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Introduction

Stroke remains the second-leading cause of death worldwide and the fifth most common cause of death in the U.S. (4, 5). More than 795,000 Americans have a stroke every year and about 1 in 4 of these have had a previous stroke (3). Globally, 12 million new strokes occur each year and more than 101 million people currently living (as of 2019) are post stroke (5). The morbidity, mortality, and costs of strokes can be astronomical.  

In the U.S., stroke is a leading cause of serious long-term disability, reduces mobility in over half of stroke survivors aged 65 and older, and is the number one cause of neurological disability in adults (1, 4). In 2021, the U.S. death rate from stroke was 41.1 per 100,000, a number that has risen from the previous year (3). Globally, stroke is the third-leading cause of death and disability combined (5). Strokes are costly to the healthcare system. From 2018 to 2019, strokes cost the U.S. $56.5 billion. Globally, this number is over $721 billion (4, 5).  

Nurses play a vital role in assessing patients, applying new protocols, and providing overall care in stroke treatment plans. This Post Stroke Care course will help nurses maintain competency in stroke rehabilitation for patients who are acutely ill in the emergency room (ER), intensive care unit (ICU), post stroke unit, rehabilitation unit, or at home. 

Epidemiology 

A stroke is a disorder involving sudden interruption of blood flow to the brain that causes neurological deficit (1). The primary causes are ischemia (tissue death) and hemorrhage. Ischemic stroke is the most common type of stroke in the world, typically resulting from a thrombosis or embolism (5). Hemorrhagic strokes result from a rupture in a brain vessel. An individual can also have stroke symptoms without evidence of an acute cerebral infarction (termed transient ischemic attack or TIA) (1). 

With any stroke, the sooner the treatment, the better the prognosis. Ischemic strokes, however, tend to have lower prognoses. Both ischemia and blood (from the hemorrhagic strokes) damage brain tissue, but ischemia is most damaging. Individuals who have had a hemorrhagic stroke have a better prognosis than those who have had an ischemic stroke with similar symptoms (1). However, a massive hemorrhagic stroke accompanied by intracranial hypertension has a poorer outcome (1).  

While individuals are unable to predict a stroke, many contributing factors are modifiable. High blood pressure, high cholesterol, smoking, obesity, and diabetes are the primary causes of stroke in the U.S., and 1 in 3 Americans have at least one of these risks/conditions (3).

Other modifiable risk factors include (1): 

• Lack of physical activity 
• Diets high in saturated fats, trans fats, and calories 
• Psychosocial stress 
• Use of certain drugs (such as cocaine or amphetamines) 

Non-modifiable risk factors include (1): 

• Prior stroke 
• Increased age 
• Strokes occur most often in individuals over the age of 65 to 70 (4, 5) 
• Family history of stroke 
• Sex 
• Females worldwide have more ischemic strokes than males (5) 
• Males worldwide have more hemorrhagic strokes than females (5) 
• Race/ethnicity 
• Non-Hispanic Black adults are twice as likely to have a stroke than for White adults (3) 
• Non-Hispanic Black adults and Pacific Islander adults have the highest stroke-related death rates (3) 
• Genetics 

Pathophysiology 

It is well known that patients with stroke symptoms should be transported to an acute care facility as soon as symptoms are observed. The promptness of treatment is the primary goal in stroke care. Preventing irreversible damage to the tissue is of upmost importance. However, what is truly happening from a pathophysiological standpoint? To answer this question, we must look at the brain and its function.  

The brain is a complex organ comprised of three parts: the forebrain, midbrain, and hindbrain (8).  

The forebrain controls memories, planning, imagination, thinking, reading, playing, and recognition of familiarity. The forebrain is the largest part of the brain and includes the cerebrum (which has two hemispheres divided by a deep fissure) and structures within the inner brain (hypothalamus, thalamus, hippocampus, and basal ganglia). 

The midbrain controls some reflexes and is involved in eye movements and other voluntary movements.  

The hindbrain controls vital body functions (such as breathing and heart rate) and learned movements (such as learning to play sports). The hindbrain includes the upper part of the spinal cord, the brain stem, and the cerebellum.   

In normal brain function, cerebral arteries (and their branches) supply blood to the various areas of the brain to maintain function. These include the anterior, middle, and posterior cerebral arteries. A thrombosis, embolism, or rupture can affect any area of the brain which is why symptoms can vary based on the location of damage.  

Stroke symptoms may include (1): 

• Weakness of the extremities or face 

• Aphasia (impaired communication) 

• Confusion 

• Visual disturbances 

• Dizziness 

• Loss of balance and coordination 

• Sudden severe headache (notable in hemorrhagic stroke) 

Nursing Role Post-Event 

Nurses play key roles in prevention education, acute management, and utilization of telehealth technology for stroke diagnosis in the community. Some non-stroke centers use newer imaging technology that enables expert radiologists to diagnose a stroke and/or rule out brain hemorrhage via computer tomography (CT) scans within minutes from off-site offices. Patients who live in rural settings or have limited access to care are particularly challenged in getting timely and specialized stroke care. 

Whether a patient has experienced an ischemic stroke or not, nurses in acute care units are responsible for post stroke assessments, including frequent vital signs monitoring and neurological assessments. The nursing team is also responsible for managing blood glucose levels and preventing complications such as aspiration, dehydration, malnutrition, deconditioning, pressure injuries, contractures, and thrombosis related to immobility (1). Later, we will review challenges some patients experience after having a stroke, such as dysphagia. The health care team assists patients with cognitive or functional changes (and their families) with the goal of improving quality of life.  

As we know, patient satisfaction is related to how well they understand their condition and plan of care. Other care team members, such as social workers, nutritionists, and physical therapists, rely on the clinical team to provide up-to-date clinical information that often changes daily. This data can determine whether the patient can safely discharge home or if a rehabilitation stay is recommended. Ideally, physical therapists, occupational therapists, registered dietitians, and other members of the care management team should be present for daily team rounding to keep everyone up to date on the patient’s progress. The team is often mediated by the provider who may order anticipated imaging/tests and other interventions to prevent complications (7). Team rounding helps the provider gather the appropriate information needed to update the patient’s family on the prognosis and plan. 

Post Stroke / Post Procedure Monitoring 

Acute Ischemic Stroke guidelines by the American Heart Association recommend frequent neurological and vital sign monitoring for patients receiving thrombolytics or clot-buster medications like intravenous alteplase (TPA) and those who have had a mechanical thrombectomy (MT) of a cerebral clot, also termed reperfusion therapy. Keep in mind, some patients who have had an ischemic stroke are not candidates for thrombolytics (such as patients with thrombocytopenia or those already on certain anticoagulants). Also keep in mind that thrombolytics are contraindicated in patients who had a hemorrhagic stroke. This section will focus on patients who have had an ischemic stroke. 

Per the guidelines, neurological assessments and vital signs monitoring should occur in the following order for patients who have had MT whether treated with a thrombolytic agent or not (9): 

• Every 15 minutes for 2 hours 

• Every 30 minutes for 6 hours 

• Every hour for 16 hours  

The National Institutes of Health Stroke Scale (NIHSS) score is a commonly used standardized neurological assessment tool consisting of 11 clinical assessment items to measure stroke deficits. Nurses can use this tool to perform neurological assessments. 

It is important to make a distinction between patients who received thrombolytic therapy and those who have not, as this information affects the treatment plan. In patients who had an acute ischemic stroke who received thrombolytic treatment before reperfusion therapy, blood pressure should be maintained below 180/105. In patients who had an acute ischemic stroke who did not receive thrombolytic treatment before reperfusion therapy, blood pressure should be maintained below 185/110. 

The following are guideline recommendations for blood treatment after an acute ischemic stroke (9):  

• Management of BP during and after alteplase or emergency reperfusion therapy, maintain BP <180/105 mm Hg:  

• Monitor BP every 15 min for 2 h from the start of alteplase therapy, then every 30 min for 6 h, and then every hour for 16  

• If systolic BP 180–230 mm Hg or diastolic BP >105–120 mm Hg  

• Labetalol 10 mg intravenous followed by a continuous infusion 208 mg/min; or  

• Nicardipine 5 mg/h intravenous, titrate up to desired effect by 2.5 mg/h every 5–15 min, maximum 15 mg/h; or  

• Clevidipine 1–2 mg/h intravenous, titrate by doubling the dose every 2–5 min until desired BP reached; maximum of 21 mg/h  

• If BP not controlled or diastolic BP >140 mm Hg, consider intravenous sodium nitroprusside 

New Joint Commission guidelines specify that blood pressure goals and/or treatment methods be written in the medication orders. Guidelines also state nurses should be aware of titration recommendations from the manufacturer to prevent rapid swings in blood pressure if adjusted too quickly. 

Post Endovascular Thrombectomy Complications 

After the endovascular thrombectomy procedure, the nurse must recognize potential complications related to the arterial puncture made during the procedure (9). These include possible injury to the arterial vessel or the nerves near the puncture location. Post procedure neurovascular assessments are also advised, including the arterial puncture site, distal pulses, and circulation, and the nurse should be aware of any preexisting deficits or disabilities the patient may have, using this information as a baseline (9). 

Per guidelines, monitoring parameters for neurovascular assessments post thrombectomy should follow this order (9): 

• Every 15 min for 1 hour 

• Every 30 min for 1 hour 

• Every 1 hour for 4 hours 

Another post procedure complication is hemorrhage at the access site, more specifically, a retroperitoneal bleed (9). This bleed occurs when blood enters the space behind the abdominal peritoneum. While not always immediately evident, symptoms of a retroperitoneal bleed may include: 

• Patient may appear to be in shock 

• Hemoglobin and hematocrit levels may suddenly drop 

• Blood pressure may suddenly drop 

• Patient may report of occasional back pain   

The nurse should also be aware of the potential for arterial vessel closure device failure. If this occurs, the patient is prone to bleeding at the arterial vessel access site (9). 

Rather than accessing the femoral artery, some facilities/organizations use radial artery access for thrombectomy procedures as it can eliminate the period of immobility required for patients who had femoral access. Although the femoral artery is larger, the radial artery can still bleed heavily. Compression devices can prevent or treat radial artery bleeds. However, nurses should follow manufacturer recommendations for instructions on release of pressure (9). 

Post Intravenous Thrombolytic Intervention 

Nurses should also closely monitor patients who receive IV alteplase (TPA) to dissolve the clot producing stroke symptoms. These patients are susceptible to localized and systemic bleeding. Within the 36 to 48 hours after the patient receives the “clot buster” medication (9), the nurse should closely monitor the patient’s neurological function as a sudden drop in function may indicate an intracerebral hemorrhage.

Patients with symptomatic intracerebral hemorrhage can have mortality up to 83% (9). The nurse should also frequently assess for excess bleeding from puncture sites or orifices, hematuria, or hemoptysis. Although rare, orolingual angioedema (tongue swelling) has been noted as a side effect of TPA, especially in patients taking angiotensin-converting-enzyme (ACE) inhibitor medications (9). Orolingual angioedema can compromise the patient’s airway and breathing. 

Other Complications and Assessments 

Complications after stroke can include respiratory difficulties, fever, alternations in blood sugar, venous thromboembolism, and urinary retention. The nurse’s accurate and timely assessments help to adequately manage complications, and most importantly prevent them from occurring in the first place. 

Respiratory Difficulties 

Patients in the post stroke period may have difficulty protecting and maintaining their airway due to changes in mental status and cranial nerve deficits.  For patients post stroke, the nurse should assess the patient’s: 

• Respiratory rate 

• Excursion 

• Ability to clear secretions 

• Oxygen saturation level 

• Arterial blood gas levels, if indicated (particularly if endotracheal intubation is being considered) 

Fever 

Fever is associated with worse outcomes after stroke (9). Fevers may be caused by secondary infections or by direct neurological impairment. The hypothalamus in the brain controls thermoregulation in the body, and strokes involving this area can cause central fevers. Acetaminophen may be administered to reduce the temperature. 

Alterations in Blood Sugar 

Extremes in blood glucose levels are also associated with worse outcomes after stroke (9). The goal parameter for blood sugar in the patient post stroke is 140-180 mg/dl. Insulin may be administered for elevated blood sugar. 

Venous Thromboembolism 

Patients post stroke are at risk for venous thromboembolism (VTE) events (9). These include deep vein thrombosis (DVT) and pulmonary emboli (PE). This occurs due to various factors, including immobility, age, dehydration, and other predisposing factors. Mechanical pneumatic compression devices and/or chemical VTE prophylaxis with unfractionated heparin or low-molecular-weight enoxaparin subcutaneously may be a standard protocol in facilities/organizations, particularly for patients in with a long recovery. 

Urinary Retention 

Urinary retention is common during this period, particularly within the first 24 hours of the stroke. Signs of urinary retention include the patient’s report of a full bladder and lack of urinary output despite IV fluids infused. The nurse may use a bedside bladder scanner/ultrasound to assess for urinary retention.  Some policies may be in place to limit urinary catheterization, such as identifying an acceptable amount of post-void residual. Some hospitals even have a protocol to use intermittent urinary catheterization for a limited period to avoid permanent urinary catheterization. Ultimately, indwelling urinary catheterization can be a final option for patients with urinary retention. 

Constipation 

The nurse can help the patient avoid constipation with proper hydration, mobilization, and food modification. If needed, the nurse can advocate for the patient by requesting an order from the provider for a bowel regimen medication or stool softener. 

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Nutrition and Stroke Care 

Patients who have had a recent stroke are at risk for malnutrition secondary to various factors including dysphagia and food management/access difficulties. Patients may have difficulty opening food containers, holding cups and utensils, and feeding themselves. Nurses should help feed the patient or delegate the task to a nursing aide or other unlicensed assistive personnel.

Patience is required when feeding, especially in patients with dysphagia as feeding quickly can cause patients to aspirate. Patients who have had an acute stroke should have a basic swallow screen before any oral intake of fluids or food, including small amounts that may be given with medications.  

In some facilities/organizations, the basic dysphasia screen can be performed by the nurse and begins with an evaluation of the patient’s alertness and ability to sit upright 90 degrees. The patient should be assessed for evidence of drooling and speech difficulties. If appropriate, the patient may be provided small sips of water as the nurse observes for signs of coughing, choking, wet or gurgling voice, drooling, and checks if the patient is holding liquid in their mouth. If the patient can safely swallow water in small sips, the nurse may progress to a larger amount.

If the patient appears to have difficulty swallowing and does not pass the swallow evaluation, they should be placed on a strict “nothing by mouth” (NPO) diet until an experienced speech/swallow therapist can evaluate. The nurse should observe for respiratory compromise, especially post meals. Aspiration can lead to pneumonia which increases in-hospital mortality. 

Dedicated Stroke Care Units

Not every hospital has a dedicated stroke unit. However, the standard of care should remain the same whether the patient is in a stroke care unit or not. While maintaining competency for stroke care over multiple areas and staff may be challenging, patients who receive care in a specialized stroke unit are more likely to be “alive, independent, and living at home one year after stroke,” (6).  

Psychological and Neuropsychological Concerns 

The rate of post stroke cognitive changes, including dementia, is approximately 10%. Some will develop acute delirium during the acute phase or depressive symptoms over the long term. Cognitive rehabilitation can help improve function and includes cognitive activities and specialized environments for mental stimulation. Support groups and psychotherapy may be helpful for patients experiencing mood swings and psychotherapy. 

Some patients may experience pseudobulbar effect (PBA) after a stroke. Also known as emotional lability or involuntary emotional expression disorder, PBA is characterized by involuntary bouts of crying, laughter, or anger that may seem out of proportion or exaggerated. (2) These changes may occur without any emotional trigger and the patient may rapidly switch between laughing and crying (2). This happens when the stroke injuries the part of the brain that controls emotions. Dextromethorphan/quinidine has been approved for the treatment of PBA (4).  

Staff on stroke care units should be trained to recognize delirium during the acute phase of recovery, which can be triggered by a variety of physiological or psychological disruptions. Proper sleep/wake cycles, early mobilization, and environments conducive to orientation are vital. Family and caregiver involvement is encouraged to create a sense of familiarity (6). 

Mobility and Safety 

At every level of post stroke care, the priority is to help the patient resume previous activities to the best of their ability. Evidence is divided on whether early mobilization after stroke should begin before or after 24 hours in patients who were administered a thrombolytic agent. Some studies suggest mobilization within the 24 hours post stroke prevents stroke complications (9). Other studies argue mobilization after 24 hours enhances reperfusion (9). Nurses should follow their facility/organization’s protocol on how early and often to mobilize patients after a stroke. The patient should be provided with a physical therapist that can evaluate and provide the best plan for exercise and stretching. The patient may need supportive or assistive devices to prevent contractures and imbalance issues.  

Formal rehabilitation programs are designed to assess the patient for hemiparesis, weakness, or partial paralysis on one side of the body, which can involve the limbs or face. These programs can help to reduce the risk of falls. With the help of family, the patient’s home environment should be scanned for fall risks as well. Occupational therapists are part of the team and can help the patient resume activities of daily living (transferring, bathing, dressing, cooking, and feeding, etc.) Many rehabilitation units have a life-size kitchen, bed, chair, and car models for training. 

Stroke Care Transitions 

The discharge process from acute care to another level of care is a critical time. After a stroke, patients who are going home need a home care nurse to evaluate their care needs and the safety of the home environment as evidence shows patients continue to receive suboptimal stroke care at home despite current best practices (6). Home goals include preventing another stroke, improving recovery through rehabilitation, and avoiding complications. Through readmission evaluations, we have learned that some patients and families are not prepared for self-management, or their home environment is not conducive for a healthy recovery.  

The level of family/caregiver support often determines the success of the transition, whether the patient is discharged to home or to a rehabilitation facility. Communication with the care team is imperative to maximize success. Family and/or caregivers may feel overwhelmed with the numerous activities from supportive services, such as physical, occupational, and nutrition therapy. The nurse should educate the patient and family on signs and symptoms of stroke and transient ischemic attack (TIA), risk factor modifications, and indications for medical and specialist visits.  

The community as a whole should become familiar with how to quickly access emergency medical services if needed. Key interventions involve self-management skills that enhance problem solving and self-efficiency with activities of daily living. If patients go to an acute rehabilitation center for a designated period, their skills should be resumed in the home environment. Some organizations have transitional stroke clinics where the patient can make regular office visits. Others set up follow-up nurse phone calls, which have been successful in easing transitions. Practitioners, nurses, and pharmacists are often the coordinators of medication reconciliation upon transfer to another level of care (6). Telehealth has expanded our ability to monitor patient’s progress virtually to ensure positive patient outcomes. 

Conclusion

This Post Stroke course has outlined the intricacies of nursing post stroke care in immediate and long-term management, including assessments, monitoring parameters, interventions and complications to watch for. Nurses at all levels play a vital role in the care of the patient who has had a stroke. The amount of time we spend at the bedside enables us to determine a patient’s capabilities and deficits and from there, we can develop an appropriate and individualized plan of care with the interdisciplinary team. In cases where patients have a poor prognosis after a stroke, we must be compassionate in our care when offering end-of-life options and care. Stroke care can be complex but rewarding, and it is heartwarming to see our efforts in assisting the patient’s progress. 

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