Stroke Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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Ischemic vs hemorrhagic stroke recognition, tPA eligibility, acute management, hemorrhagic stroke BP targets, post-stroke nursing care, and TIA workup.
1. Stroke Types at a Glance
| Type | % of Strokes | Mechanism | CT Appearance | Key Treatment |
|---|
| Ischemic | 87% | Thrombotic or embolic occlusion of cerebral artery | Normal first 6–24 hr; then dark (hypodense) region | tPA (within 4.5 hr) ± mechanical thrombectomy (within 24 hr for large vessel occlusion) |
| Hemorrhagic — ICH | 10% | Intracerebral hemorrhage; hypertension most common cause | Bright (hyperdense) white spot immediately | BP control; reverse anticoagulation; neurosurgery if indicated |
| Hemorrhagic — SAH | 3% | Subarachnoid hemorrhage; ruptured aneurysm most common | "Star" or "hyperdense cisterns" on CT; LP shows xanthochromia | Neurosurgical clipping or endovascular coiling; nimodipine for vasospasm prevention |
2. Stroke Activation — Time Is Brain
Every minute a large stroke goes untreated = ~1.9 million neurons lost.
Door-to-CT: ≤25 minutes | Door-to-needle (tPA): ≤60 minutes (goal) | Door-to-groin (thrombectomy): ≤90 minutes
Stroke Code Activation Steps
- Note exact time of symptom ONSET (or last known well — LKW)
- Activate stroke code immediately (do not wait for physician order)
- Obtain STAT non-contrast CT head and CT angiography
- Labs STAT: CBC, BMP, PT/INR, aPTT, glucose, type and screen
- 12-lead EKG (look for A-Fib — embolic source)
- Establish IV access (2 peripheral IVs)
- NPO — no food, water, or medications by mouth until dysphagia screening
- No bladder catheter, NG tube, or arterial line until after tPA (if given)
Check fingerstick glucose before CT: Hypoglycemia mimics stroke (BG <50 mg/dL → give D50 before tPA). Never give tPA for "stroke" that is actually hypoglycemia.
3. tPA (Alteplase) for Ischemic Stroke
tPA Eligibility Window
| Criterion | Standard Window | Extended Window (3–4.5 hr) |
|---|
| Symptom onset to treatment | ≤3 hours | 3–4.5 hours (with additional exclusions) |
| Age restriction | None (≥18) | Additional caution age >80 in some protocols |
tPA Absolute Contraindications
ABSOLUTE contraindications to tPA (memorize these):
- CT shows hemorrhage (bright area = NO tPA ever)
- Symptom onset >4.5 hours or unknown onset (unless advanced imaging shows salvageable penumbra)
- Current anticoagulation: INR >1.7, PTT >40 sec, platelets <100k, or on DOAC within 48 hr
- BP >185/110 mmHg that cannot be lowered to ≤185/110 prior to tPA (treat BP first, then give tPA if it comes down)
- Recent head/spinal surgery within 3 months
- History of hemorrhagic stroke (any time)
- Active internal bleeding (except menses)
- Blood glucose <50 or >400 mg/dL
- Ischemic stroke or head trauma within last 3 months
tPA Dose and Administration
Alteplase dose: 0.9 mg/kg IV (max 90 mg total)
- 10% of dose given as IV bolus over 1 minute
- Remaining 90% given as IV infusion over 60 minutes
- NO heparin, antiplatelet, or anticoagulation for 24 hours after tPA
- Continuous BP monitoring: goal ≤180/105 during and 24 hours after tPA
- Repeat CT head at 24 hours (before starting anticoagulation/antiplatelet)
tPA Monitoring: q15 min × 2 hours, then q30 min × 6 hours, then q1h × 16 hours
| Vital Signs + Neuro Check Frequency | What to Watch For | Action If Seen |
|---|
| Every 15 min × first 2 hr | New headache, N/V, acute hypertension, neuro deterioration | STOP tPA infusion; STAT CT head; call team |
| Every 30 min × next 6 hr | Angioedema (tongue/lip swelling), orolingual edema | STOP tPA; epinephrine + diphenhydramine; secure airway |
| Every hour × 16 hr | Symptomatic intracranial hemorrhage (neuro worsening + headache + BP rise) | Stop tPA; CT; cryoprecipitate 10 units IV; neurosurgery consult |
4. Mechanical Thrombectomy (Large Vessel Occlusion)
For large vessel occlusion (LVO) strokes: stent retriever or aspiration catheter pulls clot directly from vessel. Can be performed up to 24 hours from onset in selected patients (using advanced imaging to identify salvageable brain tissue).
- Door-to-groin time goal: ≤90 minutes
- Can be given WITH tPA (bridging) or as primary treatment if tPA contraindicated
- Post-thrombectomy care: arterial access site monitoring, BP control, antiplatelet therapy
5. Blood Pressure Management in Stroke
| Situation | BP Target | Rationale |
|---|
| Ischemic stroke — tPA eligible (before tPA) | <185/110 before starting tPA | Too-high BP increases ICH risk after tPA |
| Ischemic stroke — during/after tPA | ≤180/105 for 24 hr after tPA | Prevent hemorrhagic conversion |
| Ischemic stroke — NOT receiving tPA | Permissive hypertension: allow up to 220/120 for first 24–48 hr | Collateral flow relies on higher BP in ischemic penumbra; lowering BP can extend infarct |
| Hemorrhagic stroke (ICH) | Target SBP 130–140 mmHg (or per protocol — some use <160) | Lower BP reduces hematoma expansion |
| Subarachnoid hemorrhage | SBP <160 until aneurysm secured; avoid hypotension (causes vasospasm) | Prevent re-rupture before clipping/coiling |
Permissive hypertension in ischemic stroke: Do NOT automatically treat hypertension in a non-tPA stroke patient in the first 24–48 hours (unless SBP >220 or end-organ damage). The "ischemic penumbra" depends on collateral flow driven by the elevated BP.
6. Hemorrhagic Stroke Nursing Management
Intracerebral Hemorrhage (ICH)
- Reverse anticoagulation immediately (see anticoagulation reversal guide)
- BP target: SBP ≤140 mmHg (reduce within 1 hour) — IV labetalol or nicardipine most common
- HOB 30–45° — reduces ICP, improves venous drainage
- ICP monitoring if GCS ≤8 or signs of herniation
- Seizure prophylaxis: levetiracetam (Keppra)
- Temperature management: fever worsens outcomes — treat aggressively
- Glucose control: avoid hyperglycemia and hypoglycemia
- Neurosurgical consult: cerebellar ICH >3 cm or with hydrocephalus = high priority for surgical evacuation
Subarachnoid Hemorrhage (SAH)
Classic SAH presentation: "Worst headache of my life" (thunderclap onset, maximal at onset)
- CT head: star pattern / blood in cisterns (hyperdense) — if CT negative in 6 hr window and high suspicion → LP (xanthochromia in CSF)
- Nimodipine 60 mg PO q4h × 21 days — prevents cerebral vasospasm (a major cause of delayed ischemic injury)
- Triple H therapy historically (hypertension, hypervolemia, hemodilution) — now largely replaced by euvolemia + induced hypertension only for symptomatic vasospasm
- Transcranial Doppler to monitor vasospasm (elevated MCA velocities)
- Aneurysm secured (clipped or coiled) within 24 hr to prevent re-rupture
7. Post-Stroke Nursing Care
First 24–48 Hours
- Continuous cardiac monitoring — detect A-Fib (embolic source)
- Dysphagia screening BEFORE any oral intake — failed screen → NPO + speech therapy eval + NG tube for medications
- DVT prophylaxis: SCDs immediately; pharmacologic anticoagulation delayed until CT confirms no hemorrhagic conversion (typically 24–48 hr after ischemic stroke)
- Strict I&O and daily weights — maintain euvolemia
- Blood glucose every 4–6 hours — target 140–180 mg/dL
- Fever management — each degree Celsius above normal worsens outcome
- Avoid hypotension — ensure adequate MAP to perfuse ischemic brain
Dysphagia Screening
Bedside swallowing test before ANYTHING by mouth: Give 3 oz water (90 mL) — observe for coughing, choking, wet voice, oxygen desaturation. If ANY sign = failed screen → NPO → speech-language pathology evaluation. Aspiration pneumonia is a major preventable post-stroke complication.
Rehabilitation
- Early mobilization (within 24 hr for stable ischemic strokes) — reduces complications, improves outcomes
- Speech therapy (aphasia, dysphagia)
- Physical therapy (weakness, balance, gait)
- Occupational therapy (ADL retraining, adaptive equipment)
- Stroke education: risk factor modification (hypertension, diabetes, smoking, A-Fib, obesity)
- Secondary prevention: antiplatelet therapy (aspirin, clopidogrel) or anticoagulation (if A-Fib-related)
8. TIA (Transient Ischemic Attack)
Stroke symptoms that resolve completely, typically within minutes to <24 hours (usually <1 hour), with no infarct on diffusion-weighted MRI. NOT "mini-stroke" as a dismissal — TIA is a neurological emergency with high short-term stroke risk.
ABCD2 Score predicts 2-day stroke risk after TIA:
Age ≥60 (1pt), BP ≥140/90 (1pt), Clinical features (unilateral weakness 2pt; speech only 1pt), Duration ≥60 min (2pt; 10–59 min 1pt), Diabetes (1pt). Score 6–7 = high risk (8% at 2 days). All TIAs should be evaluated urgently (ideally within 24 hr).
TIA Workup
- MRI brain with DWI (diffusion-weighted imaging) — detects small infarcts invisible on CT
- MRA or CTA of head and neck (carotid stenosis?)
- Cardiac monitoring × 24–72 hr minimum (longer to detect paroxysmal A-Fib)
- Echocardiogram (cardiac embolic source, PFO)
- Lipid panel, HbA1c, CBC
- Carotid ultrasound if MRA not done
NCLEX High-Yield Stroke Points
- CT head before tPA to rule out hemorrhage — hemorrhagic stroke = NO tPA ever
- Door-to-needle tPA goal: ≤60 minutes
- tPA dose: 0.9 mg/kg (max 90 mg) — 10% bolus over 1 min, rest over 60 min
- tPA BP requirement: ≤185/110 before starting (treat then give if it comes down)
- Ischemic stroke NOT getting tPA: allow BP up to 220/120 (permissive hypertension)
- Hemorrhagic stroke: lower BP (target SBP ≤140); NO tPA; NO anticoagulation
- After tPA: no heparin or antiplatelet × 24 hr; monitor for ICH q15 min × 2 hr then q30 min × 6 hr
- SAH classic: "worst headache of my life" (thunderclap)
- Nimodipine for SAH vasospasm prevention
- Dysphagia screen before any oral intake post-stroke — aspiration prevention
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