Nurse knowledge leads to quick action.
- Hospitalized patients with hypertension, atrial fibrillation, and advanced age are at increased risk for stroke.
- Early recognition of stroke symptoms, followed by prompt diagnosis and treatment, leads to improved clinical outcomes.
Assessment
At 0800, Melissa, a cardiac telemetry unit nurse notes Mr. Anderson’s BP as 200/110 mmHg and pages the provider. At 0805, he develops slurring of speech, right facial drooping, and difficulty lifting his right arm. Melissa activates the Rapid Response/Stroke Alert Team.
In action
When the team arrives at 0810, Melissa confirms with the provider the time of symptom onset and Mr. Anderson’s elevated BP. The American Heart Association/American Stroke Association guidelines recommend either I.V. alteplase or I.V. tenecteplase within 4.5 hours of stroke symptom onset if BP is <185/110 mmHg. To achieve that BP goal, Melissa knows the team may consider administering labetalol or nicardipine.
The provider performs a rapid neurological assessment, including the National Institutes of Health Stroke Scale (NIHSS) with an initial severity score of 9 (out of 42). He suspects Mr. Anderson is having a stroke.
Melissa reports a fingerstick glucose of 101 mg/dL, ruling out hypoglycemia, which can mimic stroke symptoms. At 0830, Ashley, the RRT nurse, administers labetalol 10 mg I.V. push as ordered and obtains a baseline neuro check. She arranges for a stat non-contrast CT scan of the head. Knowing that I.V. labetalol peaks within 15 minutes, Ashley assesses Mr. Anderson’s BP at 0845; it’s now 174/95 mmHg. The scan shows no evidence of intracerebral hemorrhage. Selected patients with a suspected large vessel occlusion should have a CT angiography with CT perfusion. After labetalol, Mr. Anderson’s BP is <185/110 mmHg, meeting the BP eligibility for potential I.V. thrombolytic therapy after ICU transfer.
At 0900, Mr. Anderson is transferred to the ICU with a diagnosis of acute ischemic stroke. Mike, the ICU nurse, assesses Mr. Anderson: weight 78 kg, BP 164/85 mmHg, temperature 99o F (37.2o C), HR 74 bpm, RR 20 breaths per minute, controlled atrial fibrillation on continuous cardiac monitoring, and an NIHSS score of 10.
At 0920, Mike administers I.V. tenecteplase 20 mg I.V. push over 5 seconds as ordered. He assesses Mr. Anderson’s vital signs and the NIHSS every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours. Performing hourly neuro checks, Mike remains alert for changes, including severe headache, nausea or vomiting, signs of systemic bleeding, and angioedema.
Outcome
Twenty-four hours after receiving tenecteplase, Mr. Anderson’s repeat head CT is negative for intracerebral hemorrhage; his BP is 144/80 mmHg, HR 78 bpm, and RR 18 breaths per minute. His NIHSS score improves to 6.
In the stepdown unit, nursing care focuses on prevention, early recognition, and complication management to maximize stroke recovery. Mr. Anderson receives secondary stroke prevention education and a referral for rehabilitation.
Education
According to Kuczynski and colleagues, acute stroke occurs in 7% to 15% of patients hospitalized for other conditions.
Nurses can use the BEFAST mnemonic (Balance—trouble walking, Eyes—trouble seeing, Face drooping, Arm weakness, Speech difficulty, Time to call 911), developed by Intermountain Healthcare, to identify stroke symptoms and activate RRT for timely diagnosis and treatment. Melissa’s knowledge of this mnemonic ensured quick action and treatment. (See About thrombolytics)
About thrombolytics
Until recently, I.V. alteplase was the only thrombolytic approved by the U.S. Food and Drug Administration (FDA) to treat acute ischemic stroke within 3 hours of symptom onset. It’s ordered as 0.9 mg/kg (maximum total treatment dose 90 mg) with 10% of the dose administered as an initial I.V. bolus over 1 minute and the remaining 90% administered by infusion pump over 60 minutes.
In February 2025, the FDA approved I.V. tenecteplase for acute ischemic stroke within 3 hours of symptom onset. It’s ordered as a single, weight-based I.V. bolus dose (maximum dose 25 mg/5 mL) over 5 seconds (see dosing table in the tenecteplase package insert). A retrospective analysis by Tu and colleagues found comparable safety and efficacy between tenecteplase and alteplase.
*Names are fictitious.
John P. Harper was a clinical educator at Crozer-Chester Medical Center in Upland, Pennsylvania.
American Nurse Journal. 2026; 21(5). Doi: 10.51256/ANJ052664
References
Ashcraft S, Wilson SE, Nystrӧm KV, Dusenbury W, Wira CR, Burrus TM. Care of the patient with acute ischemic stroke (prehospital and acute phase of care): Update to the 2009 comprehensive nursing care scientific statement: A scientific statement from the American Heart Association. Stroke. 2021;52(5):e164-78. doi:10.1161/STR.0000000000000356
Genentech. Reconstitute Activase immediately before administration. activase.com/ais/dosing-and-administration/reconstituting.html
Genentech. TNKase (tenecteplase). tnkase.com/acute-ischemic-stroke.html?c=tnk-195a4583f41
Hogge C, Goldstein LB, and Aroor SR. Mnemonic utilization in stroke education: FAST and BEFAST adoption by certified comprehensive stroke centers. Front Neurol. 2024;15:1359131. doi:10.3389/fneur.2024.1359131
Kuczynski AM, Freeman WD, Mooney LH, Huang JF, Demchuk AM, Khosravani H. The in-hospital code stroke: A look back and the road ahead. Neurohospitalist. 2025;15(2):124-32. doi:10.1177/19418744241298035
Moawad H. New thrombolytic choices: Is one better? Medscape Neurology. May 1, 2025. medscape.com/viewarticle/new-thrombolytic-choices-one-better-2025a1000a1r?ecd=mkm_ret_250528_mscpmrk_neuro_topcontent_etid7445427&uac=90578FY&impID=7445427
Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. 2026. doi:10.1161/STR.0000000000000513
Rousseau JF, Weber JM, Alhanti B, et al. Short-term safety and effectiveness for tenecteplase and alteplase in acute ischemic stroke. JAMA Netw Open. 2025;8(3):e250548. doi:10.1001/jamanetworkopen.2025.0548
Tu CC, Mao HK, and Wessol JL. Comparing tenecteplase and alteplase for acute ischemic stroke. J Neurosci Nurs. 2025;57(3):127-31. doi:10.1097/JNN.0000000000000821
Key words: inpatient, ischemic stroke, thrombolytic
