Comprehensive Nursing Report: Acute Ischemic Stroke in Emergency Dept.

This report focuses on the critical role of nurses in the emergency department in the management of acute ischemic stroke. It begins with an introduction emphasizing the urgency of timely interventions and the significance of the phrase "time is brain." The report outlines a literature search strategy and provides an extensive literature review covering ischemic stroke, its risk factors, and the importance of early treatment, including thrombolysis. It highlights the nurses' responsibilities in patient assessment, neurological observation, and care coordination. The report discusses the role of family involvement, the challenges faced in the emergency department, and the importance of quick transfer to stroke units. The report also includes recommendations and a conclusion that summarizes the key findings and reinforces the importance of nursing care in improving patient outcomes. This report also discusses the role of stakeholders in the acute stroke intervention. The report highlights the role of nurses in acute ischemic stroke management, including primary evaluation and coordination for timely patient flow and the importance of specialized emergency treatment. The report emphasizes the significance of nurses in providing critical treatment on time, including quick transfer to acute stroke units for ongoing evaluation.

Running head: REPORT 0
NURSING
FEBRUARY 7, 2020
STUDENT DETAILS:

REPORT 1
Contents
Introduction.................................................................................................................................................2
Literature search strategy.............................................................................................................................3
Literature review.........................................................................................................................................4
Introduction.............................................................................................................................................4
Ischaemic stroke......................................................................................................................................5
Role of Nurses in emergency department with acute ischaemic stroke....................................................7
Conclusion.................................................................................................................................................17
Recommendation.......................................................................................................................................18
References.................................................................................................................................................21

REPORT 2
Introduction
It is very critical to provide care in initial hours for the better and long-term recovery of the
patient. The stroke is the medical emergency in that case. The robust evidence states the
substantial reduction in the death along with disability with earlier intervention in acute stroke
care, like thrombolysis as well as antiplatelet therapy stroke-unit care. International clinical
guidelines for stroke render significant recommendation to direct clinical practice. Though,
uptakes of care depended on evidence is variable as well as less than ideal. For instance, amongst
patients with ischemic stroke, the behaviour rate with intravenous recombinant tissue-type
plasminogen activator is lower in Australia (seven per cent) and America (Five per cent). While
compared with others, it is twelve per cent in Canada and fourteen per cent in Europe.
Further, the quick identification, imaging, consultation to comprehensive stroke centre along
with management are imperative to save the brain tissue in acute stroke situation. It is evident
that every minute is important for the life of patient. The life of patient can be saved by single
minute. All the nurses in emergency department should consider saying "time is brain" while
providing treatment to patients with neurologic emergency such as acute ischemic stroke. There
is significant role of nurses in prompt recognition as well as treatment of patient having acute
stroke, primary evaluation, along with coordination of well-timed flow of patient with acute
stroke throughout health management. They should have specialization in the emergency
treatment. The nurses help the survivors with personal care problems. They also render
training to the patients to develop understanding that how to carry out fundamental task of daily
existing. The nurse helps the patient to manage common health issues, like high BP along with
diabetes that may lead stroke survivor to other stroke. The nurse enables delivery of appropriate
critical treatment on time. The nurses provide quick transfer to acute SUs for continuing

REPORT 3
evaluation along with provision of additional cure. All the nurses should remember the phrase
"time is brain" at the time of providing care to the patient with neurologic emergency.
The purpose of this paper is to focus on the significant contribution of nursing to the convenient
transfer of acute stroke care by rendering recommendation depended on evidence for clinical
practices procedure of care as well as model of care wherever the nurse has crucial role in the
first seventy-two hours from arrival at the emergency department. The nurses have to be careful
in stroke unit care. The following parts state wide-ranging overview of nursing as well as
emergency care for patient with acute ischemic stroke encompassing beyond initial seventy-two
hours. The main procedures related to emergency department, timely evaluation, triage, as well
as quick administration of acute stroke in the emergency department are discussed in below
mentioned parts. A prompt identification, transference to comprehensive stroke department,
primary analysis along with treatment are imperative to save brain tissues through the acute
ischemic stroke. This paper describes the options of treatment in effective manner. The role of
stakeholder is also assessed in the acute stroke intervention.
Literature search strategy
The nursing search of literature databases was undertaken using medical guidelines, medical
policies, as well as reports or statistics .The main objective of this search was to find literature on
the role of nurses in the emergency department with acute ischaemic stoke. The search was
restricted to English language articles. Only the articles of previous five years are used to find
the role of nurses in emergency department with acute ischaemic stoke. Key words as well as
medical terms used to conduct research for getting better results. The focus was made on nursing

REPORT 4
and its related outcomes. The researcher faced some difficulties in conducting literature review.
It is found there are certain reports, government reports, articles, general reports, as well as
website that are restricted to use. The researcher faced difficulty in getting relevant data, facts, as
well as figures related to research concern. It made complexities for the researcher. It was also
time consuming for the researcher. In addition, there was also geographical limit in conducting
literature review. It can say that it is significant topic to conduct research about the role of nurses
in emergency department with acute ischaemic stroke. A researcher conducted research by
following ethical consideration. The personal data of the patients were not leaked. In addition,
the researcher did not leak the confidential information of nurses, clinicians as well as hospitals.
In this way, the researcher tried to avoid ethical issues in conducting research. Therefore, the
researcher collected data, figures, statistic, as well as facts from some locations of United
Kingdom with approval.
Literature review
Introduction
According to the World Health Organization “the stroke is considered as quickly establishing
clinical sign of central disturbance of rational functions, long-lasting more than twenty-four
hours or causing death with no superficial reason excluding vascular origin”. The stroke is
considered as neurologic urgency with poor prediction in black. The stroke states main cause of
illness as well as death at international level. It is at the third position as most general cause of
death in technologically advanced nation that results into long-term disabilities. It is argued by
Tong et. al. (2020) that stroke is responsible for 4 million death everywhere in the world. The
stroke has different levels of severity globally. It comes from full repossession on one hand to
non-fatal events as well as fatal occasions with neurological shortfalls, as well as practical

REPORT 5
incapacities on other side. There are two types of risk factors. These two types are non-
modifiable along with modifiable. It is stated by Ziganshina, Abakumova and Vernay (2017) that
the non-modifiable factors are age, sexual category, competition, background of family, genetic
as well as lower birth weight. On the other hand, the changeable risk elements are diabetes
mellitus, hypertension, hyperlipidaemia, fatness, hyperhomocysteinemia, atrial fibrillation
carotid artery diseases, hypercoagulable state along with selected biomarker.
Further, the stroke enhances greatly with age. It can say that the incidence of initial stroke is
approximately 200 per 100,000 yearly with occurrence of 5 to 12 per one thousand people. There
is different stroke mortality rate in different nations. It is ranged from twenty to two hundred
fifty per 100,000 people yearly. In United Kingdom, approximately 90,000 women as well as
60,000 men die from stroke in a year. It is stated by Network et. al. (2016) that the cost of stroke
to the social services are about £ 2.3 billion yearly. It can see that there is great risk of recurrent
stroke amongst the patients. It is mentioned by Watcher et. al, (2017) that approximately
fourteen per cent of survivors who suffer stroke or TIA would have the reappearance in initial
period. There are 22 % males as well as 25 % females who would have mortality in initial period
of the primary stroke. It can see that various stroke survivors had death in eight years.
Ischaemic stroke
There are two categories of stroke. First category is Ischaemic stroke along with other is
haemorrhagic stroke. The Ischaemic stroke is accountable for 85 % of each stroke. On the other
hand, the haemorrhagic stroke is accountable for 15 % of strokes (subarachnoid 5% and
intracerebral 10 %). Muir et. al. (2017) argued that Ischaemic stroke is responsible for the
sickness as well as death in the developed nations. Approximately 8% to 12% sufferers die in
thirty days of the initial stroke. In addition, the sufferers who survive initial attack are at

REPORT 6
enhanced risks of the reappearance. The Ischaemic stroke takes place by atherosclerotic vascular
disease. It is evident that this disease leads to obstruction and stenosis of main extracranial or
intracranial lines and formation of smaller penetrating lines of the mind. Additionally, the
cardioembolic stroke by the myocardial infarction is normally because of the atherosclerosis of
coronary pathways. The resulting ischaemia points direct slight in brain sue to the insufficiency
of flow, hypoxia as well as metabolic substrate. It applies the cascade of neurochemical
procedures resulting continuous damages within the time. Treatment of ischaemic stroke has
been with the utilisation of medicines like fibrinolytic agent, anticoagulant as well as antiplatelet
to increase blood flow to the brain. The avoidance of stroke is now possible at initial as well as
secondary level because of obtainability of different safer and positive involvements directed at
people having higher risks (Bronus, et. al, 2019).
Moreover, the acute ischemic stroke takes place while the arteries delivering blood to brain
becomes occluded. It can cause loss of brain tissue and focal deficit. It is explained by Goyal et.
al. (2016) that the stroke is considered as medical urgency with ischaemic stroke being
communal category globally. The hypertension has recognised as changeable threat element at
international level. The acute ischemic stroke is altering quickly because of advancements in
technologies as well as overview of intravenous recombinant tissues plasminogen activator. The
earlier involvement takes time to salvage the injured neurons. Initial twenty-four hours of
representation is very critical within the administration. Earlier acknowledgement of stroke signs
with rapid intervention may lead to the positive outcomes. The particular care at the time of
acute level in the intensive care or SUs may enhance the complete prognosis.
The overview of thrombolysis as well as committed SUs have highly advanced the
administration of individuals having stroke. On the other hand, for the benefits of these advances

REPORT 7
to be fully realised, the nurses of emergency department should be capable to identify the sign of
stroke. They should perform in appropriate and quick manner. The timing is very significant with
thrombolysis. In this way, the practitioner is required to have understanding as well as talent to
measure suitability of people for the treatment. The nurses should request brain scan
immediately. Additionally, they should refer the patient to SUs. It is found that the advancement
of neurologic results after the ischemic stroke is main societal importance. It can see that it has
drawn the attention of clinician along with researcher, government organisations, funding entities
as well as sector. However, the more significant point is that the stroke makes the patient
disabled. For each five-minute delay in endovascular reperfusion, there can be death of sufferers.
The community is in the requirement of comprehensive stroke units with talented team who can
manage tPA or can execute the acute ischemic stroke endovascular involvement in emergency.
Therefore, the processes have been stated to decreases disabilities. However, only when they are
conducted in time.
Role of Nurses in emergency department with acute ischaemic stroke
The nurse plays critical part in applying significant clinical process of care at bedside. These
clinical procedures have great connection with the advanced results. It is evident that the
accurate as well as recurrent neurological observation is helpful in earlier recognition as well as
succeeding administration of weakening. It is found that the presence of family can put impact
on the diagnostic method along with process of treatment. For instance, the impact of presence of
members of family during cardiopulmonary revivals and invasive processes should be
considered properly and effectively. It is a duty of nurse to take care of this point. The nurses
should give option to the family members. In this way, the healthcare providers should support
this. On the other hand, the policies of the ED restricts the existence of the members of family to

REPORT 8
ignore gathering. Various people desiring to accompany the patients in the ED in general, and
the stroke patient particularly, can be impacted through different elements, such as disease-
related (harshness, symptom as well as time of onset) and factors related to no disease (social,
family along with individual). It is argued by Genentech Inc. (2015) that the nurses should make
attempt to assess effect of various members of family on effectiveness of the diagnostic
procedure in ED policy. The nurses should take care that the family member as well as relatives
can serve as facilitator of fast along with effectual ED administration of stroke patient, possibly
enhancing the results. The nurses should tell about the role of families in taking decisions related
to medicinal attention. They should focus on a point that the members can play role as facilitator
of care in ED for stroke sufferers.
In addition, the determination of stroke pathogenic method is the main field of focus at the time
of stock unit care. It is useful in directing subsequent alternative prevention therapy. The
recognition of atrial fibrillation needs either telemetric cardiac observing or ECG. In this way, the
nurse plays the significant role in reviewing the aspects of care by making investigation in
relation to the stroke risk elements as well as methods, seeing diagnostic assessment result, and
rendering suggestion on alternative prevention measure to end stroke in upcoming period. It can
also say that the nurse is accountable for the education of patient along with members of family
about the ischaemic stroke care, such as stroke’s pathogenesis, treatment rendered, medication,
own risky factor, stroke symptom or sign, utilisation of urgent medical service, along with
approaches to decrease stroke risk in future. In the face of this, it is stated by latest data that
patient, carer as well as family member poorly keep data taught to them in clinic regarding
stroke. The role of nurse in emergency department with acute ischaemic stroke described from
the following points -

REPORT 9
Role of nurses in clinical presentation
The patient presents with abrupt onset of important neurological deficits like facial paresis, arms
drift, legs deficit along with unclear talking. Even though, the sufferer of acute ischaemic stroke
can have headache, vomiting, seizure, depression and other symptoms. The all signs are common
in the patient with haemorrhagic stroke. According to the clinical presentation, it is not easy
make difference between ischaemic stroke as well as other type of stoke. It is required by the
nurses to note duration of stroke. It can say that it is crucial in describing option of treatment.
The nurse should consider the previous medical background of the patient (such as habit of
taking cocaine or heroin). It is also required by nurses to make focus on the vascular risk factor
in past. These factors can be fatness, hypertension, smoking, as well as diabetes. They should
made primary neurological evaluation of the patients in brief. Different stroke scales like
National Institutes of Health Stroke Scale may be applied, as it is helpful in taking decision about
strictness of stroke (Murphy, et. al, 2017). The evaluation of airway, as well as blood circulation
can go before the assessment of stroke patient. The nurses carry out the comprehensive physical
assessment by helping the stroke team of clinician. It can reveal an unbalanced pulse,
bradycardia, heart murmurs, as well as cardiomegaly. Nurses should also evaluate the blood
pressure of patient.
Role of nurses in investigation
Besides conducting fundamental investigation like carotid Doppler, complete blood counting,
test of pregnancy, blood sugar, serum electrolyte, test of urea, serum homocysteine,
PT/PTT/INR, test of liver functions, Haemoglobin AIc, ECG, toxicology screening, cardiac
enzyme, EEG along with brain Computed Tomography or MRI is essential. The nurses make
focus on the single significant investigation to help eliminate the stroke as well as cerebral

REPORT 10
haemorrhage. This settles the diagnosis of ischaemic stroke permitting for quick action of a
situation. The nurses have to be assisted in both Troponin along with cardiac Troponin T. In
addition, the nurses should be associated with stroke severity as well as negative metical results
(Meschia and Brott, 2018).
Role of nurses in general supportive care
The evidence of impacts of nurses-led multidisciplinary interventions on outcome in acute stroke
was rendered by excellence in Acute Stroke Care Trial. It is stated by results that supported
application of three medical protocols for administration of fever, swallowing dysfunction
(sugar, fever as well as swallowing protocol) along with hyperglycemia in initial seventy-two
hours of stroke importantly reduced death as well as dependency by sixteen per cent. It decreased
the temperature, level of blood glucose and advanced swallowing administration. It is evident
that there are certain fundamental trials in stroke healthcare stating that the nursing based on
evidence may decrease the decease along with dependency. In this way, the outcomes from the
trials strengthen the prospective that nursing quality advancement initiative may have dramatic
impacts upon the outcome of patients. The nurses play great role in this. The nurses should make
significant focus on certain points, such as Airway management, hydration, way to control BP,
increased intracranial pressure, controlling level of blood sugar as well as temperature. These are
discussed below
1. Airway management - Coma is unusual in relation to the sufferers of ischaemic stroke.
Patients who have neurological decline with reduced level of consciousness have various issues
in managing the airway because of the loss of protective reflex. It can be resulted into
hypoxaemia (hypercapnia) as well as aspiration. It is argued by Mehta and Watkins (2015) that it
can enhance intracranial pressure by instigating the cerebral vasodilatation. The oxygen therapy

REPORT 11
in ischaemic stroke plays the provocative role. The reason is that it has controversial part because
of the failure of 3 medical trials of hyperbaric oxygen for stating effectiveness. It can see that the
supplemental oxygen may be managed at the dose of 10 L to 15 L per minute if there is sign of
hypoxia. This was shown to slow down the process of ischaemia and extend the therapeutic time
window for thrombolysis. In this situation, there is great role of nurses. The nurses should tell the
patient with great level of depression that it should be intubated to ignore danger of aspiration.
2. Increased intracranial pressure – the nurses should take care of the patients with ischaemic
stroke. This is required that head of bed must be elevated at thirty degree. It can be helpful in
decreasing the Increased intracranial pressure. The nurses should take care of this point in every
situation. Sheth Jahan and Gralla (2015) argued that Infusion of hypertonic saline solution (23
per cent) may be managed at the dosage of 0.5–2.0 ml per kg (Ekkar, et. al, 2017).
3. Hydration – the patient having ischaemic stroke must be hydrated daily with isotonic saline.
It is helpful in making sure proper perfusion to ischaemic penumbra. In addition, it can prevent
infarct extension. Hypotonic solutions is required to be ignored as it can lead to advanced
cerebral oedema. The nurses should have proper knowledge in this relation. They should
maintain the level of glucose to 140 mg/dL to 180 mg/dL (7.8 mmol per leter to 10 mmol per
leter). It can say that the hyperglycemic administration is significant for not only patient having
diabetes, but also the patient with hyperglycemic stroke not considered to contain diabetes
mellitus. Henceforth, the glucose reviewing for the patient with stroke is critical as well as
unnoticed (Hess, et. al, 2017).
4. Administration of blood sugar – the hyperglycaemia takes place in 20 per cent to 40 per cent
of acute stroke sufferers with no past analysis of diabetes mellitus. The overpowering medical
evidence is related to hyperglycaemia at beginning of acute ischaemic stroke having adverse