Code Stroke Triage, Last Known Well, and Initial Assessment
Key Takeaways
- Code stroke activation should occur as soon as a new focal deficit is suspected, not after imaging confirms ischemic stroke.
- Last known well is the last time the patient was at neurologic baseline; time of symptom discovery is documented separately.
- The initial nursing sequence is airway and safety, rapid stroke screen, glucose, vital signs, last-known-well clarification, stroke-team notification, and imaging readiness.
- Posterior circulation symptoms such as sudden imbalance, diplopia, dysphagia, or decreased consciousness can be time-critical even when a face-arm-speech screen is incomplete or subtle.
- Aspirin, oral intake, and routine admission tasks should not delay hemorrhage exclusion, thrombolytic screening, or thrombectomy evaluation.
Why the first minutes matter
A code stroke is a workflow emergency. The nurse's job is to recognize a possible stroke, protect immediate physiologic needs, and move the patient toward rapid imaging and expert decision-making. Do not wait for a complete history, bed assignment, or provider evaluation before using the local activation pathway when the presentation is compatible with acute stroke.
The safest SCRN answer usually preserves two ideas at once: stabilize life threats and do not waste brain-saving time. If the patient has airway compromise, hypoxemia, seizure activity, or severe instability, address that immediately while calling for help. If the patient is stable but has sudden focal deficits, the priority is stroke activation, focused assessment, glucose, last-known-well clarification, and transport to imaging.
Last known well is not symptom discovery
Last known well (LKW) means the last time the patient was known to be at neurologic baseline. If a patient wakes at 0700 with aphasia and was normal at 2230 before sleep, LKW is 2230. The time symptoms were discovered is also important, but it does not replace LKW for treatment-window decisions.
Witnesses matter. EMS, family, caregivers, facility staff, and medication records may be the only reliable sources. Ask concrete questions: When was speech normal? When did the patient walk normally? Was the weakness present on awakening? Did symptoms fluctuate? Did the patient have seizure, fall, trauma, anticoagulant use, or recent surgery?
| Data the nurse obtains | Why it changes the pathway |
|---|---|
| Exact LKW and discovery time | Determines thrombolytic and imaging-selection windows |
| Baseline function | Helps judge disability and thrombectomy candidacy |
| Anticoagulants and last dose | Changes bleeding-risk screening and labs |
| Recent surgery, bleeding, trauma | Raises contraindication concerns |
| Current deficits and severity | Guides NIHSS, LVO suspicion, and escalation |
| Family or surrogate contact | Supports history, consent, and transfer logistics |
Initial assessment without delay
Use a validated stroke screen, then move into focused neurologic assessment. BE-FAST captures balance, eyes, face, arm, speech, and time; Cincinnati Prehospital Stroke Scale focuses on facial droop, arm drift, and speech. A negative or incomplete quick screen does not clear the patient when the story suggests posterior circulation stroke, isolated aphasia, severe neglect, visual field loss, or sudden decreased consciousness.
Keep the patient NPO until swallowing safety is assessed. Do not give aspirin or other antithrombotics before hemorrhage is excluded and the reperfusion plan is clarified. Establish IV access, obtain ordered labs without delaying imaging, check weight when needed for medication verification, and place the patient on monitoring according to protocol.
Handoff that helps the team act
A useful code-stroke handoff is short and decision-focused: age, LKW, discovery time, baseline function, presenting deficits, glucose, vital signs, anticoagulants, allergies, recent procedures or bleeding, and whether family is available. Closed-loop communication matters. If the patient is headed to CT, the nurse should know who is transporting, who is monitoring, and who is notifying neurology, radiology, pharmacy, and transfer resources if needed.
For SCRN questions, avoid answers that treat code stroke like routine triage. The correct priority usually keeps the system moving while the nurse collects the facts that make thrombolysis, thrombectomy, or hemorrhage management safer.
A patient arrives with sudden aphasia and right arm weakness that began 55 minutes ago. The airway is patent and oxygen saturation is 96%. What is the best nursing priority?
A patient is found at 0700 with new left-sided weakness after going to bed normal at 2230. What should the nurse document as last known well?
Which triage action is most unsafe for a patient with suspected acute stroke before brain imaging?