NURSING ORDERS
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Check puncture sites for bleeding or hematoma (The patient is at increased risk for
uncontrolled bleeding if administered t-PA for her stroke. She is also set to receive
clopidogrel, which is an anti-platelet medication that prevents platelets from sticking together.
Warfarin is also scheduled, which is an anticoagulant)
Apply pressure to bleeding sites (The patient is scheduled to receive several medications that
both anticoagulate the blood and prevent clotting. If the patient has bleeding sites, she may not
be able to clot as quickly/effectively on her own)
No intra-arterial, IM or central venous access during t-PA infusion or for 12 hours post t-PA
infusion (t-PA is a medication that breaks apart fibrin and fibrinogen in the blood. This helps
to break up clots in stroke patients, but also leads to anticoagulation and increased risk for
bleeding)
Hold Heparin for 24 hours post t-PA infusion (Heparin is an anticoagulant. If used with t-PA,
this could lead to uncontrolled bleeding)
Smoking cessation education (Patient has smoked 1PPD for five years. Smoking increases risk
for atherosclerosis, which narrows and hardens the blood vessels, and increases blood
coagulation. This puts patients at increased risk for stroke. Narrowing and hardening of blood
vessels also increases risk for hypertension, which in turn can increase risk for stroke)
Notify physician if vitals out of range
o SBP >185 or <110 (SBP >185 is considered within the range of hypertensive crisis and
can damage blood vessels, further increasing risk of stroke. SBP <110 indicates
increased risk for falls or syncope, as blood may not be moving swiftly enough
throughout the body for adequate gas exchange. SBP <110 is especially concerning
with the patient on furosemide, as this is a diuretic that depletes extracellular fluid
volume)
o DBP >105 or <60 (as above, diastolic hypertension can damage blood vessels and
increase risk for stroke. Diastolic hypotension can increase risk for falls and syncope)
o P <50 (The heart may not be able to adequately pump oxygen-rich blood throughout the
body. The patient is on benazepril, which relaxes blood vessels and can decrease pulse
rate)
o RR >24 or <10 (Hyperventilation can decrease CO2 in the blood. If this persists, this
can lead to narrowing of the blood vessels, which can decrease oxygenation to the brain.
Hypoventilation can also result in dangerously reduced oxygenation to the brain. This
is especially concerning for this stroke patient)
o Decline in neurological status or worsening of stroke symptoms (The patient is already
showing signs and symptoms of an ischemic stroke, and is at risk for further damage.
The patient is also prescribed t-PA, Warfarin and clopidogrel, which put her at risk for
bleeding, and she could potentially develop a hemorrhagic stroke)
Two IV lines (The patient is at risk for hemorrhage. Having two IV lines increases the volume
of fluid repletion that can be given. Two lines might also be necessary if concurrent
medications need to be given with different flow rates)
NIHSS (The patient shows signs/symptoms for ischemic stroke. Monitoring neurological
deficit changes over time is important to judge course and whether patient is improving or
deteriorating)
Monitor vitals q15 minutes x 2 hours with neuro checks, then q30 minutes x 6 hours, then q1
hour x 16 hours (Vital signs may change rapidly in a patient with stroke, and with her current
medication regimen. Catching a change in a timely manner is vital)
Insert Foley catheter before t-PA (if t-PA is ordered) (Friction from catheters can cause small
abrasions or trauma to the urethra and/or bladder. If a catheter is necessary, this should be done
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before anticoagulation or clot-preventing medication, so that any incidental injury does not lead
to hemorrhage)
Medications as ordered (Patient is scheduled to receive medication to lower her blood pressure
and to help treat her clot)
Provide stroke education (This is the patient’s first stroke. She is noted to be visibly distressed
and having difficulty moving her right side/difficulty with speech. She may not know what to
expect as far as long-term prognosis, treatment options, or how to prevent future strokes)
POC glucose (If the patient has elevated glucose and is then given t-PA, this can lead to
hemorrhagic transformation where blood can leak into the brain through a disrupted bloodbrain barrier)
Weight (The patient is being given a diuretic, which may decrease her weight as fluid is
reabsorbed from tissues and emptied from the body. Some medications are also dependent on
weight for dose)
ACTIVITY ORDERS
 Bedrest (The patient has had an ischemic event, and is at increased fall risk with her current
medication regimen)
NUTRITION ORDERS
 NPO pending dysphagia assessment (The patient has neurological symptoms. Before she eats
or drinks, a dysphagia assessment is given to assure that she is not an aspiration risk)
RESPIRATORY ORDERS
 O2 via NC to keep saturation >92% (The patient has had an ischemic event. Keeping tissues
oxygenated may help reduce the risk for further hypoxic damage)
LAB/IMAGING ORDERS
 STAT PT/PTT, INR, CBC with Diff, BMP, ESR, blood type, screen if on Coumadin (The
patient is prescribed anticoagulants, medications that can change her electrolyte balance, and
anti-clotting agents. Checking her coagulation prior to med administration is vitally important,
as too much anticoagulation could lead to uncontrolled hemorrhage. ESR can indicate
inflammation and atherosclerosis, which is an increased risk for stroke. Blood typing is
important if the patient hemorrhages and needs a transfusion)
 Head CT (Imaging can show hemorrhage or damage to tissue)
 STAT urine HCG if childbearing-age female (The physician will need to determine the risk to
benefits in giving teratogenic medication if the patient is pregnant)
 EKG (Irregular heart rhythms such as a-fib can increase risk for stroke. Diagnosing and
mitigating factors that caused her current ischemia may help prevent future events)
 Carotid Doppler ultrasound (This Doppler can show narrowing of the carotids and any plaque
buildup, which could have played a role in patient’s stroke)
 CT angiogram head and neck (This test can show narrowed or blocked vessels, which again
could reveal a factor in her stroke)
 Cerebral arteriogram (This study looks at blood vessels in the brain, and can show aneurysms,
malformations that are at increased risk for bleed, and damage to or blockages within vessels.
This could show what areas of her brain were affected by her ischemia, and if there are any
underlying problems)
 2D echocardiogram (This echocardiogram shows the motion of the heart as it is beating. This
could show irregularities that might have lead to her ischemia)
 MRI/MRA brain (MRA is frequently used to detect clots or narrowing of vessels. This could
show location and severity of patient’s clot, and any other abnormalities that put her at risk for
future events. The MRI can show inflammation and areas damaged by her stroke. This can
help in the development of a treatment plan and to go over her long-term prognosis)
OT/PT/ST ORDERS
 Physical therapy consult (The patient is having right-sided weakness and difficulty using her
right extremities. PT can help develop an exercise regimen to strengthen the unaffected side,
and to help potentially regain use of the affected side post treatment)
 Occupational therapy consult (OT can help the patient learn how to return to her normal ADLs
post stroke and how to work with any deficits she may have. This may include working on
skills for grooming, cooking and eventually returning to work with a potentially adapted
environment)
 Speech therapy consult (The patient is having dysarthria. ST can help with any sensorimotor
issues)
MISCELLANEOUS ORDERS
 Critical care medicine consult (The patient is currently within the first five hours of symptom
onset. Critical care is needed to manage acute problems, coordinate anticoagulation and blood
tests, and administration of t-PA)