Guide — Critical Care
Stroke Nursing Essentials
Ischemic vs. hemorrhagic stroke, the NIHSS, thrombolytics and thrombectomy basics, blood pressure management, nursing priorities, and what to monitor after acute stroke intervention.
13 min read · Critical Care
Educational use only. Acute stroke management requires rapid, physician-directed decision-making. This content is for learning purposes and does not substitute institutional stroke protocols or clinical judgment. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Stroke Types
Stroke occurs when cerebral blood flow is interrupted, causing neuronal death. The distinction between ischemic and hemorrhagic stroke is critical because their management diverges sharply — what treats one can kill a patient with the other.
A transient ischemic attack (TIA) is a temporary focal neurological deficit that resolves completely within 24 hours (often within minutes) with no infarction on imaging. TIAs carry high risk of subsequent completed stroke, especially within the first 48–72 hours, and require urgent evaluation.
Ischemic vs. Hemorrhagic Stroke
| Feature | Ischemic | Hemorrhagic |
|---|---|---|
| Mechanism | Blockage of cerebral artery (thrombus or embolus) — no blood flow to downstream tissue | Rupture of cerebral blood vessel — blood accumulates and compresses surrounding tissue |
| Prevalence | ~87% of all strokes | ~13% of all strokes (higher mortality) |
| Onset | Often during sleep or on waking; activity or rest | Frequently during exertion; sudden severe headache common |
| Headache | Less common; usually mild if present | Severe ('worst headache of life'); common in SAH |
| Key imaging | CT: no blood (initially). DWI MRI: restricted diffusion early | CT: hyperdense (bright white) blood immediately visible |
| Thrombolytics (tPA) | May be indicated within 3–4.5 hours of symptom onset if no contraindications | Absolutely contraindicated — would worsen bleeding |
| BP management | Permissive hypertension to preserve penumbra (unless tPA given: <180/105) | Active BP lowering often targeted (SBP <140–160 per protocol) |
NIHSS Overview
The National Institutes of Health Stroke Scale (NIHSS) is a standardized 11-item neurological assessment that quantifies stroke severity, guides treatment decisions, and tracks clinical change over time. It is scored 0–42; higher scores indicate greater deficit.
| NIHSS Item | Scoring Summary |
|---|---|
| 1a. Level of consciousness | 0 = alert; 1 = drowsy; 2 = stuporous; 3 = comatose |
| 1b. LOC questions (month/age) | 0 = both correct; 1 = one correct; 2 = neither correct |
| 1c. LOC commands (open/close hand) | 0 = both; 1 = one; 2 = neither |
| 2. Best gaze | 0 = normal; 1 = partial palsy; 2 = forced deviation |
| 3. Visual fields | 0 = no loss; 1 = partial hemianopia; 2 = complete; 3 = bilateral blindness |
| 4. Facial palsy | 0 = normal; 1 = minor; 2 = partial; 3 = complete |
| 5a/5b. Motor arm (L/R) | 0 = no drift; 1 = drift; 2 = some effort vs gravity; 3 = no effort; 4 = no movement |
| 6a/6b. Motor leg (L/R) | 0 = no drift; 1 = drift; 2 = some effort vs gravity; 3 = no effort; 4 = no movement |
| 7. Limb ataxia | 0 = absent; 1 = one limb; 2 = two limbs |
| 8. Sensory | 0 = normal; 1 = mild loss; 2 = severe loss |
| 9. Best language | 0 = normal; 1 = mild aphasia; 2 = severe aphasia; 3 = mute/global |
| 10. Dysarthria | 0 = normal; 1 = mild; 2 = severe or mute/intubated |
| 11. Extinction/inattention | 0 = none; 1 = partial; 2 = profound |
| Total Score | Severity |
|---|---|
| 0 | No stroke symptoms |
| 1–4 | Minor stroke |
| 5–15 | Moderate stroke |
| 16–20 | Moderate to severe stroke |
| 21–42 | Severe stroke |
Reperfusion Strategies
IV Alteplase (tPA)
Tissue plasminogen activator dissolves the clot by activating plasminogen. Must be given within 3 hours (in selected patients up to 4.5 hours) of last known well. Time is brain — delays in administration worsen outcomes.
Key contraindications:
Mechanical Thrombectomy
Endovascular removal of the clot using a stent retriever or aspiration catheter. Indicated for large vessel occlusion (LVO) in select patients, generally within 6–24 hours depending on imaging criteria. Nurses monitor post-procedure for access site complications, neurological changes, and blood pressure management.
Blood Pressure Management in Stroke
| Scenario | BP Target | Rationale |
|---|---|---|
| Ischemic stroke — no tPA, no LVO intervention | Allow up to 220/120 | Permissive hypertension preserves perfusion to ischemic penumbra (tissue at risk but not yet dead) |
| Ischemic stroke — tPA given | <180/105 mmHg | Hypertension after tPA greatly increases hemorrhagic transformation risk |
| Ischemic stroke — post-thrombectomy | <180/105 mmHg (or per order) | Reperfusion injury risk; aggressive BP lowering may be ordered |
| Hemorrhagic stroke (ICH) | SBP <140–160 mmHg | Reduces hematoma expansion and re-bleeding risk |
| Subarachnoid hemorrhage (SAH) | Maintain systolic 100–140 (pre-clip/coil) | Balance re-bleeding prevention vs. vasospasm risk; varies by phase of care |
Nursing Priorities in Acute Stroke
| Priority | Rationale |
|---|---|
| Obtain IV access (×2 large-bore) | tPA administration and rapid fluid/medication delivery |
| Continuous cardiac monitoring | Atrial fibrillation is a common stroke etiology; arrhythmias may emerge |
| Strict NPO until swallow screen | Dysphagia is common; aspiration risk is high in acute stroke |
| Frequent neuro checks (q1–2h) | Detect hemorrhagic transformation, herniation, or worsening deficit |
| Blood glucose monitoring | Hyperglycemia worsens neurological outcomes; hypoglycemia mimics stroke |
| Avoid bladder catheterization if possible | UTI increases risk of neurological worsening |
| HOB at 0–30° (ischemic stroke, unless airway issue) | Flat positioning may improve cerebral perfusion in large vessel occlusion; elevate only for airway concerns |
| HOB 30–45° (hemorrhagic stroke) | Promotes venous drainage and reduces ICP |
| Temperature management | Hyperthermia worsens neurological outcomes — treat fever aggressively |
Post-Stroke Monitoring
NCLEX Pearls
tPA is absolutely contraindicated in hemorrhagic stroke. Always confirm stroke type on CT before any thrombolytic discussion.
For ischemic stroke without tPA, permissive hypertension (allow BP up to 220/120) preserves perfusion to the ischemic penumbra.
After tPA administration, BP must be maintained <180/105 mmHg — hypertension risks hemorrhagic transformation.
The 3–4.5 hour time window for tPA starts at 'last known well' — not time of discovery.
Dysphagia is present in up to 50% of stroke patients. Perform a swallow screen before allowing oral intake.
Atrial fibrillation is the most common cardiac cause of embolic ischemic stroke.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Society of Critical Care Medicine (SCCM) · Surviving Sepsis Campaign · American Association of Critical-Care Nurses (AACN). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →