Stroke patient won't get tPA? Avoid problems

Your next stroke patient may be aware there is a drug called tissue plasminogen activator (tPA), but he or she probably won't realize how few stroke patients are actually candidates for this treatment.

Patients and family members may not have enough time to process all the information that is delivered to them, says F.D. Testai, MD, PhD, assistant professor of neurology at the University of Illinois at Chicago Medical Center, adding that some of the inclusion and exclusion criteria for tPA are subjective.

"Thus, disagreements may occur," he says. "The condition of the patient may change rapidly, making him or her not a good candidate. In this case, withholding treatment after this had been offered may be perceived as though we are unsure on what to do."

To prevent misunderstandings, do these things:

Understand the reasoning behind the decision to offer, or not offer, tPA.

While the ED physician typically makes the decision in consultation with the neurologist, the ED nurse is spending a lot more time at the bedside, says Patricia Gomez, RN, MHA, MBA, administrative director of emergency services at Rush-Copley Medical Center in Aurora, IL.

"As the primary nurse, you should be fully prepared to answer any patient and/or family questions," says Gomez. "If you are not comfortable or don't feel you have the best answer, you should be pulling the ED physician into the conversation."

Patients may wrongly believe there are no other options if they don't qualify for thrombolytics. "Be knowledgeable about all the stroke treatments and modalities available, not only at your facility but the entire area," says Gomez.

Clearly document the reason for not offering tPA, the concerns of the patient/family members, and the information shared with them.

All reasons for not administering tPA should be documented, including contraindications, warnings, refusal by patient or family, or any other reason that resulted in the patient not receiving the thrombolytic, says Debbie Gillen, MSN, RN, CMSRN, stroke program coordinator at Our Lady of Lourdes Medical Center in Camden, NJ. She says that ED nurses should also document:

  • Any discussions with family members regarding the use or non-use of tPA;
  • Any education provided to the patient or family members;
  • Any changes in the patient's condition.

Don't avoid an upset patient.

"If patient or family is demanding tPA, reinforce the risk associated with not strictly following protocol when administering this drug," says Gillen, including the devastating results of bleeding that are more likely to occur when protocol is not strictly followed.

"Risk management should be made aware if a patient or family member feels that appropriate care was not delivered," says Gillen.

Avoiding contact with an upset patient or family member isn't a good approach, warns Testai. "If a nurse runs into this type of situation, even if he or she overhears it, offer the patient or family members the opportunity to have a longer conversation with the treating physician," he says. (See clinical tip, below, on determining when symptoms started.)


For more information on determining if stroke patients are candidates for thrombolytics, contact:

  • Debbie Gillen, MSN, RN, CMSRN, Stroke Program Coordinator, Our Lady of Lourdes Medical Center, Camden, NJ. Phone: (856) 668-8430. E-mail:
  • Patricia Gomez, RN, MHA, MBA, Administrative Director, Emergency Services at Rush-Copley Medical Center, Aurora, IL. Phone: (630) 236-4343. E-mail:
  • F.D. Testai, MD, PhD, Assistant Professor of Neurology, Neurocritical Care and Stroke Section, University of Illinois at Chicago Medical Center. Phone: (312) 996-1047. Fax: (312) 413-8215. E-mail:

Clinical Tip

Use TV show times to ID "last seen normal"

When determining when your stroke patient was last seen normal, ask if he or she remembers something specific that was occurring at the same time, such as a particular TV program or the time he or she went to bed.

"We have had people specifically state that they were last normal when they went to bed after watching the 10:00 p.m. news," says Sandy Hoelzel, RN, stroke coordinator at Resurrection Medical Center in Chicago.