24 Hours after Alteplase: Nursing Priorities – Stroke Nursing Care in ICU

00:01 In the first 24 hours, here's some universal concepts that we're going to be really watching for for any patient who, in the first 24 hours after they've had alteplase, that thrombolytic drug, IV. Okay, so vital signs and neuro status are done every 15 minutes for the first 2 hours in critical care. Then you can move to every 30 minutes for the next 6 hours, so that accounts for the first 8 hours.

00:27 Then every 60 minutes until 24 hours from the start of his thrombolytic treatment. That's generally what's recommended.

00:35 Now, the health care provider might write specifically different orders, but that's a good rule of thumb. Most new admits, you check their vital signs every 15 minutes, okay, for the first couple hours, just until you're sure that you're going to see a trend. Now, usually how you're checking vital signs in ICU is there'll be an automatic blood pressure cuff, either on the arm, or they may have for some patients put in an intra-arterial line, and you'll be able to read that on the monitor. But usually, it's going to be a blood pressure cuff, at this point. So every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every 60 minutes for 24 hours after the alteplase treatment. So, it'd be good for you to note the timing of the alteplase treatment in the chart, so you can communicate that to your colleagues when you hand off at shift.

01:22 Now, the blood pressure must be maintained at or below 180/105 during the first 24 hours.

01:31 That's a crazy high blood pressure to most of us, right? We're thinking like, "I don't want my blood pressure that high." But remember, with an ischemic stroke, we treat them a little differently. We want a little bit higher blood pressure because we're worried about perfusion. Now, the healthcare provider orders will clarify different individualized ranges and meds to be used to possibly control potential hypertension. So, what I've given you here is a guideline, but the health care provider and the health care team is going to assess Mr. Johnson individually, and might write some specialized orders. So I've just given you an example of what could be written, but watch out for specialized orders for each patient.

02:12 Now, we're still in the first 24 hours, but we want to keep in mind with anticoagulant and antithrombotic agents like heparin, warfarin, or antiplatelet drugs, shouldn't be given for the first 24 hours after they receive alteplase So, we already know with Mr. Johnson having a thrombolytic like alteplase -- don't you love how I keep pointing to my arm, so we know where we gave it to him? For the first 24 hours after Mr. Johnson receives alteplase, we don't want him to get other drugs that would encourage his tendency to bleed: heparin, warfarin, you may know it as Coumadin, or other anti-platelet drugs. We're not looking for him to have aspirin or any other type such drug, at least for the first 24 hours.

02:56 If the health care provider orders that, this is an order you would just verify and check to make sure the healthcare provider wants that given if it's ordered before that first 24-hour mark.

03:08 Now, if you can avoid putting in something like an intra-arterial catheter, and we talked about that. We call that usually an art line. But really what it is an intra-arterial catheter, is an arterial line or an art line. You put it in an artery of the arm, and then you connect transducer tube into it. So it's really kind of cool, because now you can draw arterial blood gases right from the line without sticking the patient. And you can also have continuous blood pressure monitoring. We likely would not put this in for just a regular stroke.

03:44 There's no need to have that arterial line. But if, for some reason, it was placed, remember, it either needs to go in before Mr. Johnson got the thrombolytic or for at least 24 hours after Mr. Johnson got the thrombolytic because when they stick an artery, it's going to bleed forever. You'll have to hold pressure for a very, very long time. Same thing applies to indwelling bladder catheters. An indwelling bladder catheter is sometimes called a Foley.

04:11 That's really the brand name of indwelling bladder catheter, but you get the point.

04:16 So, catheters for urinary catheters, NG tubes, you'll see that spelled out as nasogastric tubes. We call those NG tubes, should also be avoided for the first 24 hours if you can safely manage Mr. Johnson without them.

04:34 So we talked about your immediate priorities and things we don't want you to do.

04:38 Now, let's look at the first 24 hours in kind of a snapshot.

04:42 Assessment of the ABCs, level of consciousness, mentation, movement, sensation, reflexes, and the stroke scale. Remember the NIHSS was done down in ER for a baseline. And you'll do that repeatedly throughout Mr. Johnson's stay to evaluate is he getting better or are things getting worse? So that's a standardized measurement to really monitor his progress.

05:06 Now, positioning. You probably want the head of the bed elevated 30 degrees.

05:11 You also want to collaborate with a healthcare provider because he may want something more specific for Mr. Johnson, but keeping the head of the bed elevated at least 30 degrees is a general recommendation.

05:21 You want to maintain intravascular fluid volume. Now, the reason you want to maintain intravascular fluid volume is because we do not want Mr. Johnson to have low blood pressure. If he gets too dry, or has intravascular dehydration, meaning he doesn't have enough fluid volume in his intravascular space, his veins and arteries, then his blood pressure will be too low. So you don't want him fluid volume overloaded, but we definitely don't want him intravascularly dry or dehydrated.

05:52 We also want to keep a tight glucose control. See, hyperglycemia -- "emia" means in the blood, "glyc" refers to glucose. "Hyper" means high. So hyperglycemia, or high blood glucose, can make his brain injury and stroke worse. The American Heart, the American Stroke Association guidelines recommend keeping his blood sugar between 140 and 180 mg/dL. Hey, well, wait a minute. What if Mr. Johnson wasn't a diabetic? You still want to keep an eye on that blood sugar because we want to make sure that isn't elevating because of all the trauma the body's gone through, and the sympathetic nervous system overdrive.

06:33 Now, a swallow assessment is a good idea, so we want to make sure if he can safely swallow liquids or if they need to be thickened.

06:41 That is -- I hate that Thick-It stuff, but if someone has issues with swallowing, clear liquids or very thin liquids are a risk for aspiration. So we have this stuff called like Thick-It.

06:54 It's like a powder and you put it in people's liquids and you stir it up and then it becomes thick. Which the thought of drinking a thick iced tea just grosses me out. All my mind can come up with is that, it's rotten, but it allows patients to get that taste feeling if they do have a problem swallowing.

07:12 Now, our goal is also to prevent potential complications because we've got them in bed all day. Skin breakdown, aspiration, deep vein thrombosis or DVT, UTI, urinary tract infection, especially if we put a Foley in, is a high risk for that. You could have some orthopedic problems from being immobile, and also malnutrition. We need to make sure that Mr. Johnson is getting food as soon and safely as possible.

07:43 Now, fever is often associated with a really unfavorable outcome with these patients.

07:49 So figure out why you think the patient might be having elevated fever and try do whatever you need to do to keep him at a normal body temperature when possible. It's also helpful if you can talk to the family or look back at his previous records and find out what does he normally run? I know my temperature is never 98.6°F. I always tend to run really low.

08:10 So I'm more like a low 98°F.

08:12 So if I'm -- No, actually, no, 97°F. Sorry.

08:16 So if I'm running 98.6, I'm not feeling good. And if I'm at 99°F, it's really high for me.

08:23 So everybody has their own normal, but sometimes, it's different than the textbook normal. So if you can establish what his normal is, that'll also help you do a better assessment. And lastly, blood pressure management. Okay, pull back.

08:40 I want you to know, as an ICU nurse, or if you're making a care plan for an ICU patient, just possibly might be happening as a nursing student, these are the areas of focus you want to look at: your assessment, making sure ABCs are stable. You've got just your overall patient head to toe assessment. The patient is positioned correctly. He has good fluid volume status. We're watching his blood sugar. We know that he can swallow safely or not.

09:07 We're aware of potential complications he could have from immobility.

09:11 We're watching fever closely as we're watching blood pressure, and we're making sure that his blood pressure stays within the ordered parameters.

09:18 Now, this is just a quick review of the NIH Stroke Scale. We refer to that, the one that you'll repeat that was done in ER, so we're not going to go through that again. But remember, I just want to stress again, we use it at interval. So we did a baseline when he was admitted, then 2 hours post treatment, he's already up to ICU. If the bed was available, they'd want to get him up to ICU for close monitoring. Then we'll do it again at 24 hours and so on.

09:44 So this will give you an idea, just a gentle reminder about what the NIH Stroke Scale is.

09:48 Sometimes, people refer to it as the NIHSS.