Evidence-Based Practice: Managing Stroke

Every 45 seconds, someone in the United States has a stroke (cerebrovascular accident). Every 3 to 4 minutes, someone dies from a stroke. Of those over 65 who survive, 60% need assistance to walk, and 26% are in a nursing home 6 months afterward.

Fortunately, recent research has identified ways to minimize the effects of strokes and reduce their recurrence. To help you and your colleagues assist stroke victims, follow these evidence-based guidelines:

Assessment: 

  • Rapidly assess for signs and symptoms of stroke. 
  • Apply the NIH Stroke Scale. [LINK: http://www.strokecenter.org/trials/scales/nihss.html]
  • Send the patient for noncontrast computed tomography or magnetic resonance imaging of the brain, as ordered, to determine the type of stroke.
  • Collaborate with the physician to estimate the time since symptom onset and determine patient eligibility for thrombolytic therapy. In an ischemic stroke, consult the thrombolytic drug information sheet for eligibility.
  • Monitor the blood pressure. Expect to treat a systolic blood pressure above 220 mm Hg or a mean blood pressure above 120 mm Hg with the appropriate medications.
  • Monitor for signs and symptoms of increased intracranial pressure, such as decreased level of consciousness, headache, slurred speech, nausea, and vomiting. 
  • Screen for dysphagia within 24 hours. As ordered, keep the patient NPO.
  • If ordered, monitor coagulation test results and report the results to the physician.

Planning and Implementation:

  • Administer supplemental oxygen as prescribed.
  • Maintain a patent airway.
  • Apply an intermittent pneumatic compression device to the legs as ordered.
  • Administer a thrombolytic as prescribed. Monitor for adverse reactions, such as bleeding and angioedema. 
  • Give aspirin within 48 hours of an ischemic stroke as prescribed.
  • Prevent aspiration of food and drinks: Elevate the head of the bed. Provide thickened fluids and semi-solid food with a homogenous texture. Avoid thin liquids and extremely hot or cold food and drinks. 
  • Promote early activity, such as range-of-motion and rehabilitation exercises as ordered.
  • Prepare the patient and family for discharge. Stress the need to: 
    • Seek help early for signs and symptoms of stroke.
    • Modify risk factors: Stop smoking. Avoid excessive alcohol intake. Avoid a sedentary lifestyle. Follow medication regimens to control hypertension, high cholesterol, and diabetes mellitus. 
    • Maintain the rehabilitation and physical activity schedule.

Evaluation:

By discharge, the patient should:

  • Display no signs of bleeding or infection. 
  • Describe strategies for modifying risk factors.
  • Have a referral for rehabilitation therapy.

For more on managing stroke, check out the Evidence-Based Nursing Monographs: Cerebrovascular Accident (CVA) course in Mosby’s Nursing Consult.