Acute Stroke
Priority Actions and Care

When a stroke strikes, time is brain. Learn the time-sensitive priorities that protect neurons and save lives.

NCLEX-RN

What Is a Stroke?

A stroke (cerebrovascular accident) occurs when blood flow to part of the brain is interrupted, depriving neurons of oxygen and glucose. Without flow, brain tissue begins to die within minutes.

Two Major Types

Recognizing Stroke: BE-FAST

B

Balance: sudden loss of balance or coordination

E

Eyes: sudden vision loss or double vision

F

Face: facial drooping, uneven smile

A

Arm: arm weakness or drift on one side

S

Speech: slurred or garbled speech, aphasia

T

Time: note the last known well time, call 911 immediately

The Time Window Rule

Eligibility for treatment depends on time since last known well (LKW) — the last moment the patient was seen functioning normally, NOT the moment symptoms were discovered.

Core Rule: Priority Sequence

When stroke is suspected, the nurse follows a strict order. Airway and circulation come before diagnostics; CT scan must precede any clot-busting therapy.

tPA: Eligibility Checklist

Must Have

Ischemic stroke confirmed by CT, within \(4.5\) hr of LKW, age \(\geq 18\)

Exclusions

Any active bleeding, recent surgery, BP \(\gt 185/110\), platelets \(\lt 100{,}000\)

During Infusion

Frequent neuro checks, monitor for bleeding, no invasive procedures

Key Distinction: Blood Pressure

	Ischemic (no tPA)	After tPA / Hemorrhagic
BP goal	Permit \(\leq 220/120\)	Keep \(\lt 185/110\)
Why	Maintains perfusion to penumbra	Reduces bleeding risk
Action	Treat only if very high	Treat aggressively

How to Apply: First 60 Minutes

1

Assess ABCs and protect the airway; position with head of bed flat or per protocol.

2

Establish LKW time and activate the stroke alert/team.

3

Obtain stat non-contrast CT, glucose, coags, and complete an NIHSS.

4

Keep NPO until a swallow screen is passed to prevent aspiration.

5

Manage BP per type and prepare tPA or thrombectomy if eligible.

Example 1: New Arrival

A 68-year-old arrives with sudden right-sided weakness and slurred speech. Last seen normal 90 minutes ago. What is the nurse's first priority action?

Example 2: During tPA

A patient receiving IV tPA suddenly develops a severe headache, vomiting, and rising blood pressure. What does the nurse do?

Example 3: BP Decision

An ischemic stroke patient (NOT a tPA candidate) has a BP of \(196/104\). The new graduate wants to lower it quickly. Is this correct?

Common Mistakes

✕ Giving food/fluids early

Patients must stay NPO until a swallow screen passes — aspiration risk is high.

✕ tPA before CT

Never give clot-busters until hemorrhage is ruled out by CT.

✕ Lowering BP too fast

In untreated ischemic stroke, permissive hypertension protects brain tissue.

✕ Using symptom-discovery time

Eligibility is based on last known well, not when symptoms were noticed.

Summary: At a Glance

Priority	Action	Rationale
1. ABCs	Airway, breathing, circulation	Sustain life first
2. Time	Establish LKW, stroke alert	Time is brain
3. CT	Non-contrast head CT	Rule out bleed
4. NPO	Hold food until swallow screen	Prevent aspiration
5. Treat	tPA or thrombectomy if eligible	Restore perfusion

Question 1 of 5

A patient arrives with stroke symptoms. The nurse's first priority action is to:

ABCs always come first. Airway protection must be ensured before any diagnostics or treatment. tPA requires a CT first, and swallowing is unsafe to test early.

Question 2 of 5

Before IV tPA can be administered, the nurse must ensure the patient has had a:

A non-contrast CT rules out hemorrhagic stroke. Giving tPA to a bleeding patient is fatal, so CT must always precede clot-busting therapy.

Question 3 of 5

The standard IV tPA treatment window from last known well is up to:

IV tPA can be given up to \(4.5\) hours from last known well in eligible patients. Mechanical thrombectomy may extend to \(24\) hours in select cases.

Question 4 of 5

A patient receiving IV tPA develops a sudden severe headache and decreased level of consciousness. The nurse should first:

These are signs of intracranial hemorrhage, the most dangerous tPA complication. Stop the infusion immediately, notify the provider, and prepare for stat CT.

Question 5 of 5

An ischemic stroke patient who is NOT a tPA candidate has a BP of \(198/106\). The nurse should:

In untreated ischemic stroke, permissive hypertension up to \(\leq 220/120\) preserves perfusion to the penumbra. Aggressive lowering could worsen ischemia.

Acute StrokePriority Actions and Care

What Is a Stroke?

Two Major Types

Recognizing Stroke: BE-FAST

The Time Window Rule

Core Rule: Priority Sequence

tPA: Eligibility Checklist

Key Distinction: Blood Pressure

How to Apply: First 60 Minutes

Example 1: New Arrival

Example 2: During tPA

Example 3: BP Decision

Common Mistakes

Summary: At a Glance

Question 1 of 5

Question 2 of 5

Question 3 of 5

Question 4 of 5

Question 5 of 5

You've Got the Priorities

Acute Stroke
Priority Actions and Care