04.04 Stroke Assessment (CVA)

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Overview

  1. Detailed, thorough, frequent neurological assessments
  2. Early detection + early treatment = better outcomes

Nursing Points

Assessment

  1. Varies by Location
    1. MCA – classic FAST symptoms →   contralateral manifestations
    2. Basilar – decreased LOC, loss of vision, abnormal pupil response
    3. Brainstem – loss of BP regulation, Respiratory Failure, dysphagia
  2. FAST
    1. Facial Droop
    2. Arm Drift
    3. Speech Problems
    4. Time – Call 911 (time is tissue)
  3. Altered LOC
    1. Confusion, Lethargy, etc.
    2. “Not acting right”
  4. Contralateral deficits (opposite side of stroke)
    1. i.e. – Right MCA stroke →  left-sided weakness
  5. Aphasia – speech difficulty
    1. Expressive – can comprehend, can’t communicate
    2. Receptive – can communicate, but can’t comprehend spoken or written word
    3. Global – overall language dysfunction
  6. Apraxia – inability to perform physical tasks
    1. i.e. can’t comb hair or brush teeth
    2. Neuro-motor connections damaged
  7. Hemianopia – blindness in one half of visual field
  8. Dysphagia – difficulty swallowing
    1. High risk for aspiration
  9. National Institutes of Health Stroke Scale
    1. Evaluates symptoms – ataxia, speech, visual fields, extremity drift, etc.
    2. Scores 0 – 42
    3. Higher score = higher severity
    4. Specialized training required

Reference Links

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Video Transcript

Okay – so now that we’ve looked at the pathophysiology behind hemorrhagic and ischemic strokes, let’s look at what we might see in those patients and how we assess them.

You’ve probably heard or seen this mnemonic before, the key phrase to remember, is “When you see signs of stroke, you have to act FAST”. F-A-S-T. F stands for Facial Drooping, so we’ll see one side of their face much weaker or not able to move like the other side. A is for arm weakness. They’ll typically have one side of the body much weaker than the other, if not paralyzed completely. We test this by having them hold both arms out and trying to hold them up for 10 seconds. If you have this weakness, you’ll see one arm begin drifting back towards the bed. S stands for slurred speech. They may struggle to form words well, or we may even see they have aphasia, which we’ll look at in a second. And T stands for Time. Remember we’re acting FAST – so time is tissue – get help, notify the right people, as fast as possible.

So as with any neurological issue, the first thing we’re going to see is Altered Level of Consciousness. This could be anything from confusion all the way to a coma. We will see the weakness and deficits present contralateral to the stroke. That means that if you had, for example, a right MCA stroke – you would see Left sided facial drooping and left arm weakness. Then we often see aphasia, which means lack of speech or trouble with speaking. This could be expressive, receptive, or global. In expressive aphasia they understand everything you’re saying, but they cannot get the right words out. They may mumble, they may cycle on a few words – like I had a patient who just kept repeating “you know, you know”. Or they could be talking nonsense – I’ve had family members come in and say “my momma’s talking out of her head” because she just wasn’t making sense. Receptive aphasia is when they can communicate perfectly but they absolutely cannot understand anything they’re reading or that you’re saying. This is frustrating for these patients because even when they try to write a word, they look at it and think they wrote it wrong. They’ll keep saying “you aren’t making any sense!”. Global aphasia means they struggle with comprehension AND communication and may not have any speech at all. This is all very frustrating for the patient and their family. In the nursing care lesson we’ll talk about how to help these patients.

Stroke patients may also have ataxia which is when they can’t coordinate movements and apraxia which is when they can’t perform simple tasks like brushing their hair or writing their name. They just can’t coordinate the steps they know in their mind with making their hands do the right movement. Patients may also have hemianopia – okay let’s break down this word. Hemi means one side, -an means no or without, and opia usually refers to vision. So this is when they have no vision in one side of their visual field. They will completely miss anything happening on that side of their visual fields. Patients may also have difficulty swallowing because of weakness of those muscles, so we want to do swallow evals before we feed them.

The last assessment we will do is called the NIH Stroke Scale. Now, this is something you have to be specially trained for – it tests things like drift, speech, vision, and motor movements and scores the patient from 0-42. The higher the number, the more severe the stroke. This image you see here is one of the tests – we ask them to describe the image. Not only can we assess their language and speech, but we can assess their visual fields by seeing if they notice things happening on both sides of the image. They may see the mom doing dishes, but don’t see the kids stealing cookies from the cookie jar.

We briefly talked about this in the ischemic stroke lesson, but remember that the presentation will also vary based on where the stroke is located. For example, Middle Cerebral Artery strokes will give you classic FAST symptoms and that contralateral effect where the deficits are on the opposite side of the infarct. Basilar artery strokes affect the level of consciousness and the eyes, so we see loss of vision and abnormal pupillary responses. And brainstem strokes are going to cause issues with blood pressure regulation, respiratory failure, and difficulty swallowing. These are just a few examples, you can find more examples on the cheatsheet attached to this lesson. But we want you to see how this might look a little different in each patient.

So always remember to act FAST – time is tissue, so if you even suspect a stroke is occurring, call 911, call a Rapid Response, whatever the most appropriate course of action is where you are. Just get help! Remember that the symptoms of a stroke will present on the side opposite where the stroke is in the brain and that symptoms and presentation will vary by location of the stroke. The most common things you’ll see are the FAST symptoms and altered LOC. Review the neuro assessments lessons to know how to get detailed LOC and pupil assessments.

Keep working through this module to learn more about management and nursing care for a patient with a stroke. And, as always, happy nursing!

Read more

  • Question 1 of 10

A nurse assessing a client who has a new onset of stroke-like symptoms. The nurse assesses the “S” in “FAST”. This stands for which of the following?

  • Question 2 of 10

When assessing a client for signs of stroke, which of the following are priority assessments? Select all that apply.

  • Question 3 of 10

A nurse is providing community education to a group about how to recognize the signs of a stroke. The nurse teaches the group that if a person thinks they are suffering a stroke, a rapid method of detection is to follow the acronym STR by performing certain tasks that can indicate dysfunction. The letters of this acronym stand for:

  • Question 4 of 10

The nurse is caring for a client who has right-sided brain damage. The nurse knows that the client will be weaker in which of the following areas? Select all that apply.

  • Question 5 of 10

A client who has had a stroke is suffering from expressive aphasia. Which interventions would most likely improve communication with this client?

  • Question 6 of 10

Which of the following is the greatest risk factor for stroke?

  • Question 7 of 10

The triage nurse is working in the emergency department. Which of the following clients would the nurse classify as priority 2, or urgent? Select all that apply.

  • Question 8 of 10

The nurse is caring for a client whose visiting spouse suddenly becomes confused and is noted to have aphasia. What is the priority concern for this person?

  • Question 9 of 10

A nurse has assessed 4 clients in the emergency room. Which of the following is the priority to pass on to the healthcare provider?

  • Question 10 of 10

A nurse is becoming certified in stroke care. The nurse understands that in the “FAST” mnemonic for stroke, the “F” stands for which of the following?