Stroke Nursing Guide | GCCNurseJobs

FAST — Public Recognition Tool

Face

Facial drooping — ask patient to smile. Is one side drooping?

Arms

Arm weakness — raise both arms. Does one drift downward?

Speech

Speech difficulty — slurred, confused or unable to speak?

Time

Time to call emergency — note exact onset time. Every minute counts.

Ischaemic vs Haemorrhagic Stroke

Feature	Ischaemic (80–85%)	Haemorrhagic (15–20%)
Cause	Thrombus/embolus occlusion of cerebral artery	Rupture of cerebral vessel
Onset	Often gradual or sudden; wake-up strokes	Often sudden; activity-related
Headache	Less common	Severe "thunderclap" headache
Vomiting	Less common	More common
Hypertension	May be present	Often severely elevated
CT findings	Normal early; hypodense area later	Immediate hyperdense area
Thrombolysis	Eligible (if criteria met)	ABSOLUTE contraindication

Stroke Mimics — Important Differentials

Todd's paresis: Focal weakness after seizure — resolves over hours
Hypoglycaemia: ALWAYS check glucose in stroke presentations — can mimic focal deficit
Complex migraine: Hemiplegic migraine with aura
Brain tumour: Gradual onset; may present acutely if haemorrhage into tumour
Hypertensive encephalopathy: Diffuse neurological impairment, not focal
Functional neurological disorder: Inconsistent neurological signs

Acute Stroke Protocol — Time is Brain

1.9 million neurons die every minute during ischaemic stroke without reperfusion. Time targets: Door-to-CT: <25 min | Door-to-needle (tPA): <60 min | Door-to-groin (thrombectomy): <90 min

Immediate Actions — STROKE Bundle

Airway: Protect airway; intubate only if GCS ≤8 or respiratory compromise
Glucose: Immediate bedside BGL — treat hypoglycaemia (<3.5 mmol/L) with 50% dextrose IV. DO NOT aggressively treat hyperglycaemia unless >14 mmol/L
CT head: Non-contrast CT within 25 minutes — exclude haemorrhage before thrombolysis
Vital signs: BP, HR, SpO₂, temperature, RR
IV access: 2 large-bore cannulas; send bloods (FBC, U&E, coag, group, troponin, ECG)
Onset time: Document exact time of last-known-well (LKW) — critical for thrombolysis eligibility
NIHSS assessment: Trained nurse scores within minutes of arrival
Notify stroke team: Pre-alert on arrival at ED via ambulance call

BP Management in Acute Stroke

Do NOT aggressively lower BP in acute ischaemic stroke — penumbra depends on elevated BP. Only treat if: BP >220/120 (ischaemic, no thrombolysis) OR >185/110 (if thrombolysis planned) OR in haemorrhagic stroke (target SBP <140 mmHg within 1 hr).

Scenario	BP Target	Drug
Ischaemic, no thrombolysis	Only treat if >220/120	Labetalol IV; nicardipine
Ischaemic, pre-thrombolysis	Bring to ≤185/110 before tPA	Labetalol 10–20 mg IV
Ischaemic, post-thrombolysis 24 hrs	Maintain <180/105	Labetalol or nicardipine infusion
Haemorrhagic	SBP ≤140 within 1 hr	Labetalol, nicardipine, clevidipine

NIHSS — National Institutes of Health Stroke Scale

The NIHSS is a 15-item neurological examination scoring 0–42. Higher scores = more severe stroke.

Domain	Max Score
Level of consciousness (LOC)	3
LOC questions (month, age)	2
LOC commands (open eyes, grip)	2
Best gaze	2
Visual fields	3
Facial palsy	3
Motor arm (left and right)	4 each
Motor leg (left and right)	4 each
Limb ataxia	2
Sensory	2
Best language	3
Dysarthria	2
Extinction/inattention	2

Severity: 0 = none; 1–4 = minor; 5–15 = moderate; 16–20 = moderate-severe; 21–42 = severe

Thrombolysis (tPA / Alteplase)

Indication: Acute ischaemic stroke within 4.5 hours of symptom onset (or last-known-well), haemorrhage excluded on CT, no absolute contraindications.

Absolute Contraindications

Haemorrhagic stroke (any intracranial haemorrhage on CT)
Onset >4.5 hours ago (or unknown onset)
Prior intracranial haemorrhage at any time
Intracranial neoplasm, AVM or aneurysm
Recent intracranial/spinal surgery (<3 months)
BP >185/110 that cannot be safely lowered
Active bleeding or coagulopathy (platelets <100, INR >1.7, APTT >40s)
Recent serious surgery or trauma (<14 days)
Blood glucose <2.8 or >22.2 mmol/L

tPA Protocol (Alteplase)

Dose: 0.9 mg/kg IV (max 90 mg)
Administration: 10% as IV bolus over 1 minute, remaining 90% as infusion over 60 minutes
BP target during infusion: <180/105 mmHg — monitor every 15 min for 2 hrs then every 30 min × 6 hrs then hourly × 16 hrs
No anticoagulants or antiplatelets for 24 hours post-tPA
CT at 24 hrs: Before starting anticoagulation/antiplatelets

Neurological deterioration post-tPA: Suspect haemorrhagic transformation. STOP infusion, urgent CT head, call stroke team, prepare for reversal (cryoprecipitate ± platelets ± FFP).

Mechanical Thrombectomy

Indicated for large vessel occlusion (LVO — internal carotid, proximal MCA) up to 24 hrs in selected patients
Superior to tPA alone for LVO — number needed to treat = 2.6 for functional independence
Requires CT angiography to confirm LVO before transfer to interventional centre
Available at major GCC stroke centres: KFSH&RC, Cleveland Clinic Abu Dhabi, HMC Qatar

Post-Stroke Nursing Care

Swallowing Assessment — CRITICAL

NIL BY MOUTH until swallow screen completed. Dysphagia affects 40–70% of acute stroke patients. Aspiration pneumonia is a leading cause of post-stroke death.

Bedside swallow screen (water test or standardised tool) within 4 hours of admission
If swallow screen FAILS → NPO, insert NG tube for medications and nutrition, refer to speech and language therapist (SLT)
Formal swallowing assessment by SLT within 24–48 hours
Medications: crush or liquid formulations only if swallow impaired; NG/PEG for long-term dysphagia
NG tube placement confirmation: CXR or pH <5.5 aspirate — NEVER use auscultation alone

Key Nursing Observations

Parameter	Frequency	Target / Action
Neurological obs (GCS, pupils, focal deficits)	15-min × 2 hrs → 30-min × 6 hrs → hourly × 16 hrs post-tPA; hourly otherwise	Any deterioration → urgent review
Blood pressure	Every 15 min post-tPA (2 hrs)	See BP targets per phase
Blood glucose	Every 4–6 hrs acutely	Target 4–11 mmol/L; treat <4 or >12
Temperature	Every 4 hrs	Target normothermia; treat fever >37.5°C with paracetamol
SpO₂	Continuous	Target ≥94%; supplemental O₂ only if SpO₂ <94%
Urine output / hydration	Hourly	IV fluids: 0.9% NaCl; avoid glucose IV (worsens ischaemia)

Secondary Prevention

Antiplatelets: Aspirin 300 mg loading, then 75 mg daily (start 24 hrs post-tPA; immediately if no thrombolysis). Clopidogrel + aspirin dual therapy for 21 days in minor stroke/high-risk TIA
Statins: High-intensity statin (atorvastatin 80 mg) initiated on day 1 — LDL target <1.8 mmol/L
Anticoagulation in AF: Start DOAC 3–14 days post-stroke (timing based on infarct size)
Blood pressure: Start/resume antihypertensives after 24–48 hrs stability
Early rehabilitation: Mobilisation within 24 hrs (unless contraindicated); physiotherapy, OT, SLT within 48 hrs

GCC-Specific Context

Stroke in GCC Populations

Younger stroke patients: GCC sees a higher proportion of stroke in patients under 50 — linked to uncontrolled diabetes, hypertension, dyslipidaemia, smoking and metabolic syndrome
Sickle cell disease: Higher prevalence in GCC (especially Oman, Bahrain) — sickle cell stroke may affect children and young adults; managed differently (exchange transfusion)
Cardiac embolism: Rheumatic mitral stenosis with AF — still prevalent in GCC migrant workers from endemic regions — a common cause of embolic stroke
Thrombophilia: Factor V Leiden and other thrombophilias are more prevalent in consanguineous GCC families — higher rate of cerebral venous sinus thrombosis (CVST) especially in young women postpartum
Language barriers: NIHSS administration requires trained Arabic/multilingual assessors in GCC stroke units — critical for accurate scoring in non-English-speaking patients

Key Exam Tips — DHA/SCFHS/QCHP

"Time is brain" — 1.9 million neurons/minute — classic exam opener
tPA dose: 0.9 mg/kg, max 90 mg; 10% bolus + 90% over 60 min
tPA window: 4.5 hours from onset/last known well
BP pre-tPA: must be ≤185/110 before starting
Haemorrhagic stroke = absolute contraindication to tPA
Swallowing screen BEFORE any oral intake or medications
IV fluid in stroke: 0.9% NaCl (not glucose — worsens ischaemic injury)
Glucose <3.5 mmol/L mimics stroke — ALWAYS check BGL first

Exam MCQs — DHA / SCFHS / QCHP

Q1. A patient presents with sudden onset left arm weakness and facial drooping. Onset was 2 hours ago. CT head shows no haemorrhage. BP is 178/104 mmHg. What is the NEXT priority action?

A) Administer aspirin 300 mg immediately B) Lower BP to 140/90 before proceeding C) Administer alteplase (tPA) 0.9 mg/kg IV — patient is within window with no haemorrhage D) Start anticoagulation with LMWH for presumed cardioembolic stroke

✅ C — Patient is within 4.5-hour window, CT excludes haemorrhage, BP is ≤185/110 (acceptable). tPA is the priority intervention. Aspirin is withheld for 24 hrs post-tPA. LMWH is NOT used in acute ischaemic stroke management acutely.

Q2. A nurse is caring for an acute stroke patient on a general medical ward. The patient is drowsy and unable to cooperate with a swallowing assessment. What action is CORRECT?

A) Give oral medications with water as normal — priority is not missing doses B) Crush all medications and administer with thickened fluids C) Keep nil by mouth; insert NG tube; refer to speech and language therapist D) Administer IV fluids only until patient is fully conscious

✅ C — An uncooperative or drowsy stroke patient CANNOT be safely assessed for swallowing. Keep nil by mouth, insert NG tube for medications and nutrition, and refer to SLT urgently. Aspiration pneumonia kills post-stroke patients.

Q3. During alteplase infusion for acute ischaemic stroke, the nurse notes the patient's GCS drops from 14 to 9 and BP rises to 205/120. What is the IMMEDIATE action?

A) Increase infusion rate — faster delivery will improve outcomes B) Stop tPA infusion immediately, call stroke team, arrange urgent CT head C) Administer antihypertensive and continue infusion D) Check pupils and document — deterioration expected during tPA

✅ B — Neurological deterioration during tPA = suspect haemorrhagic transformation. STOP infusion immediately, call stroke team, urgent CT head. Prepare for reversal (cryoprecipitate 10 units, ± FFP, ± platelets). Do NOT continue infusion or attribute deterioration to expected side effects.

Q4. Which IV fluid is CONTRAINDICATED in acute ischaemic stroke management?

A) 0.9% sodium chloride (normal saline) B) 5% dextrose (glucose solution) C) Hartmann's solution (lactated Ringer's) D) 0.45% saline

✅ B — Glucose-containing fluids are contraindicated in ischaemic stroke. Hyperglycaemia worsens cerebral ischaemic injury through anaerobic metabolism, increased acidosis and oedema. Use 0.9% NaCl as the standard maintenance fluid.

🧠 Stroke Nursing