The Role of t-PA in Acute Ischemic Stroke Management and Care

This essay examines the clinical problem of treating acute ischemic stroke patients with tissue plasminogen activator (t-PA) to improve neurological outcomes. It discusses the underutilization of t-PA despite its approval and effectiveness, citing reasons such as poor patient education, perceived legal risks by physicians, and inadequate reimbursement. The evidence-based solution highlights studies showing that t-PA enhances recovery from ischemic stroke symptoms and improves long-run survival. The essay also details essential nursing interventions to increase patient awareness, dispel physician fears, and advocate for adequate reimbursement. Furthermore, it emphasizes the critical role of patient monitoring during and after t-PA administration, including neurologic assessments, bleeding checks, and blood pressure management. The FDA's role in approving t-PA and the importance of an acute stroke team are also discussed, advocating for the implementation of guidelines and protocols to refine future stroke care. Desklib offers a wealth of resources, including past papers and solved assignments, to support students in understanding complex healthcare topics.

Running head: ADMINISTERING T-PA 1
Administering t-PA
Name
Institutional Affiliation

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ADMINISTERING T-PA
PICOT Statement:
Do patients with acute ischemic stroke that receive tissue plasminogen activator (t-PA)
versus not receiving thrombolytic agents result in better neurological outcome within 4.5 hours
from symptom onset?"
Clinical Problem
The main clinical problem for this essay is to determine whether the treatment of acute
ischemic stroke patients using t-PA or not leads to better neurological outcome. An alteplase (t-
PA//retavase) is a thrombolytic agent alongside reteplase (r-PA/retavase) and other agents which
is a drug that can dissolve a thrombus or clot and reopen a vein or an artery. This agent can be
used to treat stroke, heart attack, and deep vein thrombosis, occlusion of a peripheral artery,
pulmonary embolism and indwelling catheter. It is a serine protease and converts plasminogen to
plasmin hence breaking down fibrinogen and fibrin as well as dissolve a clot (Lobotesis et al.,
2016).
Nonetheless, t-PA for acute ischemic stroke stays significantly underutilized despite its
approval in 1996 by the US FDA. Three reasons account for this underutilization rates of t-PA
including poor education of patients, perceived risks of legal liability by physicians from adverse
outcomes, and inadequate reimbursement. The new addition of diagnosis-linked grouping code
559 shall give higher payment for patients with stroke treated with t-PA (Mohedano et al., 2017).
Evidence-Based Solution
Administering t-PA has been shown to enhance recovery from ischemic stroke symptoms
by up to fifty percent with a severe low rate of complication. Treating ischemic stroke patients
with intravenous t-PA has been linked to enhanced long-run survival. Schmitz et al. (2014)

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studied 4292 ischemic strokes with 2146 receiving t-PA while 2146 propensity score receiving
matched non-intravenous t-PA. There was a follow-up for a median of 1.40 years. The result
showed that treatment with intravenous t-PA was linked with reduced risk of long-run mortality.
The long-run ischemic stroke recurrent and main bleeding never differed substantially between
the t-PA treated and non-treated groups. The t-PA remains an efficient and effective treatment
for ischemic stroke patients (Schmitz et al., 2014). Various studies have examined functional
outcome alongside mortality at three months following intravenous t-PA treatment and
established that treatment enhanced neurological outcomes but no influence on mortality. The t-
PA in routine clinical practice is connected to improved long-run survival which stresses the
need for ongoing efforts to increase awareness of stroke and to make sure effective organization
alongside acute stroke treatment availability.
Nursing Intervention
The nurses intervene to ischemic stroke patients using tissue plasminogen activator (t-
PA) to improve neurological outcomes. However, the intervention is slowed due to three barriers
presented above. The surveys in the United States population showed that the stroke remained
poor comprehended. Despite the t-PA's efficacy besides cost-effectiveness, treating ischemic
stroke using t-PA still stays underutilized. Nursing intervention needs to go beyond
administering t-PA but focus on increasing patients' awareness to ensure patients have sufficient
information regarding the benefits of t-PA (Ma et al., 2016).
The fear of physicians of being legally liable for t-PA administration should be dispelled
through improved and accurate diagnoses to enhance its use. Further, there is a need for adequate
reimbursement (Lyden, 2015). Nursing can also intervene by increasing education efforts to
boost awareness. Physicians need to be informed that legal risk might be significant for failure to

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administer t-PA than utilizing it. The reimbursement mechanisms including stroke-linked DRG
and CPT codes need to be changed to make t-PA provision less burdensome financially for
providers.
Patient Care
The patient must be monitored as well as managed during and following t-PA
administration. When t-PA is administered, the initial twenty-fours remains critical. The nurse
must observe and often monitor patients for neurologic alterations and any symptoms and signs
of intracranial haemorrhage alongside adverse drug reactions, in the course of recovery. During
t-PA therapy, the nurse performs a neurologic assessment, check main and minor bleeding,
monitor BP, monitor intracranial haemorrhage signs, monitor orlingual angioedema signs,
discontinue the infusion and acquire an emergency CT scan where the patient develops a severe
headache, nausea, acute hypertension, vomiting or worsening neurologic examination (Yang et
al., 2018). Following therapy, the nurse should continue monitoring neurologic deterioration,
check minor or significant bleeding, keep monitoring and controlling BP, and obtain follow-up
CT scan/MRI at twenty-four hours before beginning anticoagulants or antiplatelet agents. Also,
the nurse should continue monitoring signs of orlingual angioedema.
Health Care Agency
The FDA is essential in dealing with t-PA since it is the one approving the use of the
drug. It sets that t-PA needs to be administered within three hours following stroke onset.
Nursing Practice
The patient care after t-PA requires the formation of an acute stroke team for effective
treatment to guide a patient via the acute and hyperacute stages of stroke. The members of the
team include personnel from emergency medical services (EMS), emergency department staff

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members, staff nurses from other areas as required and other people (Kanematsu, Kimura,
Ichikawa & Inoue, 2018). The treatment of stroke using t-PA must follow guidelines, protocols,
pathways, standing orders and prospectively gather data to review and avail guidance as well as
refine future care for stroke.

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References
Kanematsu, R., Kimura, T., Ichikawa, Y., & Inoue, T. (2018). Safety of urgent STA-MCA
anastomosis after intravenous rt-PA treatment: a report of five cases and literature
review. Acta neurochirurgica, 160(9), 1721-1727.
Lobotesis, K., Veltkamp, R., Carpenter, I. H., Claxton, L. M., Saver, J. L., & Hodgson, R.
(2016). Cost-effectiveness of stent-retriever thrombectomy in combination with IV t-PA
compared with IV t-PA alone for acute ischemic stroke in the UK. Journal of medical
economics, 19(8), 785-794.
Lyden, P. (2015). Why don’t more patients receive intravenous rt-PA for acute stroke?, 12(2),
12-45.
Ma, L., Zhang, H., Liu, Y. Z., Yin, Y. L., Ma, Y. Q., & Zhang, S. S. (2016). Ulinastatin
decreases permeability of blood--brain barrier by inhibiting expression of MMP-9 and t-
PA in postoperative aged rats. International Journal of Neuroscience, 126(5), 463-468.
Mohedano, A. M. I., Pastor, A. G., Otero, F. D., Alen, P. V., Montero, M. V., Buzo, E. L., ... &
Núñez, A. G. (2017). Efficacy of new measures saving time in acute stroke management:
A quantified analysis. Journal of Stroke and Cerebrovascular Diseases, 26(8), 1817-
1823.
Schmitz, M. L., Simonsen, C. Z., Hundborg, H., Christensen, H., Ellemann, K., Geisler, K., ... &
Andersen, G. (2014). Acute ischemic stroke and long-term outcome after thrombolysis:
nationwide propensity score–matched follow-up study. Stroke, 45(10), 3070-3072.
Yang, B., Li, W., Satani, N., Nghiem, D. M., Xi, X., Aronowski, J., & Savitz, S. I. (2018).
Protective effects of autologous bone marrow mononuclear cells after administering t-PA
in an embolic stroke model. Translational stroke research, 9(2), 135-145.

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