Acute stroke: recognition, the first hours, swallow screening, positioning and neuro checks

What it is

The nurse is often the first to notice a stroke, on the ward or at triage, and the one who watches the patient most closely in the first days. Nursing care in the first hours has four parts. Recognise the sudden signs (balance, eyes, face, arm, speech) and record the exact time they began, or the last time the patient was seen well, because the treatments that open a blocked artery only work within hours. Call for help at once and get the patient ready for imaging. If the team gives clot-dissolving treatment (thrombolysis), carry out very frequent neurological and blood-pressure checks and watch for bleeding and swelling of the mouth or throat. From admission, keep everything by mouth on hold until a swallow screen is done, and check temperature and blood glucose regularly: nurse-led protocols for fever, sugar and swallowing have been shown to improve outcomes. Neuro checks themselves are explained on their own page.

What it requires

• The exact time of onset, or the last time the patient was known to be well, decides which treatments are possible: record it and hand it over.
• Clot-dissolving treatment must start within hours of the first symptoms (MedlinePlus: within 4½ hours); a clot can also be removed through a catheter (thrombectomy).
• In the nurse-led protocol studied in Europe: temperature four times a day for the first 72 hours; finger-prick glucose four times a day for the first 48 hours; swallow screen within 24 hours.
• Patients who fail the swallow screen are referred to the speech and swallowing therapist for a full assessment.
• After thrombolysis, the patient stays in a stroke unit or an equivalent ward for at least 24 hours.

Components

• A stroke-recognition tool (BE FAST) and the institution's stroke scale (for example the NIHSS, a copyrighted scale), applied as trained.
• Neuro-check chart, vital-signs monitor, glucometer and thermometer.
• The institution's validated swallow-screening tool.
• Suction and oxygen available at the bedside, used per protocol.

How it is applied (and why)

1. Check BE FAST at the first sign and call the rapid-response or stroke team: the treatments only work within hours of onset.
2. Record the time of onset or the last time seen well: the team uses it to decide on clot treatment.
3. Check blood glucose on admission as the protocol sets: glucose is part of the first assessment and is rechecked in the first days.
4. Keep the patient nil by mouth, including tablets, until the swallow screen is done: aspiration causes pneumonia.
5. Do baseline neuro checks and vital signs, then repeat them at the ordered interval: a change is the first sign of worsening.
6. If thrombolysis is given: neuro and BP checks very often for 24 h per protocol, and look for bleeding at gums, urine, skin and puncture sites.
7. After thrombolysis, avoid new tubes, catheters and punctures if possible: they can bleed.
8. Position with the head aligned with the body; raise the head of the bed to 30° if there is risk of aspiration, raised ICP or low oxygen.
9. Check temperature and glucose at the set times and report values above the protocol limits: fever and high sugar worsen brain injury.

In nursing practice

• Imaging (CT or MRI) is what shows the team whether the artery is blocked or bleeding; the nurse's part is getting the patient there fast with the time of onset.
• After thrombolysis, severe headache, nausea, vomiting, a sudden rise in blood pressure or a worse neuro check suggests bleeding in the brain: stop the infusion if running and call at once.
• Swelling of the tongue, lips, face or throat after thrombolysis is angioedema: call at once and protect the airway.
• A wet voice, cough or choking at the first sip means the patient failed the swallow: stop and refer.
• Patients with a stable mild-to-moderate stroke may start sitting and getting out of bed within 24 hours, as the team decides.

Common mistakes

• Not recording the time of onset, or recording the time the signs were found instead of when the patient was last well.
• Giving tablets or water before the swallow screen "just to take the medicines".
• Spacing out neuro checks after thrombolysis when the patient "looks stable".
• Treating a new drowsiness or confusion as tiredness instead of calling.

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Elsewhere in DurgiPedia

• Recognising a stroke: BE-FAST and the NIH Stroke Scale

Connections

← All of nursing

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Signs and symptoms of stroke (Centers for Disease Control and Prevention (CDC), 2024); Stroke (Medical Encyclopedia) (MedlinePlus, U.S. National Library of Medicine, 2024); Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe) (European Stroke Journal (Middleton S et al.), PubMed Central, 2023); Guidelines for intravenous thrombolysis, third edition: a guideline from the Japan Stroke Society (management in the first 24 h) (Neurologia medico-chirurgica (Toyoda K et al.), PubMed Central, 2019).

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