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Don't let 'stroke mimics' delay your patient's care
Perform a quick rule-out
A patient's altered mental status could turn out to be a stroke, but on the other hand, someone with unilateral weakness might end up being a post seizure patient.
"Stroke mimics can be tough, to say the least," says Anne D. Leonard, RN, BSN, senior clinical research nurse at The University of Texas Health Science Center at San Antonio. "When working with a potential stroke patient, do all that you should do. Then be glad for the patient if it ends up being a stroke mimic."
Stroke mimics specifically are addressed in a new scientific statement for nursing care of stroke patients from the American Heart Association.1 "The guidelines underscore the urgency of stroke care," says Leonard, one of the authors.
Here are ways to improve assessment of possible stroke mimics:
Obtain a thorough history, including onset of symptoms and medical history.
Ask about history of diabetes, cancer, hypertension, seizures, and whether the patient has ever taken an antileptic. "A CT scan will show some of this, but it is important to act fast in order that you don't miss something," says Leonard. "And get your ED physician to act fast as well."
Obtain certification in the National Institutes of Health Stroke Scale (NIHSS).
"A key part of the diagnosis of stroke is to have a good neuro exam. The NIHSS, if done well, is a very nice tool," says Leonard. "It gives the operator key information about the presence of lateralizing symptoms, right brain or left brain, that may be stroke."
Look for factors that increase the likelihood of stroke.
These include cognitive impairment, an exact time of onset, definite focal neurological symptoms, abnormal vascular findings such as hypertension, atrial fibrillation, and valvular heart disease. "If these are not necessarily present, then it could be a stroke mimic," says Leonard. "It then becomes a process of elimination."
Rule out mimics
Dawn Williams, RN, BSN, CEN, an ED nurse at Porter Adventist Hospital in Denver, says that the most common conditions she sees that can mimic a stroke are hypoglycemia, migraines, seizures, and Bell's Palsy.
Hypoglycemia can present as sudden onset of confusion, weakness, and sometimes changes with speech, says Williams, while migraines can cause change in vision and size of pupils along with focal headaches. "We always check blood glucose to rule out hypoglycemia right away. This can be done quickly, often before CT is even notified," says Williams.
Seizures also can mimic stroke. "They seem straightforward because many times they are witnessed," says Williams. "But the postictal phase, especially in the elderly, can mimic unilateral weakness, confusion, and/or speech abnormalities."
Initially, a 70-year-old man's wife told triage nurses he was having an allergic reaction because his skin was red all over. "As the triage nurse asked questions, the patient was repeating the same three words over and over," says Williams. "Luckily our CT scan was open. We had him in within the first 10 minutes. The patient received t-PA within 21 minutes."
Within 10 minutes of administration, the patient was speaking in full sentences. "It was awesome!" says Williams. "If it wasn't for the triage nurse's assessment, this patient could have had a totally different outcome. By the time the patient was discharged, he had absolutely no deficits."
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Do fast, easy check to rule out a stroke
Dawn Williams, RN, BSN, CEN, an ED nurse at Porter Adventist Hospital in Denver, gives this "fast and easy assessment" to distinguish a stroke from Bell's Palsy: Ask a patient to raise their eyebrows.
"If they are having a stroke, the eyebrow will rise. With Bell's Palsy the eyebrow doesn't rise, because the seventh cranial nerve is affected," says Williams. "We just had a patient last week that had Bell's Palsy. Although we still did a CT, we did not call a stroke alert."
To meet stroke times, think of relay race
ED nurses "are undergoing a paradigm shift getting the patient through the diagnosis and assessment phase as if the patient was being worked up for a STEMI [ST-elevation myocardial infarction], says Anne D. Leonard, RN, BSN, senior clinical research nurse at the University of Texas Health Science Center at San Antonio. "This requires a real change in thinking."
Protocols with time parameters help you to reach the door-to-needle time within 60 minutes, says Leonard. She says to think of the continuum of care for the acute stroke patient as a relay race:
The first leg. The ED staff quickly runs to get the needle to the patient within 60 minutes, if the patient is eligible for tissue plasminogen activator or another acute interventional procedure.
Second leg. The ED nurse hands the baton to the intensive care unit (ICU) staff for at least 24 hours.
Third leg. The ICU staff hands the baton to the step-down unit for continued care. "Lastly, the step-down unit hands the baton to the rehab folks for the last of the race, to get our stroke patients back to baseline as much as possible," says Leonard.