- Sudden vascular compromise causing disruption of blood low to brain
- Arteriovenous malformation
- Altered level of consciousness
- Weakness, numbness, or paralysis of portion of body
- Speech or visual disturbances
- Severe headache
- Heart rate increase or decrease
- Respiratory distress
- Unequal pupils
- Facial drooping on affected side
- Difficulty swallowing
- Bladder or bowel incontinence
- Nausea and vomiting
- If unresponsive, assess circulation, airway, and breathing.
- If responsive, monitor airway, breathing, and circulation.
- Call stroke code or stroke team.
- Remove dentures.
- Perform pulse oximetry.
- Maintain adequate oxygenation (SaO2 >95%) with supplemental O2, if necessary.
- Establish IV access with normal saline.
- Maintain BP according to guidelines (e.g., Cardiac Life Support).*
- Remove clothing.
- Obtain CT scan or MRI immediately.
- Perform baseline laboratory tests (including blood glucose) immediately, and treat
- Position head in midline.
- Elevate head of bed 30 degrees if no symptoms of shock or injury.
- Institute seizure precautions.
- Anticipate thrombolytic therapy for ischemic stroke.
- Keep patient NPO until swallow reflex evaluated.
- Monitor vital signs and neurologic status, including level of consciousness (NIH Stroke Scale), motor and sensory function, pupil size and reactivity, SaO2, and cardiac rhythm.
- Reassure patient and family.