📚 Deeper Dive · Scenario 47 of 57

The Face That Drooped, In Depth

Stroke recognition (BE-FAST) & response — the why behind "time is brain"
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Coach Katie
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A stroke is a race against the clock

You walk in and Mr. Nwosu looks different: one side of his face droops, his right arm drifts down, his speech is slurred — and it came on suddenly, minutes ago. This is a possible stroke, and the single most important idea is that brain tissue is dying by the minute. "Time is brain."

Think of the brain like a garden fed by a network of hoses (arteries). A stroke is a kinked or blocked hose — the section of garden it feeds starts to wilt immediately. The faster you restore the flow, the more of the garden survives. Every minute of delay loses more ground, permanently.

BE-FAST

The BE-FAST tool makes the sudden warning signs impossible to forget: Balance (sudden loss of balance or coordination), Eyes (sudden vision loss or change), Face (drooping on one side), Arms (weakness or one arm drifting down), Speech (slurred or trouble speaking), Time (call for help immediately and note the last known well time). Any one of these is a red flag.

The 'BE' catches what 'FAST' can miss. The older FAST tool covers face, arms, speech, and time — but FAST alone can miss up to about 14% of strokes. Adding Balance and Eyes catches posterior-circulation strokes that don't show the classic face-and-arm picture — so use BE-FAST.

Why the last-known-well time matters

The most effective stroke treatments must be given within a limited window from when symptoms began, and the last-known-well time drives that window. Clot-dissolving (thrombolytic) drugs are given early, but the window can stretch much further for the right patient — select thrombectomy candidates can be treated up to 24 hours from last known well. That's why you note and report the last time the patient was known to be normal — it tells the stroke team how much time they have and which treatments are possible. Note too that only a blood glucose check is required before thrombolytics — the team won't delay treatment waiting on other labs beyond protocol. Don't wait to see if it improves; even brief improvement doesn't change the urgency.

The nurse's role

Recognize the signs, activate the stroke response immediately, establish the last-known-well time, keep the patient NPO (swallowing may be impaired — aspiration risk — and urgent procedures may be needed), monitor closely, and stay. Don't give food, drink, or medications on your own — the team decides treatment after assessment and imaging.