CC CJM | Stroke [CVA]

80/20 Clinical Stroke Summary

Core Concepts & Emergency Recognition A stroke is an emergency where cell death occurs due to ischemia (inadequate blood flow, 87% of cases) or hemorrhage (bleeding, 13%)[1][2]. Interruption of blood flow alters brain metabolism in 30 seconds, stops it in 2 minutes, and causes cell death in 5 minutes[3]. The FAST protocol is critical for rapid recognition: Face drooping, Arm weakness/drift, Speech difficulties, and Time of symptom onset (critical for determining treatment eligibility)[1].

Pathophysiology & Classification

• Ischemic Stroke: Divided into Thrombotic (60% of cases; associated with hypertension, diabetes, and atherosclerosis; symptoms develop slowly/stepwise)[2][6] and Embolic (clot from the heart, often due to atrial fibrillation, travels and occludes a cerebral artery; onset is sudden with severe deficits)[2].
• Hemorrhagic Stroke: Includes Intracerebral (bleeding into brain tissue, mostly caused by hypertension)[2]and Subarachnoid (SAH) (bleeding into CSF-filled space, often from ruptured aneurysms)[9]. SAH can trigger severe vasospasms, peaking 6–10 days post-bleed[10].

Key Diagnostics & Triage Immediate noncontrast head CT or MRI is mandatory to rapidly differentiate ischemic from hemorrhage[4]. The NIH Stroke Scale (NIHSS) (scores 0–42) is the primary clinical tool to document baseline severity and track neurologic changes[11][12].

Acute Interventions & Hemodynamic Targets

• Ischemic: IV tPA must be given within 3 to 4.5 hours of symptom onset after screening out hemorrhage, active bleeding, or recent trauma[13]. Endovascular therapy with stent retrievers is highly effective[14]. Keep BP <185/110 mmHg before tPA, and <180/105 mmHg for 24 hours after[5]. If ineligible for tPA, lower BP only if SBP >220 or DBP >120 mmHg[5].
• Hemorrhagic: Anticoagulants and antiplatelets are strictly contraindicated[14]. Manage hypertension to maintain SBP <160 mmHg[14]. For SAH, administer the calcium channel blocker nimodipine to prevent vasospasm[11][15].

High-Priority Nursing ADPIE Actions

1. Airway & Aspiration: Keep the patient NPO until a formal swallowing screen is completed within 24 hours to prevent aspiration pneumonia[5].
2. ICP Management: Elevate the head of bed 30°, keep head/neck in midline, and avoid hip flexion to maximize venous drainage and reduce intracranial pressure[13][16].
3. Safety & Pattern Recognition: Left-brain stroke causes right hemiplegia, aphasia, slow/cautious behavior, and depression[18]. Right-brain stroke causes left hemiplegia, spatial-perceptual neglect, and highly impulsive, safety-compromising behavior[18][19]. Protect from injury and address one-sided neglect[19][20].
4. VTE Prophylaxis: Implement passive/active range of motion, sequential compression devices, and low-molecular-weight heparin[21].