Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
Order Set: Admission for Ischemic Stroke for Patient not Receiving tPA
This order set pertains to those admission orders from ER or direct
admit to the hospital for patients 18 years or older who present with
symptoms of recent neurologic dysfunction suggestive of brain
ischemia. These orders exclude patients with TIA, hemorrhagic
stroke or ischemic stroke receiving thourombolytic therapy.
Legend:
Open boxes are orders that a clinician will need to order by checking
the box.
Pre-checked boxes are those orders with strong supporting evidence
and/or regulatory requirements that mandate documentation rationale
for deviation from standard if not done.
Patient Information (Two are required.)
Last Name:
First Name:
Date of Birth: ___/___/_____
Patient’s age:
ID #:
Admitting Data
Admit to:
ICU bed
Step down:
with telemetry
Stroke/neurology:
with telemetry
Other
without telemetry
without telemetry
Attending physician:
Primary physician:
Contact primary care physician
Notify stroke nurse clinicians
Notify stroke research team if that patient is eligible for stroke research
Diagnosis
Admitting Dx:
Acute ischemic infarct
Other
Secondary Dx:
Patient excluded from thourombolytic therapy (tPA) due to:
Time from onset contraindications
Clinical contraindications
Laboratory contraindications
Radiologic contraindications
Condition
Stable
Code Status
Full code
Unstable
Patient history contraindications
Other
Other
DNR/DNI
Unknown
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Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
Vitals
Telemetry/monitor for first 24 hours:
Notify physician if EKG or telemetry is suspicious for atrial fibrillation
Telemetry/monitor for 48 hours
Notify physician if EKG or telemetry is suspicious for atrial fibrillation
Vital signs (BP, heart rate and O2 sat) and non-NIHSS neuro check:
every hour for 4 hours then
every 4 hours while awake (if stable)
Notify physician for antihypertensives required for blood pressure greater than 220 mmHg systolic or
120 mmHg diastolic
Notify physician for antihypertensives required for blood pressure greater than
arterial pressure greater than
mmHg after the first 24 hours.
mmHg systolic or mean
Notify physician if blood pressure is less than
mmHg or systolic
mmHg diastolic
Orthostatic blood pressure check and heart rate before patient is mobilized from bed (lying, sitting, and standing
if patient is able to stand)
Weight on admission and then every day
Input/output for 24 hours or
Temperature every 4 hours for 48 hours while awake
Temp every shift after 48 hours while awake if temp is normal
Notify physician if temp greater than 101.3oF (38.5oC)
Fall risk assessment
Activity
Bed rest for
hours with turns every
hours
In chair twice daily beginning as soon as no fluctuating neurologic status
Up with assistance
Up ad lib
Allergies/Adverse Drug Reactions
None
Yes, Name:
Type of reaction:
Type of reaction:
Type of reaction:
Nursing Orders
Keep patient with nothing by mouth until/unless patient passes nursing bedside swallowing evaluation
Bedside glucose test now (if not done in ER)
O2 saturation monitor until O2 saturations remains stable. Check with vitals
Oxygen 2 liters per minute by nasal cannula if O2 saturations less than 94%. Titrate O2 to maintain
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Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
saturation greater than or equal to 94%
Notify physician if O2 saturation is less than 91%
Cough and deep breath every hour while awake
Incentive spirometer every
hours while awake
Straight catheter
Every shift if no void
300 cc by bladder scan
Notify physician if 2 consecutive straight catheterizations needed for no void
Bedside glucose checks every 4 hours for 24 hours
Notify physician if glucose greater than 180 mg/dL AND no sliding scale ordered
Bedside glucose checks 4 times a day after 24 hours, e.g., ac and hs. Discontinue glucose checks if glucose
stable and less than 150 mg/dL
Nursing bedside swallowing evaluation – contact speech therapy for formal evaluation if fail any of the below:
- More than one swallow to empty mouth
- Wet voice after swallow
- Drooling
- Cough on water
Soft care mattress (if nursing assessment identifies risk of skin breakdown)
Fall alert (if nursing assessment identifies risk of falling)
Heel protection (if nursing assessment identifies risk of skin breakdown)
Diet (If patient fails bedside swallow screen, keep patient with nothing by mouth until speech therapy formal evaluation )
Nothing by mouth
Diet as recommended by speech therapist
IVs (Avoid use of dextrose 5% in water, especially if hyperglycemic and avoid hypotonic solutions)
Establish IV saline lock with flush every 12 hours
0.9% NaCl in water at
mL/hour
at
mL/hour
Dextrose 25 mL every 15 minutes as needed to maintain glucose level above 70 mg/dL
Sedative/Symptom Medication (Note: No oral medications until/unless patient passes a bedside swallow
screen)
Acetaminophen 650 mg maximum cumulative 4 grams per 24 hours
by mouth or
rectal suppository every
four hours as needed if
Temperature greater than 99.5oF (37.5oC) OR
pain
Sedative
mg by mouth at bedtime as needed
Bowel care:
Docusate sodium 100 mg by mouth every 12 hours as scheduled for constipation
Magnesium hydroxide (Milk of Magnesia®)
30 mL (30-60 mL) by mouth daily as needed for
constipation (maximum dose 60 mL per 24 hours)
Bisacodyl 10 mg suppository. Repeat in 1 hour if inadequate results as needed for constipation
Fleets enema as needed for constipation
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Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
Medications
Pharmacologic VTE Prophylaxis (Aspirin is not recommended as monotherapy for VTE prophylaxis.)
Dalteparin 5,000 units subcutaneous every 24 hours beginning at admission (Use low-dose unfractionated
heparin for creatinine clearance [CRCL] less than 30 mL/min.)
Initiate the following if dalteparin ordered:
- Platelet count and hemoglobin every other day beginning on day two
- Discontinue dalteparin if platelet count drops 50% or more from baseline value and
notify physician
- Initiate patient education
- Notify physician if bleeding occurs
Enoxaparin 40 mg subcutaneous every 24 hours beginning at admission (Use unfractionated heparin for
CRCL less than 30 mL/min.)
Initiate the following if enoxaparin ordered:
- Platelet count and hemoglobin every other day beginning day two
- Discontinue enoxaparin if platelet count drops 50% or more from baseline value and
notify physician
- Initiate patient education
- Notify physician if bleeding occurs
Unfractionated heparin 5,000 units subcutaneous every 8 hours beginning at admission.
Initiate the following if unfractionated heparin ordered:
- Platelet count and hemoglobin every other day beginning day two
- Discontinue unfractionated heparin if platelet count drops 50% or more from baseline value and
notify physician
- Initiate patient education
- Notify physician if bleeding occurs
(Alternative pharmacologic VTE prophylaxis program)
Mechanical VTE Prophylaxis
Pneumatic compression:
Knee-high
Thigh-high
Foot boots
Early Secondary Stroke Prevention (Document contraindications if not given. Withhold ibuprofen for 30
minutes after aspirin administration.)
Aspirin
mg (160-325 mg) immediately
By mouth
Aspirin
mg (160-325 mg) daily by mouth
Coated
Coated
Buffered
mg by mouth every
Buffered
Rectal suppository
Rectal suppository
Acute Post Stroke Hypertension Management (Consider IV regimen if swallow is questionable.)
BP less than 220/120 mmHg
Observe with vitals.
BP systolic greater than 220 OR diastolic greater than 120 mmHg or mean arterial pressure greater than
130 mmHg for the first 24 to 48 hours
Labetalol 10-20 mg IV over 2 minutes. May repeat or double every 10 minutes to achieve 10-15%
reduction in blood pressure (maximum dose 300 mg per 24 hours).
Nicardipine 5 mg/hour IV infusion initial dose; titrate up 2.5 mg/hour every 5 min. to 15 mg/hour. to
achieve 15% reduction in blood pressure (maximum 15 mg/hour).
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Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
BP diastolic greater than 140 mmHg
Labetalol
mg (100-200 mg) by mouth initially and
mg every two hours as needed to
maintain BP less than
mmHg (max. 800 mg per 24 hours)
Labetalol 10 mg IV over 2 minutes. May repeat with 40-80 mg IV every 10-20 minutes as
needed to maintain BP less than
mmHg (maximum cumulative dose 300 mg per 24 hours)
Nitroprusside 0.5 mcg/kg/minute IV infusion initial dose with continuous BP monitoring. Notify physician if
blood pressure not controlled with medication
mg every
at
hours as needed to maintain BP
mmHg
Notify physician if systolic BP greater than 220 or diastolic BP greater than 120 (MAP greater than 130) with
medication.
Notify physician if systolic BP greater than
medication.
or diastolic BP greater than
(MAP greater than
Management of Prehospital Hypertension Medication Program (Note: No oral medications
until/unless patient passes a bedside swallow screen)
Hold all prehospital antihypertensive drugs first 24 hours
Give half doses of prehospital antihypertensive drugs first 24 hours, i.e.,
Give full doses of prehospital antihypertensive drugs first 24 hours, i.e.,
Other program for prehospital antihypertensive drugs first 24 hours, i.e.,
Give full doses of prehospital antihypertensive agents after 24 hours
Ask physician for orders after 24 hours
Management of Other Prehospital Medications Program (Note: No oral medications until/unless
patient passes a bedside swallow screen)
Hold all prehospital medications first 24 hours
Other program for prehospital medications first 24 hours, i.e.,
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) with
Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
Give full doses of prehospital medications after 24 hours
Ask physician for orders after 24 hours
GI Prophylaxis
mg every
by mouth
IV
Laboratory/Diagnostics: (those not performed in ED or office)
CBC with platelet count
STAT
Electrolytes, glucose, BUN, creatinine
ALT
AST
GGT
Next routine draw (Refer to unit’s protocol.)
Next routine draw (Refer to unit’s protocol.)
STAT
Alk phosphatase
CPK (Liver and muscle enzymes are important in preparation for
statin medication initiation.)
PT/INR
STAT
Next routine draw (Refer to unit’s protocol.)
PTT
STAT
Next routine draw (Refer to unit’s protocol.)
Fasting cholesterol, triglyceride, HDL, LDL
Electrocardiogram
CT of head without enhancement
CT angiogram:
Head
Neck
Magnetic resonance imaging of head (per protocol)
Magnetic resonance angiography:
Head
Neck
Carotid doppler ultrasound
Indication:
Transesophageal echocardiogram
With bubble on day
(if suspicion of cardioembolic source when
patient is stable for study and not vunerable with hypotension and/or sedation)
Transthoracic echocardiogram
With bubble on day
Other
Rehabilitation (Therapies will be discontinued by the specific services when unnecessary. Therapies will be advanced to
twice daily as appropriate.)
Physical therapy
Occupational therapy
Speech therapy
Smoking cessation (for current users)
Consults
Neurology: reason
Hospitalist: reason
Neurosurgery: reason
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Admission for Ischemic Stroke Order Set for Patients Not Receiving tPA
Sixth Edition/July 2012
Cardiology: reason
Physical medicine and rehabilitation: reason
Chaplaincy for advanced directive OR Other
Nutrition: reason
Other:
Discharge Planning
Social service consult for assistance in discharge planning
Financial counselor consult
Authorized Prescriber Signature:
Printed Name:
Date/Time of Orders:
/
/
:
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