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.
Core Nursing ExplanationKey Concept Analysis: This question tests the critical nursing priority for a patient receiving tissue plasminogen activator (tPA) for an acute ischemic stroke. The core theme is balancing the benefit of clot lysis with the major risk of the treatment: intracranial hemorrhage (ICH). tPA is a powerful thrombolytic agent that dissolves clots but also impairs the body's normal clotting mechanisms, significantly increasing the risk of bleeding, especially in the brain. The priority nursing intervention is vigilant monitoring for this life-threatening complication.
Answer Rationale: Key Point! The highest priority is Monitoring for signs of intracranial hemorrhage every 15 minutes. During and immediately after tPA infusion, the patient is at the highest risk for bleeding complications. Frequent neurological assessments (e.g., using the National Institutes of Health Stroke Scale (NIHSS) or checking for changes in level of consciousness, new headache, vomiting, or pupillary changes) are essential for early detection. Early recognition of ICH allows for immediate discontinuation of the drug and potentially life-saving interventions.
Distractor Analysis:
Watch out for confusion!Administer aspirin 325 mg orally as prescribed: This is contraindicated and dangerous. Aspirin is an antiplatelet agent. Giving it concurrently with a thrombolytic like tPA would profoundly increase the risk of hemorrhage. Antithrombotics (antiplatelets like aspirin or anticoagulants like heparin) are typically withheld for at least 24 hours after tPA administration.
Watch out for confusion!Encourage early mobilization to prevent complications: While early mobilization is a key part of stroke rehabilitation, it is contraindicated in the acute phase, especially during and immediately after tPA infusion. The patient requires strict bed rest with the head of bed flat or slightly elevated (per protocol) to minimize the risk of bleeding and falls. Mobilization is initiated later based on neurological stability.
Provide speech therapy consultation immediately: While important for planning rehabilitation, this is not the highest priority during the acute, high-risk treatment phase. The immediate priorities are physiological stability and complication monitoring. The consultation can be arranged after the critical monitoring period.
Related Concepts: The nursing care for a stroke patient receiving tPA revolves around the "Time is Brain" principle. Care includes strict blood pressure management (often with IV medications like labetalol or nicardipine to keep SBP < 185/110 mmHg), avoiding invasive procedures (no NG tubes, urinary catheters, or IM injections unless absolutely necessary), and frequent neurovascular checks.
Concept Summary
Concept
Key Points for tPA in Stroke
Primary Goal
Restore blood flow to ischemic brain tissue ("Time is Brain").
Major Risk
Intracranial Hemorrhage (ICH) - The most feared complication.
Nursing Priority
Frequent neurological assessment for signs of bleeding (q15min initially).
Absolute Contraindication
Concurrent administration of antiplatelets (aspirin, clopidogrel) or anticoagulants.
Activity
Strict bed rest during and immediately after infusion.
Blood Pressure Management
Critical. Maintain SBP < 185/110 mmHg before and during treatment.
Side-by-Side Comparison!
Intervention
During tPA Infusion (Acute Phase - Priority)
Post-tPA / Rehabilitation Phase
Medication
NO antiplatelets/anticoagulants. Manage BP with IV drips.
Antiplatelets (e.g., aspirin, clopidogrel) started ~24 hours post-tPA if no hemorrhage.
Mobilization
Strict bed rest. HOB flat or as ordered.
Early mobilization with PT/OT once neurologically stable.
Monitoring Focus
Neurological status for ICH (q15min-1hr). Vital signs.
Avoid all non-essential invasive procedures (NGT, Foley, IM injections).
Procedures can be performed with standard precautions.
Anatomy, Physiology & Pharmacology Points
tPA Mechanism: Tissue plasminogen activator is an enzyme that converts plasminogen to plasmin. Plasmin breaks down fibrin, the main protein mesh that holds blood clots together.
Pathophysiology of ICH Risk: The ischemic stroke may have caused damage to blood vessel walls. tPA can lyse not only the target clot but also hemostatic plugs sealing these weakened vessels, leading to hemorrhage.
Neurological Assessment Signs of ICH: Sudden severe headache, nausea/vomiting, decreased level of consciousness (LOC), new focal neurological deficits (worsening weakness), pupillary changes (unequal, sluggish), seizures.
Memory Tips
Acronym: "MONITOR FIRST" for tPA priorities: Monitor neuro status, Omit antiplatelets, No invasive procedures, Intracranial bleed check, Time is brain, Observe BP, Rest (bed rest). Frequent assessments, Immediate action for changes, Risk of hemorrhage, Strict precautions, Thrombolytic therapy.
Think: "Bleeding is the Big Bad" when giving clot-busters. Your primary job is to watch for it.
High-Frequency NCLEX Topics
The NCLEX loves to test priority-setting and medication safety. tPA for stroke is a classic scenario combining both. You must know:
1. The #1 complication (bleeding/ICH).
2. The #1 nursing action (monitor for that complication).
3. Key contraindications/concurrent therapies to avoid (aspirin, heparin, IM injections).
4. Vital sign parameters (blood pressure limits).
Watch Out for Question Variations!
Shift from "Monitor" to "Act": "The nurse notes the patient's LOC decreases and one pupil becomes dilated. What is the priority action?" (Answer: Notify the physician/provider immediately and prepare for possible emergency interventions like reversal agents or surgery).
Shift to Contraindications: "Which patient finding, reported just before the scheduled tPA infusion, requires immediate notification of the provider?" (Answers could include: BP of 200/115 mmHg, recent major surgery, history of intracranial hemorrhage, or current use of anticoagulants).
Shift to Patient Education: "A patient is scheduled for tPA. Which statement by the patient indicates understanding? 'I know I need to...'" (Correct answer would relate to reporting any headache or neurological change immediately).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the Neuro-ICU. Mr. Johnson, 68, was admitted 5 hours ago with sudden left-sided weakness and slurred speech. A CT scan ruled out hemorrhage, and he met criteria for tPA, which was started 30 minutes ago. He is on a cardiac monitor, has two IV lines, and is receiving a nicardipine drip to control his blood pressure.
Nursing Intervention Strategy:
Assessment: Perform focused neurological assessments every 15 minutes during the infusion and for the first few hours after. Use a structured tool like the NIHSS. Assess: LOC (Glasgow Coma Scale - GCS), speech, facial symmetry, motor strength in all extremities, pupillary response, and complaint of headache.
Monitoring: Monitor vital signs per protocol (often every 15 min). Strictly maintain BP below 185/110 mmHg. Monitor the IV site for bleeding or infiltration.
Safety & Precautions: Maintain strict bed rest with side rails up. Ensure all team members know the patient is on a thrombolytic. DO NOT insert any unnecessary lines, take blood pressures in non-essential limbs, or give any intramuscular injections.
Patient/Family Communication: Explain the need for frequent checks and the importance of reporting any new symptoms (headache, nausea, tingling) immediately. Provide calm reassurance.
Patient Safety and Precautions:
Absolute Contraindication Post-Administration: Do not administer any antithrombotic agents (aspirin, heparin, enoxaparin) for at least 24 hours unless a follow-up CT scan confirms no hemorrhage.
If ICH is Suspected: Stop the tPA infusion immediately (if still running). Notify the provider STAT. Prepare for emergency CT scan. Anticipate orders for cryoprecipitate or fresh frozen plasma (FFP) to replace clotting factors, and possibly aminocaproic acid (an antifibrinolytic).
Minimize Trauma: Use electric razors, soft toothbrushes, and handle the patient gently during turns and positioning.
Nursing Procedure & Medication FlowtPA Administration & Monitoring Procedure:
1. Pre-Infusion: Verify two IV lines are patent. Confirm BP is within parameters. Double-check contraindications with a checklist.
2. During Infusion: Administer bolus and infusion via pump at the exact prescribed rate. Do not mix other medications in the same line.
3. Post-Infusion: Continue frequent neuro checks (e.g., q1h for 6 hours, then q2h). Monitor for systemic bleeding (gums, urine, stool, IV sites).
4. 24-Hour Mark: After 24 hours and a confirmatory CT scan showing no hemorrhage, the provider will typically order an antiplatelet agent (e.g., aspirin 81mg or 325mg) to prevent recurrent stroke.
A Word from Your Senior Nurse
"Nursing a patient on tPA is a high-stakes, high-focus assignment. You are the guardian at the bedside, watching for the subtle shift that signals trouble. Remember, your vigilant assessment is the key to catching a complication early enough to make a difference. On the NCLEX and in practice, your ability to prioritize surveillance for the major risk over other important but less urgent tasks (like consults or rehab) is what defines safe, effective nursing. Always link the drug to its action and its biggest danger—that's how you think like a nurse!"
Tissue Plasminogen Activator — A thrombolytic (clot-busting) medication used to treat acute ischemic stroke by dissolving the obstructing blood clot. Major risk is bleeding, especially intracranial hemorrhage.
Intracranial Hemorrhage — Bleeding within the skull, a life-threatening complication of tPA therapy. Signs include sudden headache, decreased LOC, vomiting, and new neurological deficits.
National Institutes of Health Stroke Scale — A standardized tool used by healthcare professionals to objectively quantify the impairment caused by a stroke. It assesses level of consciousness, vision, facial palsy, motor strength, ataxia, sensation, language, and neglect.
Time is Brain — A fundamental concept in stroke care emphasizing that rapid evaluation and treatment are critical because brain tissue dies quickly without blood flow. tPA must be given within a narrow time window (typically 3-4.5 hours from symptom onset).
Antiplatelet Therapy — Medication (e.g., aspirin, clopidogrel) that inhibits platelet aggregation to prevent clot formation. Contraindicated during and immediately after tPA administration due to increased bleeding risk.