In the first 24 hours, here's some
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.
Then every 60 minutes until 24
hours from the start of his
thrombolytic treatment. That's generally
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.
Now, the blood pressure must
be maintained at or below
180/105 during the first 24 hours.
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.
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.
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.
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.
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.
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.
That's really the brand name of indwelling
bladder catheter, but you get the point.
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
So we talked about your immediate priorities
and things we don't want you to do.
Now, let's look at the first 24 hours
in kind of a snapshot.
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.
Now, positioning. You probably want the
head of the bed elevated 30 degrees.
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
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.
We also want to keep a tight glucose control.
See, hyperglycemia -- "emia" means
in the blood, "glyc" refers to glucose.
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.
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.
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.
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.
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.
Now, fever is often associated with a really
unfavorable outcome with these patients.
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.
So I'm more like a low 98°F.
So if I'm -- No, actually, no, 97°F. Sorry.
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.
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.
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.
We're aware of potential complications
he could have from immobility.
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.
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.
So this will give you an idea, just a
gentle reminder about what the
NIH Stroke Scale is.
Sometimes, people refer to it as the NIHSS.