Medical Surgical Stroke #1

Question

The emergency department nurse receives a client with an ischemic stroke, and prepares to administer tissue plasminogen activator (t-PA). What question should the nurse ask first before administering the t-PA?

Answers

  1. Ask the client which arm or leg is affected.
    • Rationale:

      This answer is not correct because though it is important to know which side of the body is affected to determine the side of the brain that the stroke occurred, it is most important to determine onset of stroke symptoms to determine if a client is a candidate for t-PA. Tissue plasminogen activator (t-PA) dissolves the blood clot to restore perfusion to the brain. It must be started within 3 hours of when the stroke symptoms started.

  2. Ask the client if speech was slurred.
    • Rationale:

      This answer is not correct because while asking about speech changes is important, priority is to establish the time frame of stroke onset. Tissue plasminogen activator (t-PA) dissolves the blood clot to restore perfusion to the brain. It must be started within 3 hours of when the stroke symptoms started.

  3. The nurse will ask the time of onset of stroke.
    • Rationale:

      This answer is correct because the emergent need is to determine if the client is a candidate for t-PA administration. Timing of onset of stroke is important when receiving t-PA. Studies indicate that clients should receive the thrombolytic medication within 3 hours after the onset of a stroke for best outcomes.

  4. Ask what home medications the client takes.
    • Rationale:

      This answer is not correct because the ABCs of triage is at play here. Knowing a stroke client’s medications can wait until after t-PA is administered. Timing of onset of stroke is important when receiving t-PA. Studies indicate that clients should receive the thrombolytic medication within 3 hours after the onset of a stroke for best outcomes.

Overview

An ischemic stroke is when a blood clot blocks an artery to the brain. Tissue plasminogen activator (t-PA) dissolves the blood clot to restore perfusion to the brain. It must be started within 3 hours of when the stroke symptoms started.

Explanation

Learning Outcomes

Ischemic stroke signs include numbness or paralysis on one side of the body, severe headache, difficulty speaking, blurred or double vision, and loss of coordination. The acronym F.A.S.T. is utilized during stroke symptoms. F.A.S.T. stands for facial drooping, arm weakness, speech, and most importantly time. Time is of the essence during a stroke. Every minute the brain loses perfusion during a stroke, the brain loses millions of cells. Tissue plasminogen activator (t-PA) dissolves the blood clot to restore perfusion to the brain. It must be started within 3 hours of when the stroke symptoms started. Also the longer the client experiences a stroke, the risk of death is higher. The sooner the client receives treatment, the better the potential for a positive outcome.

Test Taking Tip

The medication t-Pa has 3 letters and should be administered within 3 hours of onset of the stroke.

Video Rationale