Stroke: Ischemic vs Hemorrhagic, tPA Windows and Nursing Priorities

Two very different emergencies share one name. Everything the nurse does next depends on which one it is — and the whole point of the priority intervention, the CT scan, is to tell them apart before a drug that saves one type makes the other catastrophically worse.

Step 1 — The two types, and why the difference decides everything

This is the whole reason the CT scan is the priority intervention. Every item that asks “what must occur before administering alteplase” has the same answer: imaging to exclude haemorrhage.

Step 2 — Recognise it: FAST, and the time that matters

Face drooping · Arm weakness · Speech difficulty · Time — establish when the client was last known well.

“Time of onset” is not when the symptoms were noticed; it is the last moment the client was seen at their normal baseline. A client who wakes with a deficit has an onset time of the previous night, not the morning — and that single fact often removes them from the thrombolytic window.

Step 3 — Left brain vs right brain

The safety consequence is the tested point: a right-hemisphere stroke produces an impulsive client who does not believe they are weak. That combination is the highest fall risk on the unit, and it is why the answer to “which client needs the closest supervision” is often the one who seems least distressed. For neglect, place objects and approach from the unaffected side at first, then gradually teach the client to scan toward the neglected side.

Step 4 — Thrombolytics: the window and the exclusions

Alteplase is given for ischemic stroke within 3 hours of last known well, extended to 4.5 hours in selected clients. Mechanical thrombectomy extends the treatable window considerably further in large-vessel occlusion, which is why rapid transfer to a stroke centre matters even outside the drug window.

After the infusion: no anticoagulants or antiplatelets for 24 hours, no invasive lines or injections where avoidable, neurological checks and blood pressure at frequent intervals, and immediate escalation for a sudden headache, vomiting, rising blood pressure or falling consciousness — these mean bleeding.

Step 5 — Nursing priorities on the unit

• Swallow screen before anything by mouth. No water, no food, no oral tablets until it is passed — aspiration pneumonia is the most common preventable complication after stroke.
• Positioning: head of bed elevated unless otherwise ordered; head and neck midline.
• Neurological checks at the ordered frequency — a change in level of consciousness is the earliest sign of deterioration.
• Communication: with aphasia, allow time, use short sentences, yes/no questions, pictures or a communication board. Do not raise your voice — the deficit is language, not hearing.
• Affected limb care: support the arm, reposition regularly, prevent shoulder subluxation and contractures.

If pressure inside the skull begins to rise — deteriorating consciousness, vomiting, pupil changes — the priorities change again toward managing increased intracranial pressure.

Educational use only: this article supports nursing review and does not replace clinical judgment, facility protocols, or instructions from an authorised prescriber.

NCLEX tip: If a stroke stem offers “check a blood glucose” among the first actions, it is rarely a distractor — hypoglycaemia produces an identical picture and is corrected immediately. And any option that gives fluids, food or oral medication before a documented swallow screen is wrong, however reasonable it sounds.