Access provided by
London Metropolitan University
• To refresh your knowledge of the risk factors for stroke
• To recognise the signs and symptoms of a stroke and the importance of early treatment
• To learn about the various treatment options available for a person who has experienced a stroke
Stroke is a medical emergency, resulting in a significant number of annual deaths in the UK and representing a major cause of disability. Early recognition of the signs and symptoms of stroke is vital to ensure effective and potentially lifesaving treatment. It is important that nurses are able to recognise the risk factors for stroke, as well as being aware of the potential treatment modalities. This article details the signs and symptoms, and risk factors for stroke, as well as outlining the treatment options. The author also explains the important role of nurses in stroke prevention and the long-term care of people who have experienced a stroke and their family members.
Nursing Standard. doi: 10.7748/ns.2021.e11596
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Chauhdry H (2021) Understanding the importance of recognising, treating and preventing stroke. Nursing Standard. doi: 10.7748/ns.2021.e11596
Published online: 11 October 2021
Stroke is a major healthcare concern internationally and within the UK. For example, in 2016, strokes caused over six million deaths worldwide, second only to ischaemic heart disease (World Health Organization 2020). According to the National Institute for Health and Care Excellence (NICE) (2019), there are approximately 100,000 strokes experienced every year in the UK, leading to approximately 38,000 deaths. Also, in recent years, evidence has suggested that the age profile of those who experience stroke was reducing. Public Health England (PHE) (2018) reported that between 2007 and 2016, the average age at which women experience stroke had reduced from 74.5 to 73 years, and in men from 70.5 to 68.2 years. Furthermore, strokes were more common in the 40-69 year age group in 2016 compared with 2007, primarily due to the rise in modifiable risk factors such as obesity and hypertension.
These figures demonstrated that stroke represents a major cause of disability and a substantial cost burden for the UK government. In response, the NHS Long Term Plan (NHS 2019) set out targets for improved recognition of stroke, for example, through brain imaging, an increase in acute treatments such as thrombolysis, and improved aftercare, such as integrated and higher intensity out-of-hospital rehabilitation for people recovering from stroke.
Stroke is a medical emergency and evidence shows that early recognition of the signs and symptoms of stroke is vital for the provision of effective and potentially life-saving treatment (Mellor et al 2015). It has been estimated that for every minute of stroke-related ischaemia a person experiences, they lose approximately two million neurons in the brain, and that initiating treatment 15 minutes faster could improve stroke outcomes by 4% (Saver et al 2013). Evidence has also suggested that the early recognition of stroke and understanding of the need for rapid access to healthcare interventions were variable among the general public, despite public health campaigns aimed at recognising the signs of stroke (Mackintosh et al 2012, Mellor et al 2015).
• A stroke is defined as an interruption to the brain’s blood supply, which causes the death of brain cells and subsequent symptoms that last for more than 24 hours, or lead to death
• Age and hypertension are significant risk factors for stroke. Other risk factors include smoking, the presence of diabetes mellitus, increased waist-to-hip ratio and reduced physical exercise
• Common signs and symptoms of a stroke include acute onset of weakness or numbness on one side of the body, slurred speech, acute onset of blurred vision or loss of vision, and acute onset of confusion or dizziness
• A coordinated and collaborative approach from all healthcare services and staff is required to improve stroke recognition and prevention, and to ensure timely access to effective treatments
A stroke is defined as an interruption to the brain’s blood supply, which causes the death of brain cells and subsequent symptoms that last for more than 24 hours or lead to death. There are two types of stroke – ischaemic and haemorrhagic. An ischaemic stroke occurs when a thrombus (a blood clot that forms in a blood vessel) or an embolism (a blood clot that has travelled from another part of the body) occludes the blood supply to the brain. Approximately 85% of strokes are ischaemic. Alternatively, haemorrhagic strokes occur when the pressure within a blood vessel of the brain becomes too great, often through hypertension, causing the blood vessel to rupture. While only 15% of strokes are haemorrhagic, they are more likely than ischaemic strokes to be fatal (Royal College of Physicians 2016).
Depending on which part of the brain is affected, the ongoing effects of a stroke can negatively affect a person’s mobility, speech and ability to swallow; the muscle tone in their arms, legs and face; their bladder and bowel control; and/or their vision, cognition and personality. A stroke can also cause pain, headaches and fatigue, and lead to depression and self-neglect (Stroke Association 2017). If the left side of the brain is affected by a stroke, the effects will be manifested in the right side of the body, and vice versa.
A transient ischaemic attack (TIA) can be similar to a stroke in presentation. However, unlike a stroke, the symptoms and period of neurological defect (the length of time the brain is affected) will have fully resolved within a 24-hour period, and often within 2-15 minutes of onset (Panuganti et al 2021). TIAs can often go unnoticed, and people therefore do not seek medical attention. This is a concern, however, because 10-15% of those who experience a TIA will go on to have an ischaemic stroke (Khare 2016). Therefore, it is important for nurses to understand that whether someone has a suspected TIA or a stroke, the sooner medical intervention is provided, the greater the chances of minimising the effects.
It is predicted that the number of people aged 45 years and over having a first-time stroke will increase by 59% over the next 20 years, primarily due to an ageing population (Patel et al 2018, King et al 2020). However, while stroke has traditionally been associated with older people due to advanced age being a significant risk factor, recently there has been an acknowledgement that stroke increasingly affects younger people due to the increasing prevalence of diabetes mellitus and hypertension in the young (Boot et al 2020). This has been a recent factor in public health messages, for example, a recent television advert from the Stroke Association (2019a) predominantly featured younger people, including children.
O’Donnell et al (2010) identified age and hypertension as significant risk factors for stroke, as well as the following:
• Smoking.
• Increased waist-to-hip ratio.
• Presence of diabetes.
• Increased alcohol intake (defined as more than 30 drinks per month or ‘binge drinking’).
• Reduced physical exercise.
• Cardiac conditions such as atrial fibrillation.
• Elevated blood cholesterol levels.
Gender and ethnicity are also significant risk factors, with strokes being more common in men compared with women, and people from a South Asian background having a higher prevalence of diabetes, heart disease and hypertension, compared to people from a white background, which contributes to their stroke risk (Banerjee et al 2010). Pregnancy, hormone replacement therapies and the contraceptive pill can also slightly increase the risk of stoke for women (Boardman et al 2015, Roach et al 2015). People who experience social deprivation and lower socioeconomic status also have an increased risk of stroke compared to people with a higher socioeconomic status. This is due to an elevated incidence of modifiable risk factors, including lifestyle choices such as smoking, diet and alcohol intake (Marshall et al 2015). Marshall et al (2015) also noted that those with lower socioeconomic status are less likely to have access to optimal quality healthcare and rehabilitation services.
For nurses, it is important to consider addressing patients’ modifiable risk factors such as smoking and hypertension as early as possible; for example, smoking cessation clinics, medication reviews and advice on healthy eating and exercise are recommended as methods of lowering the risk of stroke (Royal College of Physicians 2016, NHS 2019).
Recognising the signs and symptoms of stroke has long been a challenge due to the variety of symptoms, and a general lack of knowledge among patients and the general public about available treatments and how severe strokes can be (Soto-Cámara et al 2020).
A stroke is a medical emergency that requires rapid access to treatment. Due to advances in stroke treatment such as thrombolysis and thrombectomy, which can reduce the severity of the effect of stroke, recognising the signs and symptoms of stroke promptly is vital. Common signs and symptoms of a stroke include (Stroke Association 2017):
• Acute onset of weakness or numbness on one side of the body.
• Issues with accessing words or slurred speech.
• Acute onset of blurred vision or loss of vision, affecting the eyes, or just one eye.
• Acute onset of confusion or dizziness.
• Acute onset of severe headache.
To increase the awareness of stroke signs and symptoms, PHE (2021) recently relaunched the Act FAST campaign. This was partly in response to a 12% fall in admissions to hospital for stroke between March 2020 and April 2020, which was attributed to the coronavirus disease 2019 (COVID-19) pandemic (PHE 2021). Act FAST assists members of the public to recognise if a person is having a stroke with an easy-to-remember list of symptoms and their effects as follows:
• Face – has the person’s face ‘dropped’ on one side; can they smile?
• Arms – can the person raise their arms and keep them raised?
• Speech – is the person’s speech slurred?
• Time – time to call 999.
If people are able to contact the emergency services quickly using the Act FAST campaign, it provides ambulance staff with the additional time necessary to deliver patients to specialist services such as hyperacute stroke units, rather than taking them to local emergency services.
In recent years, there have been advances in acute stroke treatment such as thrombolysis and thrombectomy, alongside the reconfiguration of stroke services to provide a more regional localised service. The introduction of hyperacute stroke units in some areas – which combine professional specialties such as doctors and specialist stroke nurses into multidisciplinary teams – has meant that more patients are able to receive a timely diagnosis through rapid brain imaging and, subsequently receive increased access to evidence-based clinical interventions such as thrombolysis and thrombectomy. This has led to improved care outcomes (Ramsey et al 2015); for example, Langhorne and Ramachandra (2020) found that when patients who experienced a stroke had been treated in specific stroke units and rehabilitation areas, they were more likely to have survived, be living at home, and have achieved independence in their daily activities one year after experiencing a stroke. However, statistics from the Sentinel Stroke National Audit Programme (SSNAP) and King’s College London (2019), showed that there was still concern over timely access to hospital following a stroke; in 2017-18, for example, there was an average time of over three hours from onset of stroke symptoms to arrival at hospital, an increase of 37 minutes from 2013-14. Therefore, it could be argued that more focus needs to be placed on the ‘time’ aspect of the Act FAST campaign; that is, the need for early recognition and rapid access to hospital treatment.
Thrombolysis uses a so-called ‘clot-busting’ fibrinolytic medicine called alteplase in confirmed cases of ischaemic stroke. Fibrinolytic medicines act as thrombolytics by promoting the formation of plasmin in the body, which degrades fibrin and breaks down the thrombus. Blood flow is thereby restored to the brain, preventing further damage to the brain cells and reducing disability. In the UK, thrombolysis is administered intravenously and is licensed for up to 4.5 hours after the acute onset of stroke symptoms (NICE 2019), hence the need to urgently seek medical treatment.
According to SSNAP and King’s College London (2019), in recent years the number of people receiving thrombolysis following a stroke in the UK has remained consistent at approximately 12%. However, if extra health promotion were undertaken, it is possible that this figure could increase to 20%.
One study examined the data from nine randomised controlled trials into the efficacy of thrombolysis, which showed significant improvement in patients’ conditions and independence when thrombolysis had been administered (Emberson et al 2014). The researchers identified that 485 out of 1,375 patients who had received thrombolysis within 4.5 hours of the onset of stroke symptoms had a positive outcome (defined as no significant disability at 3-6 months following treatment). Reflecting these figures, the NHS Long Term Plan (NHS 2019) recommends an increase in the number of people accessing thrombolysis.
Thrombectomy, or intra-arterial intervention, is a relatively new procedure for confirmed ischaemic stroke. A small catheter is inserted into the groin, usually in the femoral artery, under X-ray guidance and advanced to the occluded artery to mechanically remove the thrombus or debris, restoring blood flow to the brain (NICE 2016). Thrombectomy is most effective when administered six hours after the onset of symptoms. However, the procedure can be undertaken up to 24 hours after onset of symptoms in some rare situations, for example, where brain imaging indicates the presence of salvageable brain tissue and the patient is not eligible for intravenous thrombolysis because they are on anticoagulants or have undergone recent surgery (NICE 2016, NHS England 2019).
The SSNAP (2019) guidance detailed that the amount of people receiving mechanical thrombectomy was rising, and that the treatment could increase positive outcomes by 75%. Due to the potential of thrombectomy to improve health outcomes in people who have experienced a stroke, it is essential that nurses aim to ensure that as many patients as possible understand the benefits of the technique and how to access it. However, further provision of these advanced treatments is required. The number of trusts offering thrombectomy is relatively low and disparities are evident across the country. Also, staffing is often an issue with thrombectomy because it is a challenging technique to undertake, requiring significant skill. This limits the number of units that can offer 24-hour thrombectomy services. Thus, further staff training is required if services are to be expanded (SSNAP 2019).
Thrombolysis and thrombectomy represent effective and evidence-based treatment advances for people who have experienced acute stroke. However, the data show that their availability is not universal (SSNAP 2019). Instead, treatment for acute stroke and secondary stroke prevention more commonly include a range of pharmacological treatments, including but not limited to (Royal College of Physicians 2016):
• Anti-platelet medicines such as aspirin or clopidogrel – these are administered in patients who have experienced acute ischaemic stroke. These medicines are commenced immediately after a stroke or TIA and are also used to prevent secondary stroke.
• Anti-hypertensive medicines such as ramipril – these are administered to control hypertension and thereby contribute to stroke prevention.
Other pharmacological treatments that may be administered at the acute stage and for secondary stroke prevention depend upon the individual’s medical history and presenting symptoms, but may include oxygen therapy, anticoagulants and proton-pump inhibitors, as well as optimal blood glucose control (Royal College of Physicians 2016, NICE 2019).
Along with other healthcare professionals, nurses have a significant role in the treatment of patients who have experienced a stroke. Stroke nurse specialists require detailed knowledge and practical experience of caring for those who have had a stroke. For example, they are often the first to assess patients, as well as having a range of other responsibilities including administering medicines, assisting with interventions such as thrombolysis, and monitoring patients’ recovery (Royal College of Nursing 2021). Stroke nurse specialists also have a role in the community, particularly in monitoring patients’ post-stroke recovery. For example, nurses will often undertake post-stroke reviews and secondary stroke prevention care such as medication reviews and health promotion.
Hickey et al (2018) found that suboptimal knowledge of the available stroke treatments among the general public and failure to respond to signs and symptoms of stroke were the primary reasons for suboptimal rates of access to acute treatment. The researchers found that while members of the general public could recognise the risk factors for stroke, they had minimal knowledge of the available treatments, the potential benefits of those treatments, and of their time-limited nature.
Improved health promotion focusing on the available stroke treatments could assist with overcoming this suboptimal knowledge of stroke among the general public. Nurses should consider using social media platforms to disseminate patient education because these have proved to be an effective tool for behaviour change in other areas of health promotion such as weight management (Jane et al 2018). Similarly, ongoing media campaigns featuring stroke messaging are vital, while Umar et al (2019) suggested that educating children and young people about stoke was a priority, particularly given that children often spend time with their grandparents and that the incidence of stroke among the young is increasing. However, in a study of 50 older patients, Sullivan and Katajamaki (2009) found that patient education measures were only partially effective and were dependent on the individual patient’s view of their susceptibility and personal risk factors for stroke. The researchers suggested that focusing on health beliefs and behaviours, and challenging people to make healthy lifestyle choices, may be beneficial in stroke prevention.
Overall, a coordinated and collaborative approach from all healthcare services and staff is required to improve stroke recognition and prevention, and to ensure timely access to effective treatments. For example, in the author’s clinical experience, when accessing primary care those patients who are deemed to be at high risk of stroke – such as smokers with hypertension – could be provided with Act FAST leaflets and other patient education about reducing risk through the adoption of healthy lifestyles.
Combining improved recognition of stroke, with access to timely acute treatment will potentially reduce the long-term effects of stroke. However, for those who have experienced a stroke, residual challenges may still require management. Long-term effects of stroke depend on the area of the brain affected; for example, if the stroke occurs in the middle cerebral artery, the patient is likely to experience weakness on one side of the body, a facial ‘droop’ and speech deficits (Nogles and Galuska 2020). Common long-term effects of stroke include (Stroke Association 2017):
• Weakness in the arms and legs.
• Challenges with speaking and comprehension such as reading and writing.
• Dysphagia (issues with swallowing).
• Vision disturbances such as hemianopia (partial blindness or loss of vision in one half of the visual field).
• Loss of bladder and bowel control.
• Pain and headaches.
• Fatigue.
• Cognitive deficits, including memory loss and lack of concentration.
• Paraesthesia (so-called ‘pins and needles’).
Following a stroke, many people may not be able to return to work or resume their usual lives, causing significant mental health issues and financial challenges. Connolly and Mahoney (2018) stated that even if the physical and cognitive effects of stroke for an individual are minimal, they can still find it challenging to adjust to life after stroke. For example, psychologically, people can experience feelings of embarrassment, loss of confidence, generalised anxiety and concerns about experiencing further strokes (Platten 2014). Kapoor et al (2019) found that depression and anxiety are common after stroke, and that the younger the stroke survivor, the more likely they were to have generalised depression and anxiety.
Many people who have had a stroke may also find that their relationships with friends and relatives have been negatively affected due to issues with impaired mobility, in turn leading to isolation and depression. It can also be challenging to resume or maintain an interest in a sexual relationship, either due to the physical effects of the stroke or for emotional reasons. Hall (2013) suggested that while the individual’s sexual health needs may not be an immediate factor in their rehabilitation from a stroke, nurses should consider it as part of any ongoing treatment discussions.
While experiencing a stroke can have a long-term effect on patients, it can also significantly affect their family members, with many reporting feeling alienated, insecure and experiencing a sense of ‘losing their grip’ on life as they knew it due to the sudden change in circumstances brought about by a stroke and the ongoing effects (Payne et al 2010). The dynamic of an individual’s family relationships may also change following a stroke; for example, their role may change from partner to patient. When a patient is admitted to hospital, nurses should carefully consider the care needs of family members, including them in any clinical decisions and keeping them up to date with any care changes. Patients and family carers may require support to adapt to a new way of life following a stroke. Platten (2014) found that patients and their carers required more information about the stroke and how they would manage in the future; therefore, nurses should provide the opportunity for supportive conversations, using their listening and communications skills. Nurses may also signpost family members and patients to other forms of available support, such as local stroke survivor and carer clubs.
Recently, the UK government has begun to regard stroke as a national health priority, with challenging targets outlined in the national stroke programme (Stroke Association 2019b). The primary objectives for healthcare staff such as nurses include:
• Providing enhanced education for members of the public on how to prevent stroke through healthy lifestyle choices and earlier recognition of the signs and symptoms of stroke.
• Providing enhanced management of hypertension and increased blood cholesterol levels.
• Ensuring improvements in health inequalities, particularly those associated with ethnicity and socio-economic status.
• Ensuring that 90% of patients who have experienced a stroke receive specialist care in a stroke unit.
• Increasing the numbers of patients who receive thrombolysis and thrombectomy.
• Supporting patients and carers’ self-management following stroke.
Stroke is a medical emergency and recognising the signs and symptoms of stroke quickly is essential if patients are to receive effective treatment. However, the general public’s knowledge of the risk factors of stroke remains variable. To reduce the incidence of stroke, nurses must assist in raising awareness of modifiable risk factors such as reducing smoking, alcohol consumption and hypertension. In addition, specialist stroke nurses can contribute to advanced treatments such as thrombolysis. Following a stroke, nurses also have an important role in providing ongoing support for patients and their family members.
04 September 2024 / Vol 39 issue 9
Nursing care for patients undergoing pelvic exenteration for rectal cancers
Pelvic exenteration is an established surgical procedure...
Oral cancer: diagnosis, management and nursing care
Oral cancer is estimated to be the ninth most common cancer...
Raising public awareness of mouth cancer
The Macmillan head and neck nurse specialist in a large...
Acute stroke management in emergency departments
The introduction of thrombolysis and dedicated stroke units...
Use of tourniquets in combat and civilian trauma situations
The tourniquet as a method of catastrophic haemorrhage...
