1. Vital Signs

Acute Stroke: Every 15 min until stable, then every 2h x 2, then every 4h thereafter if stable and BP within parameters: SBP 220, DBP 110. If BP exceeds parameters notify physician.

Post TPA: Every 15 min for 2h after starting the infusion, then every 30 min for 6h, then every 60 min up to 24h after starting treatment. Notify MD if: SBP 185 and/or DBP 110 (Two readings 15 min apart).

2. Neuro Checks

Acute Stroke: Neuro checks every 1h x 4, every 2h x 4, and thenevery 4h. Complete CNSS or NIHSS by RN upon admission, every 12h x 2, then every day thereafter. Chart NIHSS #1, #5, and #6 every 1h x 4, every 2h x 4, then every 4h.

Post TPA: Neuro checks per ICU routine (Complete NIHSS and CNSS as per Acute Stroke above)

3. Monitoring

Telemetry x 48 hours–May be Holter monitoring. (Discontinue monitoring ifno arrhythmia or preexisting condition.)

4. Voiding

Indwelling cath to be avoided but if present, discontinue within 48h of insertion time

Straight cath in 4h if necessary (bladder scan prior to check residuals)

Indwelling cath prn after requiring straight cath x 3 (but discontinue indwelling cath in 48h)

Bedpan with assistance

5. Notify MD immediately of

Inability to maintain BP within specified parameters

New or unexplained respiratory distress

Worsening of neurological status

6. Diagnostics

CMP / Blood Glucose (ac and hs) / CT/CTA Brain Scan / Carotid Ultrasound
CBC / CKMB, Troponin / MRI/MRA Brain / Hemoglobin A1c
PT/INR, PTT / Fasting Lipid Profile / Echocardiogram / Electrocardiogram daily x 3

7. Medications/Interventions

Saline Lock or IV Fluids(Avoid dextrose containing solutions)Oxygen per nasal cannula at 2 L/min to maintain saturation92%

8. DVT Prophylaxis:

Early mobilizationIntermittent pneumatic compression stockings

Subcutaneous unfractionated heparinSubcutaneous low-molecular-weight heparin (LMWH)

9. Stress Ulcer Prophylaxis:

Proton Pump Inhibitors orally, per nasogastric tube or intravenous

10. Stroke Prevention:

Aspirin 325 mg one time loading dose (if not on antiplatelet therapy) (hold for 24 hours after thrombolytic therapy and no signs of ICH on post tPA CT) then, ASA 80-325 mg daily. If patient NPO, give per enteral tube or rectal suppository.

Warfarin orally every evening if atrial fibrillation or known cardiac source of stroke, started only after repeat CT evaluation or neurologist recommendation.

11. Other Medications

Acetaminophen orally or per rectum every 4-6 h prn temp > 37.5° C

12. Nutrition

STRICT NPO until bedside swallow screen or patient seen and evaluated by speech–language pathology

Advance diet per organizational recommendations

13. Activity

No lifting or pulling of patient via the shoulder on affected side

14. Consults

Case Management / PT, SLP, OT (and begin treatment as appropriate)
Neurology Consultation with Physical Medicine and Rehabilitation Consultation

Date______Time______Physician Signature______

All references to identification, medications and treatment options are partial edited guides, not endorsements and should be only administered as ordered by a physician or practitioner only when patients allergies, contraindications, risk factors, symptom response, time considerations, etc. are addressed. The interventions / recommendations offered by this course are general guidelines only and are not intended to replace physician order, current guidelines or organizational policy. Healthcare professionals should follow approved current treatment guidelines and policies.