Stroke
Nursing Orders
Assessments
NIHSS upon admission and items 1,5,6 every 30 minutes Xs6 then every 4 hours
times 4 then complete NIHSS every 8 hours. Source
Assess neurologic status every 30 minutes Source
Neuro checks every 15 minutes during infusion of TPA and every 30 minutes
afterwards for the next 6 hours then hourly for 24 hours Source
Interventions
Elevate HOB to 30 degrees
Laboratory
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Complete blood cell count with automated white blood cell differential
Basic metabolic panel
Comprehensive metabolic panel
Pregnancy test, urine, point-of-care measurement
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EKG
Radiograph, chest, 1 view
Radiograph, chest, 2 views
CT, head or brain, without contrast
MRI brain witout contrast
MRA brain
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Diagnostic Tests
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Physician Dysphagia Screening Source
IV Fluids
Medications
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Saline lock
Sodium Chloride 0.9% @ _____mL/hr
Lactated Ringers Solution @ _____mL/hr.
Bolus
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Anti-platelets
aspirin 325 mg orally now
aspirin 300 mg rectally now
dipyradamole-aspirin/AGGRENOX 1 orally now
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Anticonvulsants
fospheyntoin/CEREBYX 1 g pheyntoin equivalents @ no more than 100 mg/min
fosphenytoin/CEREBYX 15 mg/kg pheyntoin equivalents @ no more than 100
mg/min
phenytoin/DILANTIN 18 mg/kg IV @ 50 mg/min or <
valproic acid/DEPAKENE 1 G IV
valproic acid/DEPAKENE 15 mg/kg IV
PHENobarbital /LUMINAL 100 mg IV
Antiemetics
droperidol /INAPSINE 0.625 milligram intravenously once as needed for
nausea/vomiting
metoclopramide /REGLAN 10 milligram intravenously once
ondansetron /ZOFRAN 4 milligram intravenously once
ondansetron /ZOFRAN 4 milligram orally once
prochlorperazine /COMPAZINE 5 milligram intravenously or intramuscularly
prochlorperazine /COMPAZINE 10 milligram po, IM, or IV
prochlorperazine /COMPAZINE 25 milligram rectally
Anithypertensives (prior to rtPA)
ASA recommendations by consensus. No data at this point supports any specific
antihypertensive in the setting of acute ischemic stroke.
If blood pressure does not decline and remains > 185/110 mm Hg, do not administer
rtPA.
labetalol /NORMODYNE 10 mg IV over 2 minutes (may repeat times 1)
labetalol /NORMODYNE 20 mg IV over 2 minutes (may repeat times 1)
Nicardipine /CARDENE 5 mg/h, titrate up by 2.5 mg/hr at 5 to 15 min. intervals to a
max of 15 mg/hr. When desired pressure is attained, reduce to 3 mg/hr.
nitroglycerin topical 2% ointment/NITRO-BID 2 inches to skin now.
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Thrombolytic therapy
The treatment window for some stroke patients is 4.5 hours of symptom onset,
according to a science advisory from the American Heart Association and American
Stroke Association, published online in Stroke. The groups stressed, however, that
therapy within 3 hours remains ideal "because the opportunity for improvement is
greater with earlier treatment." According to the advisory, patients eligible* for therapy
with recombinant tissue plasminogen activator (rtPA) who are not treated within 3
hours can be treated up to 4.5 hours — unless they:
are older than 80;
are taking oral anticoagulants with an international normalized ratio of 1.7 or lower;
have an NIH stroke scale score greater than 25;
have a history of both stroke and diabetes.
Besides bleeding complications, physicians should be aware of potential side effect of
angioedemas that may cause partial airway obstruction.
A patient with a seizure at the time of the stroke by be eligible for rtPA as long as the
physician is convinced that residual impairments are secondary to stroke and not a
postictal phenomenon.
Inclusion/Exclusion checklist for thrombolytic therapy
rtPA/ACTIVASE 0.9 mg/kg (max dose 90 mg) with 10 % of the dose given as a bolus
over 1 minute, the rest over 1 hour
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Antihypertensives (during and after treatment with rtPA)
ASA recommendations by consensus. No data at this point supports any specific
antihypertensive in the setting of acute ischemic stroke
Systolic 180 - 230 or diastolic 105 - 120 mm Hg
Labetolol/NORMODYNE 10 mg IV over 2 minutes followed by 2 mg/min infusion,
increase by 2mg/min every 5 minutes for max up to 8 mg/min. until target BP
Labetolol /NORMODYNE 10 mg IV over 2 minutes, may repeat every 10 to 20
minutes to a max of 300 mg/day.
Systolic > 230 or diastolic 121- 140 mm Hg
Labetolol/NORMODYNE 10 mg IV over 2 minutes followed by 2 mg/min infusion,
increase by 2mg/min every 5 minutes for max up to 8 mg/min. until target BP
Labetolol/NORMODYNE 10 mg IV over 2 minutes, may repeat every 10 to 20
minutes to a max of 300 mg/day.
nicardipine /CARDENE infusion 5 mg/h, titrate up to desiredeffect by increasing 2.5
mg/h every 5 minutes to a maximum of 15 mg/h
If blood pressure not controlled consider Nipride.
Antidotes and Rescue Agents
Dextrose 50% in Water (D50W) IV Syringe if hypoglycemia confirmed.
© Emergency Medicine Informatics
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