PLACE LABEL HERE
STROKE: TRANSIENT ISCHEMIC ATTACK (TIA) and
ISCHEMIC STROKE ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
 Thrombolytic = Tissue Plasminogen Activator (tPA, Activase, alteplase) has been administered.
TIA ABCD-2 Score for stroke risk within 2 days
Age over 60 years
1 point
Speech impairment without weakness
1 point
Systolic B/P  140 mm Hg
TIA duration  60 minutes
1 point
TIA duration 10-59 minutes
Diastolic B/P  90 mm Hg
Unilateral weakness
2 points Diabetes
Total score: _______
Low risk (1%) score 0-3
Moderate risk (4.1%) score 4-5
1 point
2 points
1 point
1 point
High risk (8.1%) score 6-7
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time
spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
 Yes, admit as inpatient, proceed to # 2 No, place in observation
2. If admitted as inpatient, Inpatient Physician Certification:
Diagnosis: ________________________________________________________________________________
Level of Care:
 Confirmed cerebellar stroke  Neuro Intermediate
 Neuro ICU
th
 Acute Care Stroke Unit (Neuroscience or GMC-D 4 floor) q 4 hr neurological checks/vital signs
 Intermediate Care (Neuroscience/GMC-D 3rd floor) q 2 hr neurological checks/vital signs
 Critical Care (Neuro ICU/GMC-D ICU) q 1 hr neurological checks/vital signs
 Post tPA (Neuro ICU/GMC-D ICU) per tPA administration orders q 15 min for 2 hrs, then q 30 min for 6
hrs, then hourly for 16 hrs.
3. Telemetry: If patient Medical/Surgical, must complete form # 36084, Indication: TIA/Stroke
4.  Isolation:  Contact  Droplet  Airborne For: _________________
5.
6.
7.
8.
9.
10.
11.
12.
 Neurology consult:____________________________________________________________
 Neurosurgical consult for cerebellar stroke
 Confirmed or suspected large Middle Cerebral Artery (MCA) infarct - see attached malignant
MCA guideline
Use Stroke Plan of Care (form # 15694)
O2 per Protocol
 Smoking Cessation
Rehab: Physical Therapy, Occupational Therapy, Speech Language Pathology
 Post tPA:
 Bedrest for 24 hours  Begin PT/OT/SLP as tolerated
Lab:
Fasting Blood Glucose  HgA1C
Fasting Lipid Profile
Diagnostics:
 Post tPA non-contrast CT at 24 hours indication stroke
 CT Brain w/o contrast Time:_____________, Indication: TIA/Stroke
 MRI with diffusion of brain without contrast, Indication: TIA/Stroke
VASCULAR IMAGING:  MRA head and neck
OR  CTA head and neck including aortic arch indication stroke
 Transthoracic echocardiogram (TTE), Reason: TIA/Stroke, Read by: ___________________
Other: ________________________________________________________________________
Assessment: Vital signs/neuro checks per level of care.
NIHSS each shift for the first 3 days. (Call Stroke Unit for assessment).
Consults:
Order writer’s initials _______
Copy to pharmacy
*3-15695*
FORM 3-15695 REV. 01/2016
Page 1 of 2
PLACE LABEL HERE
STROKE: TRANSIENT ISCHEMIC ATTACK (TIA) and
ISCHEMIC STROKE ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
13.
14.
15.
16.
Diet:
NPO until bedside swallow screen per RN
If swallow screen normal, begin diet as tolerated: ____________________________________________
If swallow screen abnormal, maintain NPO, elevate head of bed 30°, and await Speech Language
Pathology evaluation
Nutrition Supplement Orders (form # 31417), initiate if patient meets criteria
Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
Activity: Progress as tolerated
MEDICATIONS:
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
IVF:  NS
 LR
 D5NS
 D5 ½ NS with 20 KCl
at ___________ml/hr
Antiplatelet:
 If tPA administered, hold first dose of all antiplatelet or anticoagulant drugs including, but not limited to:
Heparin, Lovenox (enoxaparin), Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxaban),
Eliquis (Apixaban), Aspirin, Aggrenox (aspirin/dipyridamole), Plavix (clopidogrel), Effient (prasugrel)
or Brilinta (ticagrelor) for 24 hrs
 Aspirin 325 mg po or per rectum daily
 Aspirin 81 mg po daily
 Plavix (clopidogrel) 75 mg po daily
 Other: ___________________________
Blood pressure management:
 Trandate (labetalol) 10-20 mg IV q 1 hr PRN HTN (see below), Hold for heart rate < 50/min. Recheck
BP within 30 min and notify physician if not in parameters.
 Hydralazine 10 mg IV q _____ hrs PRN HTN (see below), Recheck BP within 30 min and notify
physician if not in parameters.
 ICU only, Cardene (nicardipine): Initial infusion 5 mg/hr, increase by 2.5 mg q 15 min to max of 15
mg/hr, see Titration Protocol (form # 33883)
Blood Pressure (BP) Administration Parameters (must be completed):
 Permissive HTN: Maintain BP ≤ 220 mm Hg systolic and/or ≤ 120 mm Hg diastolic.
or
 Maintain systolic BP < _____ mmHg and/or diastolic BP < _____ mmHg.
or
 DC other parameters if thrombolytic or anticoagulant given, keep systolic B/P ≤ 180 mm Hg and/or
diastolic BP ≤ 105 mm Hg.
or
 Notify physician if systolic BP > _____ mmHg and/or diastolic BP _____ mmHg for medication
orders.
Cholesterol lowering therapy recommended for LDL > 100 mg/dl or consider for diabetics LDL > 70 mg/dl
 Contraindication to statin therapy
 Lipitor (atorvastatin) _________________mg po at bedtime
 Other: _____________________________________________________mg po at bedtime
VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)
 Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75). Hold for 24 hrs if tPA administered
or  Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30) Hold for 24 hrs if tPA administered
and/or  Mechanical devices: SCDs
 Nicotine patch 14 mg once daily prn apply topically after smoking cessation education
 Mild pain/temp > 99.5F/HA: Tylenol (acetaminophen) 650 mg po or per rectum q 4 hrs prn
 Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
 Constipation: Milk of Magnesia (MOM) 30 ml po daily prn
 Electrolyte Replacement Protocol (form # 21340)
___________
Date
____________
Time
_________________________________
Physician Signature
____________
PID Number
Copy to pharmacy
FORM 3-15695 REV. 01/2016
Page 2 of 2
REFERENCE - Not Part Of Medical Record
Guidelines for Neurosurgical Consult and Possible Decompressive Hemicraniectomy in
Malignant Middle Cerebral Artery Infarctions
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
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Large volume > 50% of MCA territory infarction on CT or DWI volume > 145 ml on MRI after 16 hours
of onset of symptoms
NIHSS > 16 for non-dominant hemisphere stroke or NIHSS > 20 for dominant hemisphere stroke
Patients < 60 yrs with malignant MCA infarction
Decompressive hemicraniectomy should preferably be performed within 48 hours of stroke onset
Decompressive hemicraniectomy should be offered on a case by case basis for healthy patients > 60
yrs and beyond 48 hrs after stroke onset
A thorough discussion with the patient and family about limited evidence of benefit, and likelihood of
poor neurologic outcome needs to be addressed.
Adequate craniectomy with a target 14 cm anterior, posterior and temporal bone removed down to the
middle fossa and duroplasty
Above is based on Class 1: Level of Evidence B from the American Stroke Association 2013 Ischemic
Stroke Guidelines.
Jauch, E et al. (2013). Guidelines for the Early Management of Patients With Acute Ischemic Stroke.
Stroke. Jan. 31, 2013
REFERENCE - Not Part Of Medical Record