situation, not just the number.
✓ Quick Self-Test
Answer before checking:
1. What does BE-FAST stand for?
2. What is the tPA treatment window for ischemic stroke?
3. What blood pressure must be achieved BEFORE giving tPA?
4. Name three post-tPA nursing restrictions that last 24 hours.
5. Why is aggressive BP lowering dangerous in acute ischemic stroke?
Answers:
1. Balance · Eyes · Face drooping · Arm weakness · Speech difficulty · Time to call 911.
2. 3 hours from symptom onset (or last known well) for standard tPA eligibility; up to 4.5 hours in selected patients. Mechanical thrombectomy extends to 24 hours for large vessel occlusions in selected patients.
3. Below 185/110 mmHg — must be achieved before tPA is administered. Above this threshold, tPA causes unacceptable risk of hemorrhagic transformation.
4. Any three of: No anticoagulants, no antiplatelet agents (aspirin, clopidogrel), no arterial punctures in non-compressible sites, no Foley catheter (unless necessary), no NG tube (unless essential), avoid all invasive procedures.
5. Elevated BP in acute ischemic stroke maintains perfusion pressure to the ischemic penumbra — the viable but at-risk brain tissue surrounding the infarct core. Lowering BP reduces this perfusion pressure, causing the penumbra to infarct and expanding the stroke. Permissive hypertension (allowing BP up to 220/120 without tPA) is the standard of care.