A 68-year-old client arrived with right-sided weakness, dysarthria, and facial droop that began 2 hours ago. CT shows no hemorrhage, the NIH Stroke Scale score is 12, and blood pressure is 188/102 mmHg. The provider is considering IV alteplase for acute ischemic stroke. Which nursing actions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
IV alteplase is time dependent, so the nurse confirms last known well and supports rapid eligibility assessment (Choice 1). Blood pressure must be below 185/110 mmHg before treatment and maintained below 180/105 mmHg for 24 hours afterward (Choice 3). Establish necessary access before treatment when feasible, then perform frequent neurologic and blood-pressure monitoring and urgently evaluate findings that can indicate intracranial hemorrhage (Choice 4). Antiplatelet and anticoagulant therapy is generally withheld for the first 24 hours until follow-up imaging excludes hemorrhage, and nonessential traumatic procedures are deferred (Choice 5). Eligibility requires a current protocol-based review of clinical history, medications, tests, imaging, and blood pressure because exclusions and precautions are nuanced (Choice 6). Starting aspirin or heparin immediately after the infusion, before follow-up imaging, increases bleeding risk (Choice 2).
Acute Ischemic Stroke — Hyperacute Care 1. FAST/BEFAST recognition; last known well (LKW) verification 2. Non-contrast head CT to rule out hemorrhage 3. IV alteplase (tPA) within 4.5-hour window for eligible clients (some extended-window per imaging) 4. Mechanical thrombectomy candidacy if large-vessel occlusion (extended window up to 24 hr per imaging) 5. NIH Stroke Scale, BP control, glucose control 6. Avoid hyperthermia; control glucose; head of bed per facility protocol
tPA Eligibility Highlights - Within 4.5 hr of LKW - Measurable neuro deficit - CT no hemorrhage - BP ≤185/110 (treat to control before infusion) - Age ≥18; some pediatric/geriatric considerations
Major Absolute Contraindications - Intracranial hemorrhage - Recent intracranial or spinal surgery (≤3 months) - Recent stroke (≤3 months) - Active internal bleeding - Severe uncontrolled hypertension - Bleeding diathesis - Anticoagulant with elevated INR/PT/aPTT/anti-Xa - Recent major head trauma
BP Targets - Pre-tPA: BP <185/110 (treat with labetalol or nicardipine) - Post-tPA × 24 hr: BP <180/105 - Avoid sudden BP drops (cerebral hypoperfusion)
Post-Alteplase Monitoring × 24 hr - NIH Stroke Scale q15 min × 2 hr, then q30 min × 6 hr, then q1 hr × 16 hr - BP per the same schedule - HOLD antiplatelets/anticoagulants × 24 hr - HOLD invasive procedures (NG, Foley, arterial puncture) × 24 hr - Avoid IM injections - Sudden severe headache, decreased LOC, nausea, new deficit → STOP infusion + STAT head CT
Memory Tip "LKW + CT + BP <185/110 + No bleeding contras; HOLD all anti-platelet/anticoag × 24 hr"
Scenario68 yo, sudden right-sided weakness + slurred speech + facial droop, 2 hr from LKW, CT no hemorrhage, NIHSS 12, BP 188/102. Provider considering IV alteplase.
Action Map1. Verify LKW (within 4.5 hr)2. BP control: pre-tPA <185/110; post-tPA <180/105 × 24 hr3. Contraindication screen4. Two large-bore IVs; continuous monitoring; NIHSS q15 min during infusion5. ICH surveillance: severe HA, decreased LOC, nausea, new deficit6. HOLD antiplatelet/anticoag × 24 hr; HOLD NG/Foley/arterial puncture; avoid IM
Avoid- Aspirin/heparin within 24 hr of alteplase- Sudden BP drop- Missing the time window- Skipping contraindication screen
IV Alteplase (tPA) for Acute Ischemic Stroke — Tissue plasminogen activator administered IV for eligible acute ischemic stroke clients to dissolve the occluding clot. Standard time window: within 4.5 hours of last known well; some clients with favorable advanced imaging may be candidates beyond. Major risks: intracranial hemorrhage, systemic bleeding, angioedema. Standard dose: 0.9 mg/kg (max 90 mg) — 10% bolus over 1 minute, remainder infused over 60 minutes. Strict BP control before and after, continuous neurologic monitoring, and bleeding precautions for 24 hours post-infusion.
BP Targets and Time Window — Pre-alteplase: BP must be ≤185/110 mmHg; treat with IV labetalol or nicardipine to achieve target before starting infusion. Post-alteplase × 24 hours: BP <180/105 mmHg with frequent monitoring (often q15 min × 2 hr, then q30 min × 6 hr, then q1 hr × 16 hr). Avoid sudden large drops in BP that cause cerebral hypoperfusion. Time window: ≤4.5 hours from last known well for standard candidates; mechanical thrombectomy may extend to 24 hours per advanced imaging when large-vessel occlusion is present.
Post-Alteplase Bleeding Precautions — For at least 24 hours after IV alteplase: HOLD antiplatelets (aspirin, clopidogrel) and anticoagulants; HOLD invasive procedures including NG tube placement, indwelling urinary catheter insertion, and arterial puncture; avoid intramuscular injections; minimize venipunctures and use small-gauge IVs already in place. Surveillance: monitor for signs of intracranial hemorrhage (sudden severe headache, decreased level of consciousness, nausea/vomiting, new neurologic deficit) — STOP infusion if active and obtain STAT head CT. Aspirin is typically started 24 hours after alteplase pending follow-up imaging.