Medications (Davis & Lockhart, 2016; Schweickert, et Al., 2016)

• Alteplase: A tissue plasminogen activator (tPA); the only FDA approved drug to treat ischemic stroke. It is a natural enzyme that initiates fibrinolysis (breaks down thrombus).
• Tenecteplase: May be used as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion (Powers, et al. 2018).
• Heparin: Used for an acute stroke during mechanical thrombectomy, when administering intraarterial alteplase, and in the presence of large, intraluminal thrombotic or embolic filling defect of the major cerebral arteries.
• Furosemide (Lasix): Loop diuretic used to reduce intracranial fluid volume in hemorrhagic stroke and to decrease the risk of herniation.
• Mannitol: Osmotic diuretic used to decrease cerebral edema, tissue damage and reduce the risk of herniation. Fosphenytoin: Antiepileptic drug that stabilizes neuronal membranes and decreases seizure activity.
• Phenytoin: Antiepileptic drug used to inhibit the spread of seizure activity in the cerebral motor cortex and brainstem centers responsible for the tonic phase of grand mal seizures.
• Antiplatelet treatment: Administer aspirin within 24 to 48 hours after stroke onset. For patients that have been treated with alteplase, delay aspirin until 24 hours following therapy.
• Anticoagulant: Urgent anticoagulation is NOT recommended.

Surgical Procedures (Davis & Lockhart, 2016)

For acute ischemic stroke

• Endovascular thrombectomy: mechanical removal of the thrombus to reestablish blood flow.
  • Treats thrombus in minutes versus alteplase which may take 2 hours to dissolve the clot.
  • Effective in large cerebral vessels, but not in smaller arterial cerebral vessels.
  • Do not delay mechanical thrombectomy to observe a clinical response after IV alteplase.
  • Maintain BP ≤ 180/105 mmHg during and for 24 hours after the procedure.

For hemorrhagic stroke

• Superficial temporal artery to middle cerebral artery bypass graft: the graft bypasses the cerebral vessel that has the thrombus or unruptured aneurysm (may also treat ischemic stroke).
• Guglielmi detachable coils: small platinum coils are used to occlude an inoperable, ruptured, or unruptured aneurysm.
• Aneurysm clipping: surgical clips may be placed to seal bleeding from a fusiform aneurysm (ruptured or unruptured) or multiple small vessel aneurysms.

Nursing Interventions for the Stroke Patient (Davis & Lockhart, 2016; Powers, et Al., 2018)

• Support airway, breathing and circulation
  • Provide supplemental oxygen to maintain oxygen saturation > 94% in hypoxic patients.
  • Ventilator support for respiratory depression, fatigue, decreased consciousness or a compromised airway.
• Monitor vital signs at least every 15 minutes.
• Neurologic assessments should be performed hourly or as needed.
  • Monitor for signs of brain stem herniation (increased intracranial pressure, decreased strength in extremities, focal or global seizure activity, or asymmetrical pupils.)
  • Monitor for seizure activity, implement seizure precautions.
  • Do not administer anti-seizure medication prophylactically.
• Treat hyperthermia with antipyretic medications.
• Treat hyperglycemia to keep blood glucose levels between 140-180 mg/dL and treat hypoglycemia (blood glucose < 60 mg/dL) per hospital protocol.
• If surgery is performed, assess the patient for the following and if present, notify the health care team immediately.
  • Surgical site for a puncture site hematoma or signs of infection, such as localized edema and erythema.
  • Change in vital signs such as tachycardia, hypo- or hypertension, and elevated temperature.
  • Neurologic changes (decreased LOC, visual changes, new-onset weakness), which may indicate extension of the stroke area, cerebral vasospasm, or cerebral brainstem herniation.

Strategies to Minimize Post-Procedure Complications:

• Ensure the patient remains NPO to prevent aspiration; a bedside swallowing assessment should be performed before allowing the patient to eat, drink or consume medications.
• Keep the head of bed elevated at a minimum of 30 degrees unless contraindicated.
• Blood pressure management (Anderson, 2016):
  • Avoid hypotension in patients with ischemic stroke to prevent further cerebral ischemia; correct hypotension and hypovolemia to maintain perfusion and organ function.
  • Avoid hypertension in patients with hemorrhagic stroke to prevent expansion of intracranial bleeding.
  • Avoid rapidly lowering BP which can lead to worsening ischemia.
  • Do not lower the BP during the initial 24 hours of acute ischemic stroke unless BP > 220/120 mmHg.
  • Start or restart antihypertensive therapy during hospitalization in neurologically stable patients with BP > 140/90 mmHg to improve long-term BP control, unless contraindicated.

Nutrition (Powers, et al., 2018)

• Start enteral diet within 7 days of admission after an acute stroke.
• Screen for dysphagia before the patient begins eating, drinking or receiving oral medications to identify risk for aspiration.
  • For patients with dysphagia, use nasogastric tubes for feeding in early phase of stroke (first 7 days); percutaneous gastrostomy tube may be needed if unable to swallow safely for longer than 2-3 weeks.
• Consider nutritional supplements for patients who are or at risk for malnourishment.
• Implement oral hygiene protocols to reduce the risk of pneumonia.

Deep Vein Thrombosis (DVT) Prophylaxis (Powers, et al., 2018)

• Use intermittent pneumatic compression (IPC) in addition to routine care (aspirin and hydration) to reduce the risk of DVT in immobile stroke patients, unless contraindicated.
• Do NOT use elastic compression stockings in ischemic stroke patients.

Additional Recommendations (Powers, et al., 2018)

• Screen for post-stroke depression and administer antidepressants if not contraindicated.
• Avoid routine use of indwelling bladder catheters to prevent catheter-associated urinary tract infections.
• Perform regular skin assessments during hospitalization and inpatient rehabilitation. Minimize skin friction and pressure; provide support surfaces; avoid excessive moisture; and maintain nutrition and hydration to prevent skin breakdown. Regular turning, good skin hygiene, special mattresses, wheelchair cushions, and seating should be used until mobility returns.
• Antithrombotic treatment
  • In non-embolic stroke, use antiplatelet agent in place of oral anticoagulation to reduce risk of recurrent stroke.
  • For most patients with atrial fibrillation and stroke, it is reasonable to begin oral anticoagulation within 4-14 days after onset of neurological symptoms.
  • For patients with extracranial carotid or vertebral artery dissection, it is reasonable to treat with antiplatelet or anticoagulant therapy for 3 to 6 months.
• Statins: Continue statin therapy for patients taking statins or initiate in-hospital statin therapy for patients who qualify.
• Carotid revascularization: When revascularization is indicated for secondary prevention in patients with minor, nondisabling stroke, the procedure may be performed between 48 hours and 7 days after the stroke.
• Smoking cessation: Advise every patient to quit smoking and provide counseling and high-intensity behavioral therapies in-hospital.
• Stroke education: Provide patients with stroke education, information, advice, and the opportunity talk about the impact of illness on their lives.