Stroke nursing care: what to assess and what to do first

The pathophysiology in one pass

A stroke is either ischaemic or haemorrhagic, and the split matters because the treatments run in opposite directions. Ischaemic stroke, roughly 87% of cases, is a clot blocking flow — the fix is to dissolve or retrieve it. Haemorrhagic stroke is a bleed, and giving a clot-busting drug into a bleed makes it worse. This is why imaging comes before any drug decision.

In ischaemic stroke, a core of tissue dies within minutes of occlusion, but a surrounding zone — the penumbra — is hypoperfused but still viable. That penumbra is what thrombolysis and thrombectomy are racing to save. Every minute it goes untreated, more of it converts to permanent infarct, which is the physiological reason the field talks about time in minutes, not hours.

Haemorrhagic stroke follows a different clock. Bleeding raises intracranial pressure and can cause herniation, so the priority shifts from restoring flow to controlling pressure and blood pressure. A patient on anticoagulants who bleeds needs reversal agents, not a clot-buster — knowing which category you are managing changes the first order you expect to see.

Assessment findings that matter

Time of last known well is the first question, asked before vital signs, before the neuro exam, before anything else — because it decides thrombolysis eligibility. It is not a detail buried in the history; it is the number that determines whether tPA or thrombectomy is even on the table. If the patient woke up with symptoms, the clock starts at when they were last seen normal, not when they were found.

FAST — face drooping, arm weakness, speech difficulty, time — is the screening tool, but the NIHSS is what quantifies severity and guides treatment decisions once the patient is in your department. Look for asymmetry: one-sided facial droop, one-sided drift on arm hold, slurred or absent speech, visual field cuts.

Distinguish stroke syndromes by pattern where you can. Anterior circulation strokes tend to produce hemiparesis, aphasia, and facial droop; posterior circulation strokes produce dizziness, ataxia, diplopia, and dysphagia, and are more often missed because they don't fit the classic FAST picture. A sudden, severe headache with a bleed points toward haemorrhagic stroke, particularly subarachnoid haemorrhage.

What the exam asks about this

NCLEX questions on stroke usually test the time-window decision: given a last-known-well time and a current time, can you calculate whether the patient still falls inside the thrombolysis window, and can you identify the absolute contraindications — active bleeding, recent major surgery, blood pressure above the treatment threshold, anticoagulant use with an elevated INR. Expect a question that gives you a plausible-sounding history and asks you to spot the detail that rules tPA out.

You'll also be tested on priority-setting: given a stroke patient with several findings, which do you address first. The answer is almost always airway and neuro status before anything comparatively stable, and recognising a change in level of consciousness as the earliest warning sign rather than waiting for a dramatic new deficit.

A third common pattern is distinguishing stroke mimics — hypoglycaemia, seizure with Todd's paralysis, migraine with aura — because a question will describe a stroke-like presentation and expect you to know that checking blood glucose is part of the initial workup before assuming stroke.

Nursing interventions in priority order

Airway, breathing, circulation first, as with any acute presentation — a depressed level of consciousness threatens the airway before it threatens anything else. Check blood glucose immediately; hypoglycaemia mimics stroke and is instantly reversible, so ruling it out is not optional.

Establish time of last known well with whoever is present, and get the patient to CT without delay — most stroke protocols set a door-to-CT target of 25 minutes or less. Keep the patient NPO until a swallow screen is done; dysphagia is common and aspiration is a real early risk.

Monitor and support blood pressure according to the stroke type and treatment plan — permissive hypertension is often allowed in ischaemic stroke to maintain perfusion to the penumbra, while haemorrhagic stroke usually calls for tighter control to limit further bleeding. Position with the head of bed as directed by the team; this varies by protocol and perfusion needs, so follow the specific order rather than a default. Reassess neuro status on a fixed schedule and document any change immediately — deterioration is the signal that changes the plan.

Medications and monitoring

Alteplase (tPA) is the standard thrombolytic for eligible ischaemic stroke patients, given within the approved window from last known well. Once it's running, blood pressure must be kept below the treatment threshold, and the patient needs neuro checks and vital signs at short, fixed intervals — the immediate post-tPA period carries the highest bleeding risk, and a new headache, sudden hypertension, or a drop in level of consciousness suggests haemorrhagic conversion until proven otherwise.

No anticoagulants, antiplatelets, or intramuscular injections in the first 24 hours after tPA, and no arterial punctures or urinary catheter insertion during the infusion if avoidable — each one raises bleeding risk at the exact moment the drug is working.

For haemorrhagic stroke, expect blood pressure management with agents titrated to a specific target, and possibly reversal agents if the patient is on anticoagulants. For patients not eligible for thrombolysis, aspirin is typically started once haemorrhage is excluded, alongside statins and blood pressure management for secondary prevention.

When to escalate

Any drop in level of consciousness, a new or worsening deficit, or a sudden severe headache during or after treatment is an immediate call to the provider — these are the signs of haemorrhagic conversion, rebleeding, or extending infarct, and they don't wait for the next scheduled check.

Escalate immediately for a blood pressure reading outside the ordered parameters, especially post-tPA, and for any sign of airway compromise, seizure activity, or a failed swallow screen with ongoing oral intake. A widening pulse pressure with bradycardia and irregular breathing — Cushing's triad — signals rising intracranial pressure and needs urgent notification, not a wait-and-watch approach.