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9.3 Medical Emergencies: Stroke (CVA)

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NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

9.3 Medical Emergencies: Stroke (CVA)

Key Takeaways Explain This Topic AI

FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911

Ischemic stroke (clot) may be treated with tPA (alteplase) if within 3-4.5 hours of symptom onset and no contraindications

tPA contraindications include recent surgery, active bleeding, history of intracranial hemorrhage, and uncontrolled hypertension

Hemorrhagic stroke requires blood pressure management and possible surgical intervention; tPA is contraindicated

Positioning for stroke patients: elevate HOB 30 degrees to reduce intracranial pressure; affected side up when lateral

Last updated: January 2026

Stroke, also called cerebrovascular accident (CVA), is a medical emergency requiring immediate intervention. "Time is brain" - every minute without treatment results in the death of approximately 1.9 million neurons.

Types of Stroke

  • Type Mechanism Percentage Treatment
  • Ischemic Blood clot blocks artery ~87% tPA, mechanical thrombectomy
  • Hemorrhagic Blood vessel ruptures ~13% BP control, surgery
  • TIA Temporary blockage N/A Prevention of future stroke
  • FAST: Rapid Stroke Assessment

The FAST mnemonic enables anyone to quickly identify stroke symptoms:

  • F - Face Drooping
  • Ask the person to smile

Is one side of the face drooping or numb?

  • Look for uneven smile
  • A - Arm Weakness
  • Ask the person to raise both arms

Does one arm drift downward?

Is there weakness or numbness on one side?

  • S - Speech Difficulty
  • Ask the person to repeat a simple phrase

Is speech slurred or strange?

Is the person unable to speak or hard to understand?

  • T - Time to Call 911
  • If ANY of these symptoms are present, call 911 immediately
  • Note the time symptoms started (critical for treatment decisions)
  • "Last known well" time determines tPA eligibility
  • Additional Stroke Signs and Symptoms

Beyond FAST, watch for:

  • Sudden severe headache ("worst headache of my life" suggests hemorrhagic)
  • Sudden confusion
  • Trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance
  • Sudden numbness on one side of body
  • Ischemic vs. Hemorrhagic Stroke Signs
  • Feature Ischemic Stroke Hemorrhagic Stroke
  • Onset Can be gradual Sudden, severe
  • Headache Usually absent Severe, "thunderclap"
  • LOC Changes May be subtle Often profound
  • Vomiting Uncommon Common
  • Neck Stiffness Absent May be present (SAH)
  • Diagnostic Workup

Immediate Imaging:

  • CT scan without contrast - First-line to rule out hemorrhage
  • Must be completed within 25 minutes of arrival
  • Hemorrhagic stroke appears bright white on CT
  • Ischemic stroke may not show changes initially

Additional Tests:

  • Blood glucose (hypoglycemia can mimic stroke)
  • CBC, coagulation studies (PT/INR, aPTT)
  • Basic metabolic panel
  • ECG (atrial fibrillation is a stroke risk factor)
  • MRI (more sensitive for ischemic stroke)
  • Treatment of Ischemic Stroke
  • Thrombolytic Therapy (tPA/Alteplase)

Tissue Plasminogen Activator (tPA) dissolves clots and restores blood flow.

Eligibility Criteria:

  • Symptom onset within 3-4.5 hours (some protocols extend to 4.5 hours)
  • CT confirms no hemorrhage
  • Measurable neurological deficit
  • Age 18 or older

Contraindications (Do NOT give tPA if):

  • Absolute Contraindications
  • Active internal bleeding
  • History of intracranial hemorrhage
  • Recent intracranial/spinal surgery (within 3 months)
  • Known intracranial neoplasm or AVM
  • Uncontrolled hypertension (SBP > 185 or DBP > 110)
  • Current anticoagulant use with INR > 1.7
  • Platelet count < 100,000

Nursing Considerations During tPA:

  • Strict blood pressure monitoring (every 15 min for 2 hours, then every 30 min for 6 hours)
  • Neuro checks every 15 minutes during infusion
  • NO anticoagulants or antiplatelets for 24 hours
  • Watch for bleeding (intracranial, GI, from puncture sites)
  • Do NOT place Foley, NG tube, or arterial lines during/immediately after infusion
  • Mechanical Thrombectomy
  • Catheter-based clot removal
  • For large vessel occlusions
  • Can extend treatment window to 24 hours in select patients
  • Used alone or with tPA
  • Treatment of Hemorrhagic Stroke

tPA is CONTRAINDICATED in hemorrhagic stroke - it would worsen bleeding.

Treatment Goals:

  • Blood pressure management - Lower gradually to prevent rebleeding
  • Target varies by type and severity
  • Typically maintain SBP < 140-160 mmHg
  • Reverse anticoagulation if applicable
  • Vitamin K for warfarin
  • Protamine for heparin
  • Surgical intervention for large bleeds
  • Craniotomy for hematoma evacuation
  • Ventriculostomy for hydrocephalus
  • Nursing Care for Stroke Patients
  • Positioning
  • Elevate HOB 30 degrees to reduce intracranial pressure
  • When turning, affected side up (protects weakened side)
  • Avoid neck flexion (impedes venous drainage)
  • Neurological Monitoring
  • Use NIH Stroke Scale for standardized assessment
  • Document baseline and compare frequently
  • Report any deterioration immediately
  • Swallowing Assessment
  • NPO until swallow evaluation (dysphagia is common)
  • Bedside swallow screen before any oral intake
  • Speech therapy consult for formal evaluation
  • Aspiration precautions if dysphagia present
  • Preventing Complications
  • DVT prophylaxis (SCDs, anticoagulation when safe)
  • Early mobilization when stable
  • Skin integrity monitoring
  • Fall precautions
  • Time Windows in Stroke Care
  • Benchmark Target Time
  • Door to physician 10 minutes
  • Door to CT completion 25 minutes
  • Door to CT interpretation 45 minutes
  • Door to tPA administration 60 minutes

Exam Tip: For NCLEX, remember "Last known well" not "symptom discovery time" determines tPA eligibility. If a patient wakes with symptoms, the last known well time is when they went to sleep.

  • Key Points for the NCLEX
  • FAST is the rapid assessment tool for stroke
  • Ischemic stroke = clot = may receive tPA (if within window and no contraindications)
  • Hemorrhagic stroke = bleed = NO tPA (would worsen bleeding)
  • CT scan without contrast is first-line imaging to differentiate types
  • NPO until swallow evaluation is complete
  • Elevated HOB 30 degrees reduces intracranial pressure
  • "Time is brain" - rapid intervention improves outcomes