Admission Orders for Ischemic Stroke Following R-TPA /Alteplase Administration)

*GBH__* GBH

ACUTE ISCHEMIC STROKE ORDERS FOLLOWING r-tPA (Alteplase) ADMINISTRATION)

 Admit to ______( ICU ) DATE & TIME ______ Attending:______Resident: ______ Diagnosis ______S/P THROMBOLYSIS  Condition ______ Allergies ______ Weight ______kg  IV fluids: NS @ ______cc/hr  Elimination: □ Bathroom privileges ad lib □ Bedpan □ Use of bedside commode with transfer training  Vital Signs and Neuro Checks using the MEND Scale: During r-TPA (Alteplase) infusion: Every 15 minutes during infusion

Post Infusion: Every 15 minutes x 2 hours then every 30 minutes x 6 hours then: Every 1 hr x 24 hours, then

Every 2 hours (FOR ICU PATIENTS) Every 4 hours (FOR NON ICU PATIENTS)

Any change in patient status call physician.  Activity: Strict bed rest until cleared by Physical Therapy then activity level as directed by PT □ No lifting or pulling of shoulder on affected side □ HOB elevated 30 degrees □ Turn every 2 hours  Monitor Cardiac Rhythm  Nasal 02: titrate to greater than 95% saturation □ Discontinue oxygen if saturation above 95%.  Diet: Dysphagia screening completed by RN prior to ANY oral intake or medications given: Pass: □ YES □ NO ______RN Signature ______Date/Time □ DIET: ______□ NPO until clinical bedside dysphagia exam performed by speech pathologist.  Fall Precautions  VTE Prophylaxis: Refer to Deep Vein Thrombosis Prophylaxis Assessment and Orders form  SCD  Blood Pressure Management Systolic Blood Pressure 180 to 230 or Diastolic 105 to 120. 1. Consult MD IMMEDIATELY 2. Give Labetolol 10mg IV over 1-2 minutes. 3. May repeat Labetolol 10 mg IV or double the bolus every 10 minutes for a MAXIMUM DOSE OF 300mg. 4. Initiate continuous blood pressure monitoring 5. If response unsatisfactory consult MD

HOLD FOR ACUTE ASTHMA OR CHF EXACERBATION OR FOR HEART RATE LESS THAN 50 OR FOR RHYTHM OF 2ND OR 3RD DEGREE HEART BLOCK. Systolic Blood Pressure greater than 230 1. Consult MD immediately OR 2. Begin Nicardipine IV drip protocol (ICU ONLY). Admission Orders for Ischemic Stroke following r-TPA *«PatientNumber»* /Alteplase Administration) ACCT# «PatientNumber» DOB:«BirthDate» «Gender» «Age» Page 1 of 3 Revised 9/2008 «PatientName» «AdmitDate» «AdmitTime»

1 MR#«MedicalRecordNumber» «AttendingDoctorName» *GBH__* GBH

ACUTE ISCHEMIC STROKE ORDERS FOLLOWING r-tPA (Alteplase) ADMINISTRATION)

 For diabetic patients: Check blood glucose before each meal and at HS. If blood glucose is greater than 140 on two consecutive readings call House Officer for instructions. Notify physician of ALL admission blood glucose greater than 140.  Consult PT, OT, ST for evaluation and treatment upon admission  Consult Nutrition Services for evaluation and dietary education.  Consult Case Management for discharge planning.  Notify Stroke Coordinator (5-4243).  Consult Stroke Educator for Stroke Education (5-4613).  Provide Stroke Education: Types of Stroke, Complications, Personal Modifiable Stroke Risk Factors, Stroke Warning Signs and Symptoms; FAST; How to Activate EMS:911; Need for Follow up after Discharge; Prescribed Medications; Smoking Cessation; Heart Healthy Diet  Diagnostics to be performed in AM:

□ MRI Brain & MRA Brain and Neck without contrast: Stroke protocol □ MRA (Intracranial / Extracranial / Both) for Dx: Stroke □ MRI Brain without contrast, without MRA Dx: Stroke □ CT of Brain without contrast for stroke, following IV r-tPA (Alteplase) patient cannot have MRI □ Carotid Duplex Ultrasound for diagnosis stroke □ Echocardiogram for diagnosis stroke: Dr. ______to read.  Medications DO NOT ADMINISTER WITHIN 24 HOURS OF COMPLETING r-TPA INFUSION ASPIRIN HEPARIN TICLOPIDINE WARFARIN CLOPIDOGEL (PLAVIX) AGGRENOX NON STEROIDAL ANTI INFLAMMATORIES ANTI PLATELETS OR ANTI COAGULANTS □ ANTIPLATELET THERAPY AFTER 1ST 24 HOURS □ Aspirin 81 mg po daily □ Aspirin 325 mg po daily □ Plavix 75 mg po daily □ Aggrenox 1 capsule po BID □ Coumadin ______mg po Daily □ PT/INR daily □ Coumadin Education □ Lorazepam 1 mg IV every 20- 30 minutes prior to imaging procedure for agitation. May repeat X ______□ STATIN: ______(Consider STATIN for LDL greater than or equal to 100mg/dL; For Diabetic patients LDL greater than 70) □ ACE Inhibitor: ______□ Thiazide Diuretic: ______□ Laxative: ______□ Phenergan 12.5 mg PO/IV (diluted in 50 ml normal saline) every 4 hours PRN nausea □ Acetaminophen 1000 mg PO/PR every 4-6 hours PRN temp greater than 101.5 or for headache (NOT TO EXCEED 4 GRAMS DAILY) ACUTE ISCH EMIC STROKE ORDERS FOLLOWING r-tPA/ Alteplase ADMINISTRATION) *«PatientNumber»* Page 2 of 3 ACCT# «PatientNumber» DOB:«BirthDate» «Gender» «Age»

Revised 9/2008 «PatientName» «AdmitDate» «AdmitTime» MR#«MedicalRecordNumber» «AttendingDoctorName» 2 *GBH__* GBH ACUTE ISCHEMIC STROKE ORDERS FOLLOWING r-tPA (Alteplase) ADMINISTRATION)

 Medications □ Other Medications:

______

 Labs:

□ CBC w/diff, Platelets, □ Daily □ PT/PTT/INR □ Daily □ Basic Metabolic Profile □ Daily □ Cardiac enzymes q 8 hrs x 3 □ Fasting Lipid Profile (if not already done) □ Hgb A1C (if not already done) □ UA □ Urine C&S □ 2 Hour Glucose Tolerance Test □ ______□ ______□ ______

 Smoking Cessation Education  Pneumovax Vaccination Protocol

□ Verbal orders, read back x 1 and verification completed.

□ Telephone orders, read back x 2, and verification completed.

MD SIGNATURE:______ACUTE ISCHEMIC STROKE ORDERS FOLLOWING r-tPA/ Alteplase ADMINISTRATION) *«PatientNumber»* Page 3 of 3 ACCT# «PatientNumber» DOB:«BirthDate» «Gender» «Age» Revised 9/2008 «PatientName» «AdmitDate» «AdmitTime» 3