Ischemic Stroke Clinical Pathway Legal Treatments Advance Directives Refer to the ED Stroke Algorithm Patient exam: review history, Check VS/Neuro every 2 hour or per M.D. order Strict I & O s Cardiac Monitoring weight as ordered PT/OT ordered Speech and Swallow Eval VTE Prophylaxis as appropriate Notify Primary Care MD if appropriate Discuss probable discharge date and needs with patient and family Patient exam: review history, Check VS/Neuro every 4 Discuss Rehab/SNF placement with patient and family. weight as ordered Strict I & O s PT/OT as ordered Nursing Standard of Care Stroke Video for Patient and/or Family Patient exam: review history, Check VS/Neuro every 4 Strict I & O s PT/OT as ordered Nursing Standard of Care Arrange primary care and/or Neuro follow-up Patient exam: review history, Check VS/Neuro every 4 Continue I & O s as indicated PT/OT as ordered Nursing Standard of Care Arrange primary care and/or Neuro follow-up if Write prescriptions if Dictate a summary if Repeat Stroke Video for Patient and/or Family if necessary Patient exam: review history, Check VS/Neuro every 4 Continue I & O s PT/OT as ordered Nursing Standard of Care Arrange primary care and/or Neuro follow-up if Write prescriptions if Dictate a summary if Patient exam: review history, Check VS/Neuro every 4 Nursing Standard of Care Arrange primary care and/or Neuro follow-up Write prescriptions if Dictate d/c summary/include NIHSS Assessment NIH Stroke Scale by certified nurse or MD Speech & Swallow screen Assess for discharge needs 1
Labs- Tests Labs: CBC w/diff PT/PTT BMP Lipid Screen (first am blood draw) Homocysteine, Lupus Anticoagulant DRVVT Anticardiolipin Ab Hemogloblin AIC Plavix 2C19 Genotype Sed rate Urine toxicology screen Ck MB Troponin Urine Pregnancy test for Women of child bearing age CBC BMP asindicated Oximetry Spot Check every check is < 92% 02 saturation call house officer 02 liters 02 PRN CBC BMP Oximetry Spot Check every saturation call house officer 02 liters 02 PRN CBC BMP Oximetry Spot Check every saturation call house officer 02 liters 02 PRN CBC BMP Oximetry Spot Check every saturation call house officer 02 liters 02 PRN Electrolyte panel as indicate Repeat fasting lipid Approx. 30 days from discharge. Follow-up appt scheduled Labs-Tests Head CTA Neck CTA MRI LASH (limited acute stroke head-for acute stroke < 10 hours from onset) Brain MRI w/o gadolinium Diagnostic cerebral angiogram Carotid Duplex Bilateral Transesophegial agitated saline (Bubble Test) TTE w/bubble study Transcranial Doppler EEG Oximetry Spot Check every check is < 92% 02 saturation call house officer 02 liters 02 PRN Consider if indicated: Consider if indicated: Consider if indicated: Consider if indicated: 2
Medications - IV s Aspirin mg per rectum Aspirin Enteric Coated, E.C. Dipyridamole (Persantin) Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Aspirin mg per rectum Aspirin Enteric Coated, E.C. Dipyridamole (Persantin) Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Aspirin mg per rectum Aspirin Enteric Coated, E.C. tablet mg 1 tab PO Dipyridamole (Persantin) tab 75 mg, 1 tab, PO three Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Aspirin mg per rectum Aspirin Enteric Coated, E.C. tablet mg 1 tab PO Dipyridamole (Persantin) tab 75 mg, 1 tab, PO three Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Aspirin mg per rectum Aspirin Enteric Coated, E.C. Dipyridamole (Persantin) tab 75 mg, 1 tab, PO three Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Aspirin mg per rectum Aspirin Enteric Coated, E.C. Dipyridamole (Persantin) Dipyridamole XR 200 mg/ Clopidogrel (Plavix) tab 75 mg 1 tab, PO Atoravastatin mg PO Atoravastatin mg PO Atoravastatin mg PO Atoravastatin mg PO Atoravastatin mg PO Atoravastatin mg PO OTHER : Tylenol 650mg (o) every for temp >37.5 rectal or oral Famotidine 20mg IV every 12 hrs IV NS with 20 meq Kcl per ltr at ml per hour IV NS at m ml per hour Warfarin mg PO daily Tylenol 650mg (o) every for temp >37.5 Maalox 15-30mL (o) every DOSS 250 mg caps or Dulcolax PR daily prn Warfarin mg PO daily Tylenol 650mg (o) every for temp >37.0 Maalox 15-30mL (o) every DOSS 250 mg caps or Dulcolax PR daily prn Discontinue IV s when taking adequate fluids (saline lock when discontinued) Warfarin mg PO daily OTHER : Tylenol 650mg (o) every for temp >37.5 Maalox 15-30mL (o) every DOSS 250 mg caps or Dulcolax PR daily prn Discontinue IV s when taking adequate fluids (saline lock when discontinued) Warfarin mg PO daily Maalox 15-30mL (o) every DOSS 250 mg caps or Dulcolax PR daily prn Warfarin mg PO daily Maalox 15-30mL (o) every DOSS 250 mg caps or Dulcolax PR daily prn Warfarin mg PO daily 3
Medications - IV s Labatelol 5 mg IV push now may repeat in 20 min. If SBP still over 220 and diastolic over 110, notify House Officer STAT Nicardpine Drip 50 mg/250 ml NS, protocol titration, goal and rate per MD order. Diuretic Beta Blocker Ace Inhibitor NS 50-100mL or as Decrease IV fluid rate as Diuretic Beta Blocker Ace Inhibitor NS 50-100mL or as Decrease IV fluid rate as Diuretic Beta Blocker Ace Inhibitor NS 50-100mL or as Decrease IV fluid rate as Diuretic Beta Blocker Ace Inhibitor NS 50-100mL or as Decrease IV fluid rate as Diuretic Beta Blocker Ace Inhibitor NS 50-100mL or as Decrease IV fluid rate as PO intake increases AVOID SEDATIVES, HYPNOTICS, OPIODS, ANALGESICS! Insulin Standard Correctional Scale Reference Set Nutrition Consider Keofeed tube if prolonged NPO NPO Now until swallow screen is done. Diet to be based on swallow screen or evaluation and nutritional screening Consults Activity Head of bed at 30 degrees PT/OT evaluation OOB w/assistance as per MD order Head of bed at 30 degrees PT/OT evaluation Assess and advance as tolerated patients with restricted mobility 4
Teaching Plan Research protocol initiated if indicated. Optimize Cerebral Perfusion and the need to call 911 if safe safe safe safe Patient/family demonstrates progress in stroke education program Personal Stroke prevention strategy safe Patient/family understand and support rehab/snf goals if Patient/family know facility to which pt will go, approx. LOS, plan for home care after d/c Patient/family can state when to notify physician, activity restrictions, f/up appointment Coumadin clinic if indicated 5