Acute Ischemic Stroke with tpa

Transcription

1 Admission/Condition/Diagnosis Admission: Admitting Physician Attending Physician Assign to Inpatient Status Transfer to Level of Care: Physician MUST document in notes the risk, severity, and skilled nursing need of the patient to justify the status below. ICU Stroke unit Diagnosis: Ischemic Stroke tpa Given Condition: Critical Stable Guarded Consult neurologist (Reminder: Physician to Physician is required) Vital Signs For ICU Patients Vital Signs including abbreviated NIHSS for the first 24 hours. (Q15MIN for 2 hours, then Q30 min for 6 hrs, then QHR for 16 hrs) + Vital Signs & Neuro checks Q1hr and NIHSS Qshift, with neurological changes and at discharge after the first 24 hours For Non ICU Patients Vital Signs including abbreviated NIHSS for the first 24 hours.(q 15min for 2 hours, then Q 30min for 6 hours, then QHR for 16 hours) + Vital Signs & Neuro checks Q4hr and NIHSS Qshift, with neurological changes and at discharge after first 24 hours Core Measure Orders To Include: Mechanical VTE Prophylaxis Core Measure Compliance Orders ( By checking you are ordering the orders listed on page 6) MUST order Intermittent Pneumatic Compression ( IPC) or select or document contraindication No Mechanical Prophylaxis due to: Sequential Compression Device Knee High Amputee Congestive heart failure Patient non-compliant-refused intervention/support. Right AKA Burn to lower limb Mechanical prophylaxis refused (Required) Left AKA Dermatitis o Intermittent pneumatic calf-thigh compression Right BKA Hypervolemia o Venous foot pump Left BKA Deformity of leg Injury to lower extremity Sensory neuropathy Peripheral Vascular Disease Suspected deep vein thrombosis of lower extremity Peripheral ischemia Clouded consciousness Vascular insufficiency of limb Surgical procedure of lower extremity Patient enrolled in clinical trial Edema of leg Lower limb ischemia History of occlusive disease of artery of lower extremity At risk for falls Comfort care management Aspiration Precautions ORDERSET #:ST-BH08 Page 1 or 6 Published: v-4 April 15, 2014 Approved FEBRUARY 2014

2 Core Measure Medications A. Antiplatelet Do not give antiplatelet for 24 hours post TPA infusion and no hemorrhage on repeat imaging study Aspirin 81 mg 325 mg Oral Daily to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt Dipyridamole Aspirin [Aggrenox] 200mg-25mg SR Cap PO BID to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt Clopidogrel [Plavix] Tab 75mg Oral Daily to start in 24 hours or Aspirin 300 mg Suppository PR daily for NPO pt Medication not needed/indicated (Document reason) B. Anticoagulant: For atrial fibrillation or atrial flutter (current or history of) Do not give anticoagulant for 24 hours post TPA infusion and no hemorrhage on repeat imaging study Warfarin [Coumadin] mg Oral Daily to start tomorrow at 2100 Medication not needed/indicated + Other Anticoagulant/Antithrombotic Medications Enoxaparin [Lovenox] and Heparin are contraindicated if patient prescribed any non-warfarin anticoagulants including the VTE Prophylaxis dose. Dabigatran [Pradaxa] Cap 150mg oral BID to start in 24hrs. Dabigatran [Pradaxa] Cap 75mg oral BID, if CrCl is 15-30ml/min, to start in 24hrs. Rivaroxaban [Xarelto] Cap 20mg oral Daily, to start in 24hrs. Rivaroxaban [Xarelto] Cap 15mg oral Daily, if CrCl is 15-30ml/min, to start in 24hrs. Reasons for not administering antithrombotic/anticoagulant (by end of day 2) Bleeding Hemorrhagic cerebral infarction Anterior cerebral circulation hemorrhagic infarction Posterior cerebral circulation hemorrhagic infarction Renal impairment Medical contraindication Surgical contraindication Platelet count below reference range Blood coagulation disorder due to liver disease Blood coagulation disorder Warfarin therapy started Refusal of treatment by patient Additional reasons for Patient not receiving therapy: Pateint enrolled in clinical trials comfort measures only Patient admitted for elective carotid intervention procedure Page 2 of 6

3 C. VTE Prophylaxis (Physician should reassess daily) If GFR < 30 ml/min, reduce Enoxaparin dose to 30 mg subq daily Do not give anticoagulant for 24 hours post TPA infusion and no hemorrhage on repeat imaging study Enoxaparin [Lovenox] 40 mg 30mg subq daily to start in 24 hours Exclusion Criteria for VTE Prophylaxis (Check all that apply) Anticoagulation allergy Blood coagulation disorder due to liver disease Acute spinal cord injury Heparin induced thrombocytopenia Platelet count below reference range Indwelling epidural catheter Blood coagulation disorder Renal impairment Lumbar puncture, spinal anesthesia, Hemorrhagic cerebral infarction Refusal of treatment by patient or epidural removed within the last 2 hours Bleeding Patient enrolled in clinical trial Uncontrolled or severe hypertension Anticoagulation not tolerated Comfort care management Hypersensitivity to anticoagulants D. Statin or Other Cholesterol Reducing Medications For LDL greater than or equal to 100 and/or pt on lipid lowering agent prior to admission Simvastatin [Zocor] Tab 20mg oral nightly 40mg oral nightly Other Cholesterol Reducing Medications Atorvastatin [Lipitor] Tab 20mg oral nightly 40mg oral nightly 80mg oral nightly Rosuvastatin [Crestor] Tab 40mg oral nightly Niacin Timed- Release Cap + Simvastatin [Zocor] Niacin Timed Release Cap 500mg oral nightly 750mg oral nightly 1000mg oral nightly + Simvastatin [Zocor] 10mg oral nightly 20mg oral nightly Ezetimibe [Zetia] + Simvastatin [Zocor] Ezetimibe [Zetia] 10mg oral nightly + Simvastatin [Zocor] 10mg oral nightly 20mg oral nightly Page 3 of 6

4 Medications Blood Pressure Medications (Select one only) Initiate if SBP greater than 180 mmhg or DBP greater than 105 mmhg on 2 readings 10 minutes apart. Target SBP mmhg, DBP mmhg during and 24HR post TPA. Labetalol [Normodyne] 10MG 20MG 40MG IV PRN. May repeat Q10MIN to max of 300 mg. DO NOT give if pulse less than 60 BPM. Give over 1 min. Labetalol [Normodyne] Infusion -Labetalol [Normodyne] Injection 10MG 20MG 40MG IV bolus. Give over 1 min. DO NOT give if pulse less than 60 BPM. -Labetalol [Normodyne] Infusion 2MG/MIN 4MG/MIN 8MG/MIN IV (Dose range 2 8 mg/min) DO NOT give if pulse less 60 BPM. nicardipine [ Cardene ] Infusion Start IV infusion at 5mg/hour. Titrate by 2.5mg/hour Q5MIN up to 15mg/hour to target BP, then decrease to 3mg/hour. Stroke Work-Up Studies Hemoglobin A1C, Routine Once Trans-thoracic Echo order with doppler, colorflow and bubble study Interpreting Cardiologist Ultrasound Carotid Duplex, bilateral CT head Without contrast With contrast MRI head Without contrast With contrast MRA Brain Without contrast With contrast IV Fluids Start Saline Lock + Maintain Saline Lock + Saline Flush Sodium Chloride 0.9% [Normal Saline] 50ml/hr 75 ml/hr 100ml/hr 125ml/hr Other ml/hr Sodium Chloride 0.45% [1/2 Normal Saline] 50ml/hr 75 ml/hr 100ml/hr 125ml/hr Other ml/hr Page 4 of 6

5 Consults Diabetic Education Consult For Intracranial Hemorrhage after Alteplase Infusion Administer Cryoprecipitate 5 units/pack Single unit + Type + Screen + Transfuse Cryoprecipitate + Verify patient has signed informed consent for blood and blood products Administer Platelet Pheresis 1 unit + Type + Screen + Transfuse Platelet Pheresis + Verify patient has signed informed consent for blood and blood products Administer aminocaproic acid [Amicar] 5g/250ml NS IV over 1 hour followed by 5g/250ml NS IV at 50ml/hr x 5 hours or until bleeding ceases Page 5 of 6

6 Core Measure Compliance orders for AIS with TPA Medication communication: Do not give Antithrombotic, Antiplatelet, Anticoagulants or NSAIDs for 24 hours post-tpa infusion & no hemorrhage on repeat imaging study. Refer to the Antiplatelet and Anti-coagulant medication list on the utilities menu under patient education. Notify physician if patient exhibits any of the following during or within 24 hours after Alteplase administration: acute neurological deterioration, new headache, acute hypertension, nausea and vomiting and a 4 point or more increase in the previous NIHSS score: a. Suspect intracranial hemorrhage b. If Alteplase is infusing Stop immediately c. Notify physician immediately d. STAT lab: PT/Aptt, Platelet Count, fibrinogen, type and screen e. STAT non contrast CT of head. Notify Physician if Temp > 99.4 F, Respiratory rate > 24, Systolic BP < 110 or > 180 mmhg, Diastolic BP < 60 or > 105 mmhg, Pulse < 50 or > 110, Blood Glucose > 140 Nursing: Order a non contrast CT of head 24 hrs post TPA. Bedrest Seizure/fall risk precautions Elevate HOB > 30 degrees Document fall risk assessment NPO until after tpa infused then continue NPO until patient passes dysphagia screen or formal swallow study. If pt fails, order nutrition consult. Notify physician if patient passes dysphagia screen for diet order Maintain O2 Sat > 92%. If < 92%, start O2 at 2 liters/min via nasal cannula and notify MD Smoking cessation order : Give pt advice/counseling Dietary consult: For caloric and dietary orders Document that the "Stroke Information & Education for You" booklet and each component of its content was discussed with patient / family / caregiver CBC with auto diff in AM Fasting Lipid panel in AM Comprehensive metabolic panel in AM RN case mgmt / Social Svc consult: To assess/assist with patient needs and initiate discharge planning Pastoral care consult: For patient spiritual assessment as needed Physical therapy consult : evaluate and treat Occupational therapy consult : evaluate and treat Speech therapy order to evaluate and treat and Bedside swallow evaluation (on weekends, call facility operator to connect you to speech voic and leave message) PHYSICIAN S PRINTED NAME, SIGNATURE and ID# DATE: TIME: Page 6 of 6