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Evidence Based Care
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PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Emergency Evaluation of Suspected Stroke
NIH STROKE SCALE
________ 1A Level of Consciousness –Is the patient alert, drowsy,ect
Document time of onset of symptoms (if known), or the last time the patient was known to be at previous baseline or ________ 1B LOC Questions –Ask patient the month and their age
________ 1C LOC commands –Ask patient to open/close eyes and then
NIH Stroke Scale Score: _________________ ________ 2 Best Gaze-Only horizontal movement tested. Oculocephalic
reflex is OK, but not calorics. Eyes open patient follows finger • Record weight in kg: __________________ 0= normal 1= partial gaze palsy 2= forced deviation • CT head now. Notify Radiology of suspected stroke. ________ 3 Visual –Test by confrontation. Introduce visual stimulus to
Radiologist to notify ordering physician of CT results patient’s upper an lower field quadrants 2= complete hemianopia 3= bilateral hemianopia ________ 4 Facial Palsy-Ask patient to show teeth/smile, raise eyebrows
• STAT Complete Blood Cell Count with differential. ________ 5A&B Motor Arm -Extend arm, palm down, to 90 degrees if
Other: _____________________________________ ________ 6A&B Motor-Leg-Elevate leg to 30 degrees and flex at hip always
Other: _____________________________________ • Initiate and maintain saline lock if no other IV access. • Normal Saline at ___________________ (specify rate), or ________ 7. Limb Ataxia –Finger-nose, heel-shin tests done on both
Other IV fluid: ________________________________ Blood Pressure treatment and parameters:
________ 8 Sensory Use a pinprick to face, arm, trunk and leg-compare
For patients receiving t-PA: Alteplase (Activase) see side to side. Assess patient’s awareness of being touched.
Labetalol orders on page 2 of 3 of this order set. For patients who are NOT candidates for t-PA: Alteplase
________ 9 Best Language-Ask patient t name items, describe a picture,
(Activase), AHA Guidelines for the Early Management of read a sentence; intubated patients should write responses.
Adults with Ischemic Stroke (May 2007) recommends that 0= No aphasia 1= Mild to moderate aphasia medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is ________ 10 Dysarthria-Evaluate speech clarity by asking patient to repeat
0= Normal Articulation 1= Mild to moderate dysarthria 2= Near to unintelligible UN= Intubated or other barrier ________ 11 Extinction and Inattention-Use information from prior testing to
____________________________________________ identify neglect or double simultaneous stimuli testing. 0= No neglect 1= Partial neglect 2=Complete neglect _______________ (Date)____________(Time) ______ NIHSS Total Score
S:\Evidence Based Care\EBC Order Development\FY2008 Orders\Stroke\Word Processing Versions\DOCS-#85204-v1-EBC_-_Emergency_Evaluation_of_Suspected_Stroke_-_Alegent_Health_Administration_-_AH_(METRO).DOC 11/5/2007 Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Emergency Evaluation of Suspected Stroke
INCLUSION Criteria for t-PA: Alteplase (Activase)
Clinical diagnosis of ischemic stroke causing a Patient DOES NOT MEET criteria for t-PA: Alteplase
Base line CT scan showing no evidence of • STOP: Refer to Acute Stroke Management order
set (Doc #85510).
Time of symptom onset well established to be less than 180 minutes before treatment would begin. Patient is a candidate for t-PA: Alteplase (Activase).
Patient and/or family aware of the risk of • Emergency Department patient to remain in the hemorrhage (1 in 16) and potential benefit (30% Emergency Department until t-PA: Alteplase greater chance of improvement to No or Minimal Disability at 3 months compared with those that did • Transfer in hospital non-ICU patient to ICU as soon as not receive t-PA: Alteplase (Activase) therapy). EXCLUSION Criteria for t-PA: Alteplase (Activase)
Administer t-PA: Alteplase (Activase)
Contraindications / (Absolute/Relative)
Evidence of intracranial hemorrhage on pretreatment Alteplase (Activase) 0.09 mg/kg IV once for 1 minute Clinical presentation suggestive of subarachnoid • Alteplase (Activase) 0.81 mg/kg IV once for 59 minute maintenance dose. Maximum dose 81 mg. Refer to
CT shows multilobar infarction (hypodensity greater dosing table on page 3 of 3 for reference.
• Perform neuro checks and measure blood pressure every 15 minutes during the infusion and for 2 hours History of aneurysm or AVM or neoplasm. Acute bleeding diathesis including but not limited to: If the patient develops severe headache, acute - received heparin within 48 hours and has an hypertension, nausea, or vomiting, discontinue the t- PA: Alteplase (Activase) infusion, notify the physician, - currently on oral anticoagulants or recent use with an elevated prothrombin time >15 seconds or INR >1.7 • Whenever possible, avoid the placement of Uncontrolled hypertension: At the time treatment nasogastric tubes, indwelling bladder catheters, or systolic BP > 185 mmHg or diastolic BP > 110 mmHg intra-arterial pressure catheters for 24 hours after t-PA: Alteplase (Activase) infusion end time. Active internal bleeding or acute trauma. • No anticoagulants or antiplatelet agents (including,
Arterial puncture at a non-compressible site in the but not limited to: warfarin, aspirin, plavix, lovenox or heparin) within 24 hours of t-PA: Alteplase
Intracranial, intraspinal surgery or serious head Pregnancy, lactation, or parturition within the previous Labetalol 20 mg IV over 2 minutes for systolic blood pressure > 185 mm Hg or diastolic blood pressure Relative Contraindications
• If systolic BP remains > 185 mm Hg or diastolic BP Only minor (NIHSS <3) or rapidly improving stroke remains > 110 mm Hg for 10 minutes after first Labetalol dose, then administer Labetalol 40 mg IV Major surgery or other serious trauma during • Refer to Acute Stroke Post t-PA: Alteplase (Activase) order set (Doc #85511) for further orders. Recent acute MI or pericarditis within 3 months. Post myocardial infarction pericarditis Abnormal blood glucose <50 or >400mg/dl. ____________________________________________ CT scan shows evidence of large middle cerebral artery territory infarct: edema, mass effect, and _______________ (Date)____________(Time) obliteration of sulci in more than 1/3 of middle S:\Evidence Based Care\EBC Order Development\FY2008 Orders\Stroke\Word Processing Versions\DOCS-#85204-v1-EBC_-_Emergency_Evaluation_of_Suspected_Stroke_-_Alegent_Health_Administration_-_AH_(METRO).DOC 11/5/2007 Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Emergency Evaluation of Suspected Stroke
Dosing Table for t-PA: Alteplase (Activase):
100 mg vial to be prepared as a single stock bottle
with both the loading and maintenance doses
administered from this supply with unneeded
volume discarded.

S:\Evidence Based Care\EBC Order Development\FY2008 Orders\Stroke\Word Processing Versions\DOCS-#85204-v1-EBC_-_Emergency_Evaluation_of_Suspected_Stroke_-_Alegent_Health_Administration_-_AH_(METRO).DOC 11/5/2007 Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke Management Orders
Admit to Inpatient
__________________________________________ Neurology: Dr. __________________________ notified Pulmonary: Dr. __________________________ notified Cardiology: Dr. __________________________ notified Other: Dr. ______________________________ notified • Refer to medication reconciliation for home medications. • Neurocheck with vital signs per nursing unit protocol. • Assess tobacco status. Offer cessation education to all patients with a history of use in the past 12 months. • Pneumoccocal & Influenza screening and vaccination per • Oxygen and Oxygen Monitoring per RT Protocol. • Accurate intake and output every 8 hours. • Initiate and maintain saline lock if no other IV access. _______________________________________ (avoid use of hypotonic or glucose-containing replacement fluids) • Speech therapy to conduct bedside swallowing evaluation (if not already done); Notify physician of results.
• NPO until swallowing evaluation completed. • Speech, Physical and Occupational therapies each to
Acute Inpatient Rehab Referral (Call 572-2886) Referral is to admission coordinator for case review and facilitation. This is not a physician consult. DVT / Venous Thromboembolism (VTE) Prophylaxis:
• Nursing to screen all patients 18 years or greater for DVT/VTE Risk Factors. Place Thrombosis Prophylaxis order (Doc #83629) on chart and document total risk score for physician review and order modification as appropriate. Doc # 85510 v1, continued on page 2 of 2 DOCS-#85510-v1-EBC_-_Acute_Stroke_Management_Orders_-_Alegent_Health_Administration_-_AH_(METRO).DOC Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke Management Orders
Laboratory Orders: (specify date/time or frequency)
CBC: ________________________________________ Basic metabolic panel: ___________________________ PTT: _______________________________________ PT and INR: ___________________________________ Other: _____________________________________ Other: _____________________________________
Additional Diagnostics:
Other: _____________________________________ Evidence Based Reminders:
Other: _____________________________________ Medications:
Blood Pressure Treatment in Acute Stroke
Labetalol 10 mg IV over 2 minutes for systolic blood AHA Guidelines for the Early Management of Adults With pressure > 220 mm Hg or diastolic blood pressure > 120 mm Hg. May repeat every 20 minutes x 2. It is generally agreed that patients with markedly elevated blood pressure may have their blood pressure lowered. A reasonable goal would be to lower blood ___________________________________________. pressure by ~15% during the first 24 hours after onset of stroke. The level of blood pressure that would Warfarin (Coumadin) ___________________________ mandate such treatment is not known, but consensus for patients with atrial fibrillation, a cardioembolic source exists that medications should be withheld unless the of stroke, or a mechanical prosthetic heart valve. systolic blood pressure is >220 mm Hg or the diastolic Platelet Inhibitors for patients who do not have an
indication for Warfarin (Coumadin): Choose ONE Option.
(Class I, Level of Evidence C). This recommendation has changed from previous statements in that a potential goal Aspirin 81 mg orally once daily, OR
for lowering blood pressure is now included. (Stroke. Aspirin 325 mg orally once daily, OR
Aggrenox 25mg/200mg, 1 capsule orally twice daily, OR
Clopidogrel (Plavix) 300 mg loading dose times one dose, Contraindications to Statin Therapy
Pregnancy, breast feeding, active liver disease, or unexplained persistent elevation of serum transaminases.
________________________________________
Ordering MD/DO/NP/PA signature
_________________ (Date) _____________ (Time)
Doc # 85510 v1
DOCS-#85510-v1-EBC_-_Acute_Stroke_Management_Orders_-_Alegent_Health_Administration_-_AH_(METRO).DOC Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke POST t-PA: Alteplase (Activase) Orders

This order set is strictly for acute stroke patients who
have received t-PA: Alteplase (Activase) infusion and
should be executed immediately following the infusion.

• Document end time of t-PA: Alteplase (Activase) infusion:
Date: _________________ Time: ________________ • Admit to inpatient and place patient in ICU. • eICU Category II – Critical Care Management. • Place Acute Stroke Management order set (Doc #85510) on chart for physician review and completion. ______________________________________________ Neurology: Dr. __________________________ Pulmonary: Dr. __________________________ notified Cardiology: Dr. __________________________ notified Other: Dr. ______________________________ notified • Perform neuro check and measure blood pressure every
15 minutes for 2 hours, then every 30 minutes for 6 hours, • Oxygen and oxygen monitoring per RT protocol. • Speech therapy to conduct bedside swallowing evaluation; Notify physician of results and recommendations. NPO until swallowing evaluation completed. • Whenever possible, avoid the placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters for 24 hours after t-PA: Alteplase • No anticoagulants or antiplatelet agents (including, but
not limited to: warfarin, aspirin, plavix, lovenox or heparin) within 24 hours of t-PA: Alteplase (Activase) infusion end
Doc # 85511 v1, continued on page 2 of 2 DOCS-#85511-v1-EBC_-_Acute_Stroke_POST_t-PA_Alteplase_(Activase)_Orders_-_Alegent_Health_Administration_-_AH_(METR.DOC Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke POST t-PA: Alteplase (Activase) Orders
• Notify physician if patient exhibits worsening of
For symptomatic hemorrhage after t-PA has been
neurological symptoms, new or worse headache, or
given consider the following:
nausea/vomiting.
→ STAT head CT, if ICH suspected → Consult Neurosurgery for ICH → Check CBC, PT, PTT, platelets, fibrinogen and D- • IV fluids: ___________________________________ dimer. Repeat every 2 hours until bleeding is (avoid use of hypotonic or glucose-containing replacement fluids) → Give fresh frozen plasma 2 units every 6 hours for Labetalol 10 mg IV over 2 minutes for systolic blood pressure > 185 mm Hg or diastolic blood pressure → Give cryoprecipitate 20 units. If fibrinogen level < 200 mg/dL at 1 hr, repeat cryoprecipitate dose. • If systolic BP remains > 185 mm Hg or diastolic BP remains > 110 mm Hg for 10 minutes after first → Institute frequent neurochecks and therapy of Labetalol dose, then administer Labetalol 20 mg IV → May give aminocaproic acid (Amicar) 5 g in 250 cc ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ________________________________________ Ordering MD/DO/NP/PA signature _________________ (Date) _____________ (Time) Doc # 85511 v1 DOCS-#85511-v1-EBC_-_Acute_Stroke_POST_t-PA_Alteplase_(Activase)_Orders_-_Alegent_Health_Administration_-_AH_(METR.DOC Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke Discharge Orders
Discharge patient to:
Home with Home Health Care with the following: PT evaluate and treat _________ x per week OT evaluate and treat _________ x per week ST evaluate and treat _________ x per week SNF (must complete community wide transfer sheet) Transfer to Acute Rehab according to previously established plan (evaluation and acceptance). PT evaluate and treat 3 times per week for 4 weeks OT evaluate and treat 3 times per week for 4 weeks ST evaluate and treat 3 times per week for 4 weeks Other: _______________________________________\ Other: _______________________________________ Other: _______________________________________ Schedule Appt with Dr. ____________________________ Schedule Appt with Dr. ____________________________ Stroke Discharge Instructions
• Provide and review with patient/family the Acute Stroke • Dietitian to educate on post Stroke diet and weight Doc #85509 v1, continued on page 2 of 2 DOCS-#85509-v1-EBC_-_Acute_Stroke_Discharge_Orders_-_Alegent_Health_Administration_-_AH_(METRO).DOC Evidence Based Care
EBC Feedback Contact 717-6996
PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
PROGRESS NOTES/CONSULTATION
Acute Stroke Discharge Orders
Stroke Prophylaxis:
_______________________________________ _______________________________________ Other Medications:
For all appropriately selected patients with cerebrovascular disease (eg, history of transient ischemic attack or stroke), consider the use of antidepressants (eg, _______________________________________ selective serotonin reuptake inhibitors) for the prevention and treatment of depression. (Stroke 2006;37:2796- ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ __________________________________________ Ordering MD/DO/NP/PA signature _________________ (Date) _____________ (Time) DOCS-#85509-v1-EBC_-_Acute_Stroke_Discharge_Orders_-_Alegent_Health_Administration_-_AH_(METRO).DOC

Source: http://nestrokecouncil.com/protocols/pdf/AlegentHealthSystemDocs.pdf