A nurse is caring for a client who experienced an acute ischemic stroke 6 hours ago and is receiving tissue plasminogen activator (tPA). Which nursing intervention should be the highest priority?
1Administer aspirin 325 mg orally as prescribed
2Encourage early mobilization to prevent complications
3Monitor for signs of intracranial hemorrhage every 15 minutes✓ 정답
4Provide speech therapy consultation immediately
해설
Monitoring for intracranial hemorrhage is the highest priority due to the significant bleeding risk with tPA. Other interventions like aspirin or early mobilization are contraindicated or lower priority during active thrombolysis.
Clinical Judgment
The core of this question assesses the nurse's ability to recognize a life-threatening complication that can occur after tPA administration and to respond immediately. tPA dissolves clots in ischemic stroke but simultaneously greatly increases the risk of cerebral hemorrhage (intracranial hemorrhage). A newly developed severe headache and nausea/vomiting are classic signs of increased intracranial pressure, strongly suggesting cerebral hemorrhage. This is an absolute indicator that ongoing treatment must be stopped and emergency measures initiated.
Memory Tip: A headache after tPA is a Red Flag! Remember "Red Flag Headache." A headache occurring after tPA administration is a red flag signaling cerebral hemorrhage.
KR vs US: In Korea, blood pressure management goals after tPA administration may be somewhat stricter, but by NGN/US standards, a blood pressure around 160/90 mmHg is often managed gradually within an acceptable range during tPA administration. The most critical aspect is monitoring for signs of neurological deterioration (headache, change in consciousness, etc.).
Clinical Monitoring Protocol Post-tPA
Following tissue plasminogen activator (tPA) administration for acute ischemic stroke, the patient enters a critical 24-hour monitoring phase. The highest priority is serial neurological assessment to detect intracranial hemorrhage (ICH).
Perform neurological checks every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours post-infusion.
Assess for: change in level of consciousness, severe headache, nausea/vomiting, acute hypertension, and new focal deficits.
Maintain strict blood pressure control, typically keeping systolic BP below 180 mmHg and diastolic below 105 mmHg.
Avoid any anticoagulants or antiplatelet agents (including aspirin) for at least 24 hours.
Delay placement of nasogastric tubes, urinary catheters, and invasive lines if possible to minimize bleeding risk.
Immediate Actions if ICH is Suspected
If the patient develops signs of intracranial hemorrhage, immediate action is required:
Stop any remaining tPA infusion immediately.
Notify the provider and activate the stroke team or rapid response.
Prepare for emergent non-contrast CT scan of the head.
Obtain stat labs: PT/PTT, fibrinogen, CBC, and type and crossmatch.
Anticipate administration of cryoprecipitate or antifibrinolytics as ordered.
Nursing Priority Rationale
The 24-hour post-thrombolysis window carries the highest risk for hemorrhagic transformation. Frequent, structured neurological assessments are the primary means of early detection, allowing for rapid intervention that can be lifesaving. This safety monitoring supersedes other interventions such as early mobilization, medication administration, or rehabilitation consults during this acute phase.
tissue plasminogen activator (tPA) — A thrombolytic agent that dissolves clots to restore cerebral blood flow in acute ischemic stroke, with a major risk of causing intracranial hemorrhage.
intracranial hemorrhage (ICH) — Bleeding within the skull, a life-threatening complication of thrombolytic therapy characterized by sudden neurological deterioration.
hemorrhagic transformation — The conversion of an ischemic stroke into a hemorrhagic one, often occurring within the first 24-36 hours after thrombolysis.
neurological checks — Serial assessments of level of consciousness, motor function, pupil reactivity, and vital signs to detect early signs of brain injury.
hyperacute stroke phase — The first 24 hours after stroke onset, a critical period for intervention and monitoring to prevent secondary brain injury.