8.4 Stroke and TIA: FAST Recognition, Acute Care & Rehabilitation
Key Takeaways
- RCSI lists stroke under both cardiac-vascular reading and chronic disease management OSCE examples, citing the Irish Heart Foundation FAST campaign and caring for a person affected by stroke.
- FAST stands for Face, Arms, Speech, Time to call 112 or 999; sudden onset of any one of these findings is treated as a stroke until proven otherwise.
- Ischaemic stroke accounts for the large majority of strokes; a non-contrast CT brain is needed urgently to exclude haemorrhage before thrombolysis, and no aspirin is given until haemorrhage is excluded.
- Blood pressure is not lowered in acute ischaemic stroke unless it exceeds about 220/120 mmHg, or 185/110 mmHg where thrombolysis is planned, because permissive hypertension preserves perfusion of the ischaemic penumbra.
- A capillary blood glucose must be checked immediately in any suspected stroke because hypoglycaemia is a common stroke mimic, and swallow screening must be completed before any oral food, fluid or medication.
Stroke and TIA: FAST Recognition, Acute Care & Rehabilitation
Stroke appears twice in RCSI's published material: in the cardiac-vascular reading group - where it cites the Irish Heart Foundation's FAST campaign, Caring for a Person Affected by a Stroke, and INTERSTROKE research on stroke triggers - and again as a current example for the chronic disease management OSCE station. Expect it both as a theory topic and as a scenario in which you must teach, assess or plan care.
Definitions
- Stroke: an acute focal neurological deficit caused by interruption of the cerebral blood supply, lasting more than 24 hours or leading to death.
- Transient ischaemic attack (TIA): the same clinical picture resolving completely, usually within an hour, without infarction. A TIA is a warning, not a reassurance - the risk of completed stroke is highest in the days immediately afterwards, so a TIA requires urgent assessment, not a routine appointment.
- Ischaemic stroke (the large majority): thrombotic or embolic occlusion, commonly cardioembolic from atrial fibrillation.
- Haemorrhagic stroke: intracerebral or subarachnoid bleeding. It cannot be distinguished from ischaemic stroke on clinical grounds - only on imaging.
Recognition: FAST
| Letter | Sign | How to test |
|---|---|---|
| F - Face | Has the face fallen on one side? Can the person smile? | Ask the person to smile or show their teeth; look for asymmetry |
| A - Arms | Can the person raise both arms and keep them there? | Ask them to lift both arms; watch for unilateral drift |
| S - Speech | Is speech slurred, or can the person speak at all? Do they understand you? | Ask a simple question; ask them to repeat a short sentence |
| T - Time | Time to call 112 or 999 immediately if any single sign is present | Note and record the time of onset or the time the person was last seen well |
The onset time is a clinical datum, not an administrative detail. Thrombolysis eligibility depends on it, and for a patient who wakes with symptoms the relevant time is when they were last seen well.
Signs FAST does not capture, which still require an emergency response: sudden severe headache described as the worst ever (subarachnoid haemorrhage), sudden visual loss, sudden vertigo with ataxia, sudden confusion, and sudden numbness on one side.
Immediate Nursing Priorities
- ABCDE assessment. Protect the airway; a reduced conscious level or bulbar weakness threatens it. Position to protect the airway and give oxygen only if hypoxaemic.
- Capillary blood glucose immediately. Hypoglycaemia is the classic stroke mimic and is instantly reversible - failing to check it is an examinable error. Other mimics include seizure with Todd's paresis, migraine with aura, sepsis and hyponatraemia.
- Full observation set and INEWS, including ACVPU; a new deficit with altered consciousness is an emergency response.
- Activate the stroke pathway and escalate for urgent non-contrast CT brain to distinguish ischaemic from haemorrhagic stroke.
- Nil by mouth until a swallow screen is completed - no food, no fluids, and no oral medication.
- Establish IV access, take bloods including coagulation screen, obtain an ECG (looking for atrial fibrillation), and record a baseline neurological assessment using GCS and limb power.
Swallow Screening
Dysphagia after stroke is common and aspiration pneumonia is a leading cause of avoidable death. Until a trained screener has assessed swallowing:
- Strictly nil by mouth, including sips of water and oral tablets.
- Escalate promptly for screening; prolonged unnecessary fasting is itself harmful.
- Where swallow is unsafe, medicines must be reviewed and re-prescribed by an appropriate route - never crushed and given in defiance of a nil-by-mouth order.
- Refer to speech and language therapy; involve dietetics and consider enteral feeding if unsafe swallow persists.
- Maintain scrupulous mouth care - a dry, colonised mouth increases pneumonia risk in a patient who is not eating or drinking.
Blood Pressure in Acute Stroke
This is counter-intuitive and frequently tested.
In acute ischaemic stroke, a raised blood pressure is usually a compensatory response maintaining perfusion of the ischaemic penumbra - the tissue around the infarct core that is underperfused but still viable. Lowering it abruptly can extend the infarct.
| Scenario | Approach |
|---|---|
| Acute ischaemic stroke, no thrombolysis planned | Permissive hypertension. Blood pressure is generally not lowered unless it exceeds approximately 220/120 mmHg |
| Thrombolysis planned or given | Blood pressure must be controlled to below approximately 185/110 mmHg before and maintained after, because of haemorrhagic transformation risk |
| Haemorrhagic stroke | More active blood pressure lowering, directed by the medical team |
The nurse's role is to measure accurately and frequently, record, and escalate - not to withhold or administer antihypertensives on their own initiative. Regular antihypertensives are commonly withheld in the acute phase pending medical review, which must be a documented decision.
Antiplatelets and Anticoagulants
No aspirin, no antiplatelet and no anticoagulant until haemorrhage has been excluded on imaging. Giving aspirin to a patient with an intracerebral bleed is catastrophic. Once ischaemic stroke is confirmed and thrombolysis considerations allow, antiplatelet therapy is commenced as prescribed.
Ongoing Nursing Care
| Domain | Priorities |
|---|---|
| Neurological | Regular GCS and limb power; report any deterioration immediately, as it may signal haemorrhagic transformation or cerebral oedema |
| Positioning | Support the affected limb; avoid pulling on a flaccid shoulder during transfers, which causes subluxation and long-term pain |
| Skin | High pressure injury risk from immobility and sensory loss; apply the SSKIN bundle and reposition |
| VTE | High risk; anti-embolism stockings are contraindicated after stroke because of evidence of harm, so intermittent pneumatic compression and pharmacological prophylaxis are used as prescribed |
| Continence | Assess rather than catheterise reflexively; an indwelling catheter brings CAUTI risk and undermines rehabilitation |
| Nutrition | MUST screening, food and fluid charts, dietetic referral |
| Communication | Distinguish dysarthria (weak articulation, intact language) from aphasia (impaired language). For expressive aphasia, allow time, use closed questions, offer picture or writing aids, and never finish the person's sentences |
| Mood | Post-stroke depression and emotional lability are common and under-recognised; screen and refer |
| Neglect | With non-dominant hemisphere stroke, the person may ignore the affected side entirely - approach from the unaffected side initially, then work to reintegrate awareness as rehabilitation progresses |
Secondary Prevention and Rehabilitation
Modifiable risk factors are the substance of a teaching or discharge station:
- Atrial fibrillation - anticoagulation dramatically reduces cardioembolic stroke risk; adherence education is essential.
- Hypertension - the single largest population risk factor, and the reason ambulatory monitoring appears on RCSI's reading list.
- Smoking cessation, alcohol within low-risk limits, physical activity, weight management and a healthy diet - the HSE Chronic Disease Management Programme and the food pyramid both belong here.
- Diabetes and lipid management as prescribed.
Rehabilitation is multidisciplinary and starts on day one: physiotherapy, occupational therapy, speech and language therapy, dietetics, medical social work, and the stroke clinical nurse specialist. Early mobilisation as tolerated counters deconditioning; the HSE Get Up, Get Dressed, Get Moving approach applies directly. Discharge planning should begin at admission and must include the carer, home supports, the public health nurse, equipment and follow-up.
A 71-year-old man develops sudden left-sided weakness and slurred speech. He is drowsy, and his blood pressure is 196/104 mmHg. Which action must be taken first?
Three days after an ischaemic stroke, a patient remains immobile with a dense hemiparesis. Which venous thromboembolism prevention measure is contraindicated?
A patient recovering from a left-hemisphere stroke understands instructions but produces only single words with visible effort. Which communication approach is most appropriate?