How do you recognize an acute stroke and what does the nurse do first?
NCLEX-RN topic: Medical emergencies
- BE FAST: Balance, Eyes, Face, Arms, Speech, Time to call.
- Onset is the time last known well, not when symptoms were found.
- A noncontrast head CT rules out bleeding before any clot-dissolving drug.
- Keep the client NPO, including oral medications, until a swallow screen.
- Thrombolytics go IV within 3 hours, up to 4.5 hours for selected clients.
Key facts
- BE FAST: sudden loss of Balance, Eye (vision) changes, Face drooping, Arm weakness or drift, Speech trouble, Time to call for help.
- Stroke onset is the time the client was last known well (last seen without symptoms), not the time symptoms were found.
- A noncontrast head CT is usually the first test because it shows whether the stroke is bleeding (hemorrhagic) or not.
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- Low blood glucose can mimic a stroke, so glucose is checked early.
- Clot-dissolving drugs (alteplase or tenecteplase) are given IV within 3 hours of last known well, or up to 4.5 hours for selected clients, only after bleeding is ruled out; bleeding, especially in the brain, is the major risk.
- Keep the client NPO, including oral medications, until a trained nurse or speech-language pathologist completes a swallow screen.
- After a thrombolytic, the client is monitored closely for at least 24 hours with frequent neuro checks and blood pressure kept at or below 180/105 mm Hg.
Quick check1 question · 2 more at the end
A client on a medical unit was seen by the assistive personnel at 0545 talking normally and asking for water. At 0720 the nurse finds the client with a drooping mouth on the left side and slurred speech. The client cannot say when the symptoms started. Which time should the nurse report to the stroke team as the onset of symptoms?
Correct answer: B.
Stroke onset is counted from the time the client was last known well, meaning last seen without symptoms. Here that is 0545, when the client was talking normally. The time symptoms were discovered (0720) is later than the true onset, and using it could make the client look eligible for time-sensitive treatment when they are not.
A 0720 is when the symptoms were found, not the last time the client was known to be well.
B Correct: 0545 is the last time the client was seen acting normally, so it is the time last known well.
C The time of the stroke response call does not tell the team when the brain lost its blood flow.
D The time of the previous evening's assessment is not the most recent time the client was known to be well.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Sudden face droop, arm weakness, speech trouble, balance loss or vision loss means a possible stroke. Activate the stroke response, record the time the client was last known well, check glucose and keep the client NPO until a swallow screen. A noncontrast head CT rules out bleeding before any clot-dissolving drug is considered.
1 How do you recognize a stroke quickly?Stroke signs appear suddenly and often affect one side of the body. 1 min
Stroke signs appear suddenly and often affect one side of the body. The CDC and Open RN both teach the BE FAST check, and each letter is something you can test at the bedside in seconds.
| Letter | What to check |
|---|---|
| B (Balance) | Sudden loss of balance, dizziness or trouble walking |
| E (Eyes) | Sudden vision loss or trouble seeing in one or both eyes |
| F (Face) | Ask the client to smile; one side droops |
| A (Arms) | Ask the client to raise both arms; one drifts down or is weak |
| S (Speech) | Slurred or strange speech, or trouble understanding |
| T (Time) | Call for help right away and note the time |
A sudden, severe "worst headache of my life" points to a hemorrhagic (bleeding) stroke.
2 Why does the time last known well matter so much?Every treatment that restores blood flow to the brain depends on how much time has passed. 1 min
Every treatment that restores blood flow to the brain depends on how much time has passed. Stroke onset is counted from when the client was last known well, meaning last seen acting normal without symptoms. If a client was fine at 0700 and found with symptoms at 0930, onset is 0700.
Ask the client, family or staff when the client was last seen without symptoms, and document the exact clock time.
3 Who can receive a clot-dissolving drug?Only a client with an ischemic (clot) stroke and no bleeding in the brain can receive a thrombolytic. 1 min
Only a client with an ischemic (clot) stroke and no bleeding in the brain can receive a thrombolytic. Alteplase and tenecteplase dissolve the clot. They are given IV within 3 hours of last known well, and up to 4.5 hours for selected clients. A noncontrast head CT comes first, because a thrombolytic would make a brain bleed worse.
Bleeding risk excludes many clients, for example recent head trauma or stroke, recent internal bleeding, a low platelet count, or anticoagulant use with prolonged clotting times. The provider and stroke team decide eligibility using the current AHA/ASA guideline; the nurse gathers the data they need.
A mechanical thrombectomy (removing the clot through a catheter) is an option for a large-artery clot, up to 24 hours from last known well.
4 What the nurse doesThe nurse acts fast, protects the airway and gathers the data the stroke team needs. 1 min
The nurse acts fast, protects the airway and gathers the data the stroke team needs.
- Assess: level of consciousness, BE FAST signs, airway and breathing, vital signs and a fingerstick glucose (low glucose can mimic stroke).
- Priority action: activate the stroke response, record the time last known well, keep the head, neck and body aligned, and give oxygen per protocol.
- Prepare: keep the client NPO, including oral medications, until a swallow screen is done; place two large-bore IV lines; get an accurate weight because thrombolytic doses are weight-based.
- After a thrombolytic: monitor in an ICU or stroke unit for at least 24 hours with frequent neuro checks and vital signs. Keep blood pressure at or below 180/105 mm Hg and use bleeding precautions.
- Teach: risk-factor control (blood pressure, glucose, smoking, activity) and calling 911 for any new BE FAST sign.
5 Which changes after treatment are emergencies?New or worsening neurologic signs after a thrombolytic can mean the stroke has started to bleed. 1 min
New or worsening neurologic signs after a thrombolytic can mean the stroke has started to bleed. This hemorrhagic transformation usually happens within 24 hours of a thrombolytic or thrombectomy.
Report at once a new severe headache, vomiting, a falling level of consciousness, new weakness or pupil changes. The drug label says to stop the infusion if serious bleeding occurs. Swelling of the lips or tongue during or up to 2 hours after alteplase is angioedema, another reason to stop the infusion and get help.
Aspirin is held for 24 hours after alteplase, and repeat brain imaging is done before antiplatelet or anticoagulant therapy starts.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Onset is the time last known well, not the time the nurse found the symptoms.
Watch out: Give nothing by mouth until the swallow screen, not sips of water to see how the client does.
Watch out: A new severe headache or a drop in level of consciousness after a thrombolytic is a possible brain bleed, not an expected side effect.
Watch out: Antiplatelet or anticoagulant drugs wait for repeat brain imaging about 24 hours after a thrombolytic, not the first evening.
How to remember it
Think of the first hour as a checklist you can say out loud while you act.
Memory hook: "Find it FAST, date it, scan it, and keep the mouth shut." BE FAST finds it, last known well dates it, the CT scans for bleeding, and NPO protects the airway until the swallow screen.
Self-check:
- Name the six BE FAST letters and what each one tests.
- A client was last seen normal at 2200 and found with symptoms at 0600. What is the onset time?
- List three findings after a thrombolytic that you report immediately.