Guide — Neurology
Stroke Recognition and Initial Management
Acute stroke recognition and initial nursing management — ischemic vs. hemorrhagic stroke types, FAST and BE-FAST screening, last known well, NIHSS overview, CT priority, treatment windows, and time-critical nursing priorities.
11 min read · Neurology
Educational use only. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
TIME IS BRAIN. Every minute of untreated ischemic stroke = approximately 1.9 million neurons lost. Suspected stroke is a CODE STROKE — activate immediately.
Stroke Types Overview
Ischemic Stroke
~87% of strokes
Cause: Arterial occlusion — thrombotic (clot in situ) or embolic (clot travels from heart or proximal vessel)
Findings: Focal neurological deficit: weakness, aphasia, vision loss, neglect — sudden onset, usually without headache
Treatment: tPA within 3–4.5 hours. Thrombectomy up to 24 hours (with favorable imaging). BP management: do NOT aggressively lower BP unless >185/110 (if tPA candidate) or >220/120 (if not candidate).
Hemorrhagic Stroke
~13% of strokes
Cause: Intracerebral hemorrhage (ICH): HTN, AVM, coagulopathy. Subarachnoid hemorrhage (SAH): ruptured aneurysm.
Findings: Often sudden severe headache (SAH: “thunderclap”/worst-of-life), vomiting, rapid LOC deterioration, HTN
Treatment: NO tPA — tPA is absolutely contraindicated in hemorrhagic stroke. BP lowering, reversal of anticoagulation, neurosurgical consultation.
Hemorrhagic vs. ischemic stroke CANNOT be reliably distinguished by symptoms alone — CT scan without contrast is required immediately.
FAST / BE-FAST Screening
BE-FAST adds Balance and Eyes to capture posterior circulation strokes missed by FAST alone.
| Letter | Stands For | Assessment |
|---|---|---|
| B | Balance | Sudden loss of balance or coordination, ataxia, unsteady gait |
| E | Eyes | Sudden vision loss, double vision, or visual field cut in one or both eyes |
| F | Face | Ask patient to smile — facial droop or asymmetry? |
| A | Arms | Ask patient to raise both arms — does one drift downward? |
| S | Speech | Ask patient to repeat a phrase — slurred, wrong words, or unable to speak? |
| T | Time | Time of symptom onset (= last known well). CALL CODE STROKE IMMEDIATELY. |
Last Known Well
Last known well (LKW) is the last time the patient was known to be at their neurological baseline — without any stroke symptoms. It is NOT the same as when symptoms were discovered.
- If a patient wakes up with symptoms, LKW = when they were last awake and symptom-free (bedtime)
- LKW determines tPA and thrombectomy eligibility windows
- Document LKW immediately — ask patient, family, witnesses
- “Wake-up strokes” (LKW unknown) may still be candidates for thrombectomy based on DWI-FLAIR mismatch on MRI
Never delay CT to gather history. Activate code stroke FIRST.
NIHSS Overview
The NIH Stroke Scale (NIHSS) objectively quantifies stroke severity. Score 0–42 (higher = more severe).
| Domain | What It Assesses | Score Range |
|---|---|---|
| Consciousness (LOC) | Level of consciousness, orientation, commands | 0–3 |
| Gaze | Horizontal eye movement — gaze palsy | 0–2 |
| Visual Fields | Visual field cuts | 0–3 |
| Facial Palsy | Facial symmetry and movement | 0–3 |
| Motor (arms + legs) | Limb strength and pronator drift (4 items) | 0–4 each |
| Limb Ataxia | Cerebellar coordination | 0–2 |
| Sensory | Pinprick sensation loss | 0–2 |
| Language / Aphasia | Naming, reading comprehension, repetition | 0–3 |
| Dysarthria | Articulation clarity | 0–2 |
| Extinction / Neglect | Inattention to one side of space | 0–2 |
CT Priority — Why Imaging Comes First
A non-contrast CT head must be obtained before any decision to give tPA because:
- CT can rule out intracranial hemorrhage (contraindication to tPA) in minutes
- CT is universally available and faster than MRI
- CT cannot always visualize early ischemic changes — a “normal CT” does not rule out stroke
- CT angiography (CTA) of head and neck is added to identify large vessel occlusion (LVO) for thrombectomy planning
- Target: door-to-CT within 25 minutes; CT read within 45 minutes
Treatment Windows
| Intervention | Window from LKW | Key Requirements |
|---|---|---|
| IV tPA (Alteplase) | 0–3 hours (standard) | Ischemic confirmed on CT, no hemorrhage, no major exclusions |
| IV tPA (extended) | 3–4.5 hours | Additional exclusions apply (age >80, prior stroke + diabetes, anticoagulation, NIHSS >25) |
| Mechanical Thrombectomy | 0–6 hours (standard) | LVO on CTA; ASPECTS score ≥6 |
| Thrombectomy (extended) | 6–24 hours | Requires favorable DWI-FLAIR mismatch (DAWN/DEFUSE-3 criteria) |
| Blood pressure control | Immediate | tPA candidates: BP <185/110 before giving tPA; <180/105 during/after |
Acute Nursing Priorities
ACTIVATE CODE STROKE
Call immediately — do not delay for full assessment. One phone call initiates the entire stroke team response.
Establish IV access
Two large-bore IVs. Draw labs: CBC, BMP, coagulation (PT/INR/PTT), type and screen, glucose (POC glucose immediately).
Establish LKW
Ask patient, family, witnesses. Document exact time. This determines tPA and thrombectomy eligibility.
Obtain 12-lead ECG
Atrial fibrillation is a major embolic stroke cause. Identify concurrent ACS. Do not delay CT for ECG.
Continuous monitoring
Cardiac monitor, pulse oximetry. Maintain SpO2 ≥94%. Supplemental O2 only if hypoxic — avoid hyperoxia.
Blood pressure management
Do NOT aggressively lower BP unless >185/110 (tPA candidate) or >220/120 (no tPA). Permissive hypertension supports penumbra perfusion.
Glucose management
Treat hypoglycemia immediately (BG <60 mg/dL mimics stroke). Avoid hyperglycemia — worsens infarct size.
NPO status
NPO until formal swallowing evaluation — stroke patients are at high aspiration risk.
NCLEX Pearls
- ✦CT head without contrast MUST be done before tPA — hemorrhagic stroke is an absolute contraindication to tPA.
- ✦Last known well ≠ time symptoms were discovered. Wake-up stroke LKW = bedtime.
- ✦BP target before tPA: <185/110. If BP is higher, treat BP first, then give tPA — do NOT give tPA with BP above threshold.
- ✦Permissive hypertension for ischemic stroke WITHOUT tPA: allow BP up to 220/120 — the brain needs this pressure to perfuse the penumbra.
- ✦TIA (transient ischemic attack): same symptoms as stroke but resolve within 24 hours (usually minutes). TIA is a major predictor of imminent stroke — treat urgently.
- ✦Subarachnoid hemorrhage classic presentation: sudden severe headache described as worst of life (thunderclap). Immediate CT and neurosurgical consult.
- ✦Swallowing assessment before any oral intake — stroke causes dysphagia and aspiration pneumonia is a major post-stroke complication.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Heart Association / American Stroke Association (AHA/ASA) · American Association of Neuroscience Nurses (AANN). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →