Med-Surg · Neurological
Stroke (CVA) & TIA
open a plain-language definition. Tap or click them, or press Enter on the keyboard.
On this page
Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
A is sudden neurologic deficit from interrupted brain blood flow. A is a brief episode of stroke-like symptoms without permanent infarction—still a medical emergency and a warning for future stroke.
| Type | Mechanism | Key nursing implication |
|---|---|---|
| Ischemic (~85%) | Thrombotic or embolic vessel occlusion | May be eligible for thrombolysis / thrombectomy if within window |
| Hemorrhagic | Intracerebral or subarachnoid bleeding | No thrombolytics; BP and ICP control; neurosurgery possible |
Time last known well drives every acute decision. Brain imaging (noncontrast CT first) distinguishes bleed from ischemia before reperfusion therapy.
Hemisphere clues (typical): left → aphasia/language; right → neglect, impulsivity, spatial problems. Brainstem/cerebellar strokes threaten airway and coordination.
2. Causes and Risk Factors
- Modifiable: hypertension (strongest), AF, carotid stenosis, diabetes, dyslipidemia, smoking, obesity, sleep apnea, physical inactivity
- Nonmodifiable: age, prior stroke/TIA, family history, sex/race disparities
- Hemorrhagic triggers: uncontrolled HTN, aneurysms/AVMs, anticoagulants, trauma, cocaine
3. Signs and Symptoms
Use : Balance, Eyes (vision), Face droop, Arm weakness, Speech difficulty, Time to call 911.
- Sudden unilateral weakness/numbness, facial asymmetry
- Aphasia, dysarthria, confusion, vision loss, severe “worst headache” (SAH)
- Ataxia, vertigo, dysphagia
- Altered LOC, seizures
- Cushing’s triad is a late ICP sign, not an early stroke screen
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Typical / note | Nursing relevance |
|---|---|---|
| Noncontrast head CT | First-line | Rule out hemorrhage before tPA |
| CT angiography / perfusion, MRI | — | Large-vessel occlusion, penumbra |
| Glucose | Treat hypo—it mimics stroke | Fingerstick immediately |
| PT/INR, aPTT, platelets | tPA eligibility | Anticoagulant status |
| ECG / telemetry | — | Detect AF |
| NIHSS | Score severity | Serial neuro checks |
| Lipid panel, HbA1c | Secondary prevention | Risk modification |
5. Priority Nursing Assessments
- Time last known well and symptom onset
- ABCs; SpO₂; glucose
- Focused neuro exam / NIHSS; pupils; GCS
- BP (know permissive hypertension targets for ischemic stroke vs tighter control for hemorrhage—follow order/protocol)
- Swallow screen before any oral intake, including meds
- Bleeding precautions after thrombolysis; puncture-site and neuro change monitoring
- Aspiration, skin, DVT, and fall risk ongoing
6. Priority Nursing Interventions
- Activate stroke team / EMS pathway; keep NPO until swallow cleared
- Head of bed per protocol (often ~30° if no contraindication); head midline
- Oxygen only if needed to keep SpO₂ at target
- Establish IVs; avoid unnecessary sticks if tPA likely
- Alteplase / tenecteplase within eligibility window after bleed excluded—monitor for angioedema, ICH (neuro decline, severe headache, vomiting, acute HTN)
- Endovascular thrombectomy candidates: rapid transfer to capable center
- Hemorrhagic: reverse anticoagulation as ordered; BP management; ICP precautions; possible EVD/OR
- After stabilization: antiplatelets (ischemic), statin, PT/OT/ST, DVT prophylaxis, early rehab
7. Medications
| Class / examples | Role | Nursing considerations |
|---|---|---|
| Thrombolytics (alteplase, TNK) | Lyse clot (ischemic) | Strict criteria/time window; BP parameters; no anticoagulants immediately after per protocol; hemorrhage watch |
| Antiplatelets (aspirin, clopidogrel) | Secondary prevention | Hold until hemorrhage excluded |
| Anticoagulants | AF-related stroke prevention | Timing after acute stroke individualized |
| Antihypertensives | Per stroke-type targets | Avoid overcorrection in acute ischemic stroke unless above protocol threshold |
| Statins | High-intensity often | Muscle/LFT monitoring |
| Anticonvulsants | If seizures occur | Not routine prophylaxis for all strokes |
| Nimodipine | SAH vasospasm prevention | Hypotension monitoring; give on time |
8. Patient Education
- Call 911 for BE-FAST symptoms—note the clock time
- Medication adherence (antiplatelet/anticoagulant/statin/BP/diabetes meds)
- Lifestyle: sodium, smoking cessation, exercise as cleared, sleep apnea treatment
- AF clients: anticoagulation importance and bleeding precautions
- Aspiration strategies from speech therapy; one-sided neglect safety (scan the room)
- Depression after stroke is common—encourage reporting mood changes
9. Complications
- Increased ICP / herniation
- Hemorrhagic transformation after thrombolysis
- Aspiration pneumonia
- DVT/PE, contractures, pressure injuries
- Seizures, SIADH/cerebral salt wasting
- Depression, aphasia-related communication barriers
10. Memory Aids
- “BE-FAST + last known well”
- “CT before tPA”
- “NPO until swallow screen”
- “Left language, right reckless/neglect” (typical teaching mnemonic—verify with actual deficits)
- “Time is brain”
11. NCLEX-Style Practice Questions
1. Most important information for acute stroke treatment decisions?
A. Favorite foods
B. Time last known well
C. Childhood illnesses
D. Hearing aid brand
Answer: B. Reperfusion therapies are time-limited.
2. Before giving oral aspirin after suspected stroke, the nurse must:
A. Give it with milk only
B. Confirm hemorrhage is excluded and swallow safety is addressed per protocol
C. Crush it into juice immediately on arrival without imaging
D. Wait 72 hours regardless of CT
Answer: B. Imaging rules out bleed; then antiplatelet therapy proceeds as ordered with safe administration route.
3. A post-tPA client becomes suddenly more lethargic with a pounding headache. Priority?
A. Give another dose of tPA
B. Stop infusions per protocol, notify provider, prepare for urgent CT—possible ICH
C. Ambulate the client
D. Give oral fluids
Answer: B. Neuro decline after thrombolysis suggests intracranial bleeding until proven otherwise.
4. Which finding fits a right-hemisphere stroke more often?
A. Expressive aphasia only
B. Left-sided neglect and impulsivity
C. Global aphasia always
D. Right facial droop with aphasia only
Answer: B. Right-hemisphere injury commonly causes contralateral neglect and poor insight/impulsivity.
5. Why perform a swallow screen after stroke?
A. It replaces the CT scan
B. Dysphagia is common and aspiration can cause pneumonia
C. It measures BP
D. It dissolves clots
Answer: B. Keep NPO until screening (or ST evaluation) clears oral intake.
References
American Heart Association / American Stroke Association. (2021). Guidelines for the early management of patients with acute ischemic stroke. https://www.ahajournals.org/
MedlinePlus. (n.d.). Stroke. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/stroke.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Tadi, P., & Lui, F. (2023). Acute stroke. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535369/
Centers for Disease Control and Prevention. (n.d.). Stroke signs and symptoms. Retrieved October 15, 2026, from https://www.cdc.gov/stroke/