Acute Stroke: A Comprehensive Guide for Nurses

Acute stroke is a medical emergency and one of the leading causes of disability and death worldwide. Prompt recognition and management of stroke are critical to minimizing brain injury and improving patient outcomes. Nurses play a pivotal role in the care of stroke patients, from rapid assessment and stabilization to ongoing treatment and rehabilitation.

Definition and Overview

An acute stroke occurs when there is an abrupt interruption of blood flow to the brain, resulting in neurological dysfunction. Strokes are classified into two major types:

Ischemic Stroke:

• Caused by a blockage in a blood vessel supplying the brain.
• Accounts for approximately 87% of all strokes.
• Often results from thrombus formation (clot within a vessel) or embolism (clot traveling from another site, such as the heart).

Hemorrhagic Stroke:

• Caused by bleeding into the brain tissue (intracerebral hemorrhage) or the space surrounding the brain (subarachnoid hemorrhage).
• Less common but associated with higher mortality rates.
• Often results from hypertension, aneurysm rupture, or trauma.

Pathophysiology of Stroke

Regardless of the type, the effects of a stroke are due to reduced or completely interrupted blood flow, leading to ischemia (lack of oxygen) and subsequent brain cell death. The ischemic penumbra, a region of brain tissue around the infarcted core, is at risk but salvageable if reperfusion occurs promptly.

In hemorrhagic stroke, increased intracranial pressure (ICP) due to bleeding can further compromise cerebral perfusion and cause herniation or death.

Risk Factors

Stroke risk factors are divided into modifiable and non-modifiable categories:

Non-Modifiable Risk Factors:

• Age: Risk increases with age, especially over 55.
• Gender: Men have a higher risk, though women have worse outcomes.
• Family History: Genetic predisposition to stroke or cardiovascular conditions.
• Prior Stroke or Transient Ischemic Attack (TIA): Previous events increase the likelihood of recurrence.

Modifiable Risk Factors:

• Hypertension: The leading risk factor for both ischemic and hemorrhagic stroke.
• Atrial Fibrillation: Increases the risk of embolic strokes.
• Diabetes Mellitus: Associated with accelerated atherosclerosis.
• Dyslipidemia: High LDL and low HDL levels contribute to plaque formation.
• Smoking: Damages blood vessels and promotes clot formation.
• Obesity and Physical Inactivity: Contribute to other vascular risk factors.
• Excessive Alcohol Intake or Drug Use: Particularly cocaine and amphetamines.

Clinical Manifestations

The symptoms of stroke are often sudden and depend on the affected area of the brain. Common signs and symptoms include:

FAST Symptoms:

• Facial drooping: One side of the face appears uneven or droops.
• Arm weakness: Inability to raise one or both arms.
• Speech difficulties: Slurred or incomprehensible speech.
• Time: Time to call emergency services immediately.

Other Neurological Signs:

• Sudden numbness or weakness, especially on one side of the body.
• Sudden confusion or difficulty understanding.
• Sudden visual disturbances in one or both eyes.
• Sudden severe headache (more common in hemorrhagic stroke).
• Sudden loss of coordination, balance, or dizziness.

Differentiating Hemorrhagic Stroke:

• Severe headache described as “the worst headache of my life.”
• Nausea and vomiting.
• Altered level of consciousness or seizures.

Nursing Assessment

A rapid and systematic assessment is critical for stroke management. The following components are essential:

Initial Assessment:

• Airway, Breathing, and Circulation (ABC): Ensure a patent airway, adequate oxygenation, and stable circulation.
• Obtain a quick history, including the time of symptom onset or last known well (critical for treatment decisions).

Focused Neurological Examination:

• Perform the National Institutes of Health Stroke Scale (NIHSS) to assess stroke severity.
• Document Glasgow Coma Scale (GCS) score for level of consciousness.
• Evaluate cranial nerve function, motor strength, sensation, and coordination.

Vital Signs:

• Blood pressure, heart rate, and temperature.
• Monitor oxygen saturation and administer oxygen if SpO₂ <94%.

Diagnostic Tests:

• Non-Contrast CT Scan: Differentiate between ischemic and hemorrhagic stroke.
• MRI: Provides detailed imaging, often used after stabilization.
• Blood Tests: Include glucose, coagulation profile (PT/INR, aPTT), and CBC.
• ECG: Detects atrial fibrillation or other arrhythmias.
• Carotid Ultrasound or CT Angiography: Identify blockages or stenosis in vessels.

Management of Acute Stroke

The treatment of stroke varies based on its type and the time since symptom onset. Goals include restoring blood flow (for ischemic strokes), preventing complications, and minimizing long-term disability.

Management of Ischemic Stroke

Thrombolytic Therapy:

• Administer intravenous tissue plasminogen activator (tPA) if within 3-4.5 hours of symptom onset and no contraindications exist.
• Closely monitor for signs of bleeding post-tPA administration.

Mechanical Thrombectomy:

• Performed within 6-24 hours for eligible patients with large vessel occlusion.

Antiplatelet and Anticoagulant Therapy:

• Aspirin is typically started 24-48 hours after symptom onset in most ischemic stroke patients.
• Long-term anticoagulation may be prescribed for atrial fibrillation or hypercoagulable states.

Management of Hemorrhagic Stroke

Blood Pressure Control:

• Lower elevated BP carefully to reduce bleeding risk while maintaining cerebral perfusion.
• Common agents include labetalol or nicardipine.

Management of ICP:

• Elevate the head of the bed to 30 degrees.
• Use osmotic agents like mannitol or hypertonic saline for severe cases.

Surgical Interventions:

• Hematoma evacuation or aneurysm clipping may be necessary for certain patients.

Supportive Care

• Ensure adequate oxygenation and fluid balance.
• Prevent complications such as aspiration pneumonia, deep vein thrombosis (DVT), or pressure ulcers.
• Begin early rehabilitation planning.

Nursing Interventions

Nurses play a crucial role in acute stroke care. Essential interventions include:

Acute Phase:

• Monitor for changes in neurological status and report worsening symptoms immediately.
• Administer prescribed medications (e.g., thrombolytics, antihypertensives) as directed.
• Maintain airway patency and suction as needed to prevent aspiration.

Post-Stroke Management:

• Support activities of daily living and mobility.
• Implement fall precautions and skin integrity measures.
• Provide emotional support to patients and families.

Education:

• Teach stroke prevention strategies, including managing risk factors such as hypertension, diabetes, and smoking.
• Educate patients and families on recognizing early signs of stroke and the importance of seeking immediate medical attention.

Prevention of Stroke

Stroke prevention involves addressing modifiable risk factors and maintaining overall cardiovascular health. Key strategies include:

• Adhering to a healthy diet and maintaining a normal body weight.
• Engaging in regular physical activity.
• Managing chronic conditions like hypertension, diabetes, and hyperlipidemia.
• Avoiding smoking and limiting alcohol intake.
• Taking prescribed medications, such as antiplatelets or anticoagulants, as directed.

Conclusion

Acute stroke is a time-sensitive emergency requiring rapid recognition and treatment. Nurses are central to stroke management, ensuring timely interventions, minimizing complications, and supporting recovery. By understanding the pathophysiology, clinical presentation, and treatment options, nurses can provide evidence-based care that improves outcomes and enhances quality of life for stroke patients.