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DRAFT
Patient Data
REGIONAL
Acute Ischemic Stroke/TIA Orders
Bar Code Area
Bar Code Area
Rev: 30JA12
Page: 1 of 4
DRUG & FOOD ALLERGIES
Bullets are active orders*. Cross out orders not indicated (initial), place (9) in boxes as appropriate.
POST
t-PA TREATMENT FOR
Date:
____________________
Time:ISCHEMIC
_________ hSTROKE –
FIRST 24 HOURS
Admit to:
Medicine
Telemetry
MRP:________________________________
Diagnosis:
Thromboembolic Stroke
ICU/CCU
Other ______________
Neurologist Consultant: ___________________________________
High Risk TIA
Date: ________________________
NIH Stroke Scale: Baseline score = ________
(See back pg 1)
24 H score (if applicable) = ________ Date: ________________________
No
Yes
If yes, when:
Did patient receive ALTEPLASE (rt-PA)?
(patient must be 24 hours post-thrombolytic to use these orders)
Time: _________
Time: _________
Date: ___________________
Time: ______
MEDICATIONS:
•
Acetaminophen 650 mg PO/rectally q4h PRN if temperature greater than 37.5°C or if pain. Maximum 4000
mg per day (maximum 3000 mg per day if eGFR is less than 30 mL/min or frail elderly).
Antiplatelet Therapy:
STAT ASA 320 mg (4 x 80 mg) PO x 1 dose (if not already done as per Regional Stroke/TIA Initial Assessment)
• Ongoing chewable ASA 80 mg PO/NG once daily
• If NPO and no NG tube then 650 mg rectally once daily. Once NG in place, switch to ASA 80 mg via tube once
daily. When able to swallow whole pill, switch to E.C. ASA 81 mg PO once daily (notify pharmacy).
Clopidogrel 75 mg PO daily or ____________________
300 mg loading dose
Reassess dual therapy (ASA + Clopidogrel) at 30 days
Aggrenox (ASA 25 mg/Dipyridamole 200 mg SR ) one capsule PO bid (complete non-formulary form;
Physician to complete Pharmacare coverage form)
• If Aggrenox prescribed, discontinue plain ASA above
Venous Thromboembolism (VTE) Prophylaxis (see back of page 2 for more details):
Dalteparin 5000 units subcutaneously once daily
Heparin 5000 units subcutaneously
q8h
q12h
Enoxaparin
40 mg subcutaneously once daily or
40 mg q12h if morbidly obese (BMI greater than 40)
• Discontinue when mobilizing independently daily
Therapeutic Anticoagulation (see back of page 2 for more details):
• Continue with venous thromboembolism prophylaxis if previously ordered and start:
Warfarin 5 mg PO x 1 day: ___________ (mm/dd, usually started day 2-14 of ischemic stroke, after
asymptomatic ICH has been ruled out; or started immediately for patients with TIA and atrial fibrillation)
INR daily, starting: ___________ (mm/dd)
Discontinue venous thromboembolism prophylaxis when INR greater than 2 for 2 consecutive days
Discontinue ASA when INR greater than 2 for 2 consecutive days
Pharmacist anticoagulation dosing service (where applicable at sites)
Other:________________________________________________
Physician Signature: _________________________
Physician Printed Name: ____________________________
DRAFT
Patient Name
Regional Acute Ischemic Stroke/TIA Orders
(cont’d): NIH Stroke Scale
Rev 30JA12
Patient Unit Number
Back of Page 1
Recommended Frequency of Assessment : Initial & 24 hours and at Discharge
National Institute of Health Stroke Scale (NIHSS)
CATEGORY
1a. Level of Consciousness
**Patients who score 2 or 3 on this
item should be assessed using the
Glasgow Coma Scale
1b. LOC questions:
(month, age)
1c. LOC commands:
(opens/closes eyes, make fist,
release fist). May use gestures
2. Best Gaze:
Patient follows examiner’s finger or
face through full horizontal field
3. Visual:
(introduce visual stimulus/threat to
patients field quadrants)
4. Facial Palsy
(show teeth, raise eyebrows,
squeeze eyes shut). May use
gestures
5a. Motor arm – Left
Test each limb independently
for 10 seconds.
Sitting: Arms outstretched 90°
Supine: Arms at 45°
Encourage best effort.
5b.Motor arm – Right (as above)
6a. Motor Leg – Right
Test each limb independently:
with patient supine, elevate
extremity to 30°and score
drift/movement over 5 sec.
6b. Motor Leg – Left (as above)
7. Limb ataxia
(finger – nose, heel down shin)
8. Sensory (pin prick to face, arm,
trunk, and leg – compare side to
side. Aphasic pt: assess grimace
9. Best language
(name item, describe a picture, and
read sentences)
10. Dysarthria
(Evaluate speech clarity by having
patient read or repeat listed
words)
11.Extinction and inattention
(use information from prior testing
to identify neglect or double
simultaneous stimuli testing)
Date and time
CHOOSE THE BEST RESPONSE
Alert, and keenly responsive
Not alert - obey, answer, or respond to minor stimulation
Not alert - responds to repeated or painful stimuli
Unresponsive or responds only to motor, autonomic reflex
Answers both correctly
Answers one correctly
Answers neither question correctly
Answers both correctly
Answers one correctly
Answers neither question correctly
Normal
Partial gaze palsy; abnormal gaze in one or both eyes
Forced deviation –deviation or total paresis not overcomed
by oculocephalic maneuver (Doll’s eyes)
No visual loss
Partial hemianopia -or quadrant field deficit
Complete hemianopia - dense field loss, (such as ½)
Bilateral hemianopia (blind)
Normal
Minor paralysis - mild asymmetry on smiling
Partial paralysis - paralysis of lower face
Complete - one or both sides paralysis of upper, lower face
0
1
2
3
0
1
2
0
1
2
0
1
2
No drift (limb holds for 10 seconds)
Drift (limb drifts downward; does not fall/ rests on support)
Some effort against gravity (drift to fall on a support)
No effort against gravity - trace movement, limb falls
No voluntary movement
Amputation, joint fusion, etc.
0
1
2
3
4
X
No drift (limb holds for full 5 seconds)
Drift (limb drifts downward; does not fall to rest on support)
Some effort against gravity (drift to fall on a support)
No effort against gravity -trace movement, limb falls
No voluntary movement
Amputation, joint fusion, etc.
Absent
Present in one limb
Present in two limbs
Normal
Mild to moderate sensory loss (less sharp/dullness)
Sensory or total sensory loss (not aware of touch)
No aphasia
Mild to moderate aphasia(reduced fluency/comprehension)
Sever aphasia (communication exchange very limited)
Mute, global aphasia
Normal articulation
Mild to moderate dysarthria (slurred but understandable)
Severe dysarthria (unintelligible or worse)
Intubated/trached (or other physical barrier)
No abnormality (no neglect)
Visual, tactile, auditory, spatial, or personal inattention, or
extinction to bilateral stimulation in one sensory modulation
Profound: more than one modality affected
0
1
2
3
4
X
0
1
2
0
1
2
0
1
2
3
0
1
2
3
0
1
Total Score
0
1
2
3
0
1
2
3
2
R
L
R
L
R
L
R
L
R
L
R
L
DRAFT
Patient Data
REGIONAL
Acute Ischemic Stroke/TIA Orders
Bar Code Area
Bar Code Area
Rev: 30JA12
Page: 2 of 4
DRUG & FOOD ALLERGIES
Bullets are active orders*. Cross out orders not indicated (initial), place (9) in boxes as appropriate.
Date: ___________________
Time: __________
POST t-PA TREATMENT FOR
ISCHEMIC STROKE –
FIRST
24
HOURS
MEDICATIONS (continued)
ACE Inhibitor:
_____ mg _____ time(s) daily
• Ramipril
• Perindopril _____ mg _____ time(s) daily
• Other _______________________________
Lipid Lowering Medication:
• Simvastatin 10 mg 20 mg 40 mg PO once daily (at 1700 h)
• Atorvastatin 40 mg 80 mg PO once daily
Antihypertensive Medication:
• Target BP Range = ______________ ; Physician to calculate ~ 15% BP reduction in first 24h after stroke onset
(maximum 25% BP reduction; see back of page 2 for calculation table)
• Notify physician if BP remains outside target range or neurological deterioration occurs
Blood
Pressure
(mmHg)
Systolic BP
less than 220
and
Diastolic BP
less than 120
Intervention
•
•
•
Observe unless other end-organ involvement, e.g. aortic dissection, acute myocardial infarction, pulmonary
edema, hypertensive encephalopathy
Treat other symptoms of stroke such as headache, pain, agitation, nausea, and vomiting.
Treat other acute complication of stroke (including hypoxia, increased intracranial pressure)
Critical Care Areas:
Systolic
BP greater
than 220
mmHg
or
Diastolic
BP greater
than 120
mmHg
•
Labetalol 10 mg IV over 1- 2 min. May repeat Labetalol 10-80 mg (double previous dose) IV q10 min PRN to
a maximum of 300 mg in 24 h. Contact physician if target BP not achieved after 3 doses. HOLD Labetalol if
heart rate less than 60 BPM. Monitor BP q10 min until target BP achieved for 2 consecutive readings; then
vital signs and neurovital signs q30 min x 2, then q2h x 24 h.
(Note: Labetalol onset 5 minutes, peak 15 minutes, duration 2 to 4 h)
•
If BP rises above target, restart BP protocol as above.
Acute Care Areas:
•
Captopril 6.25 to 12.5 mg sublingually STAT, then q30 MIN PRN if sBP greater than 220 mmHg or dBP
greater than 120 mmHg on two readings 20 minutes apart. Contact physician if target BP not achieved 1 h of
cumulative dose 25 mg given. After each dose check BP at 15 min, 30 min, 1 h and q2h for 8 h and then
until stable. (Note: Captopril onset 15 minutes, peak 1 h, duration 6 to 8 h.)
hydrALAZINE 10 to 20 mg IV in 50 mL NS, infused over 1h PRN (maximum of 300 mg in 24 h; monitor blood
pressure q15 min during infusion and at 15 and 30 minutes after each dose; contact physician if blood
pressure not controlled after 3 doses and consider need for higher level of care
Other (see suggestions on back of page 2)___________________________
Physician Signature: ___________________________
Physician Printed Name: _____________________________
DRAFT
REGIONAL
Acute Ischemic Stroke/TIA Orders (cont’d):
Patient Name
Blood Pressure & Anticoagulation Guidelines
Patient Unit Number
Back of Page 2
Rev: 30JA12
BP Reduction Chart: 15% & 25%
Systolic BP
220
230
240
250
260
270
280
290
300
310
320
Diastolic BP
220
210
200
190
180
170
160
150
140
130
120
15%
Reduction
187
196
204
213
221
230
238
247
255
264
272
25%
Reduction
165
173
180
188
195
203
210
218
225
233
240
15%
Reduction
187
179
170
162
153
145
136
128
119
111
102
25%
Reduction
165
158
150
143
135
128
120
113
105
98
90
Other Antihypertensive Options
Caution:
ACEI used in patients receiving Alteplase
(rt-PA) have been associated with slightly
increased risk of angioedema
• Enalaprilat – 0.625 – 1.25mg IV
q6h prn; incremental doses of
0.625-1.25 mg may be repeated
every 15-60 minutes to a
maximum of 5 mg in 6 h
• Lisinopril 5-15 mg SL daily
• Nitroglycerine patch (40-60 minute
onset)
• Hydralazine 10-25 mg QID PO
• Amlodipine 2.5-5 mg daily PO
VTE Prophylaxis
VTE Prophylaxis should be offered if the patient:
• Has had or is expected to have significantly
reduced mobility for 3 or more days, OR
• Is expected to have ongoing reduced mobility
relative to their normal state, and has 1 or more of
the following risk factors:
o active cancer or cancer treatment
o age over 60 y
o critical care admission
o dehydration
o known thrombophilias
o obesity (BMI over 30 kg/m2)
o any significant comorbidity (e.g heart
disease; metabolic endocrine or respiratory
pathology; acute infectious disease;
inflammatory conditions)
o personal history or first-degree relative with
a history of VTE
o use of hormone replacement therapy or
estrogen-containing contraceptive
o varicose veins with phlebitis
(Venous thromboembolism: reducing the risk, NICE Clinical Guideline
92, January 2010)
VTE prophylaxis should continue for the duration of
increased risk
• in long term immobile patients, the risk of VTE is
significantly reduced after 4 months of immobility.
Therapeutic Anticoagulation
• Treatment dose heparin/heparinoid anticoagulation
is not recommended in acute ischemic stroke and
atrial fibrillation
• Optimal timing of oral anticoagulation following
acute ischemic stroke (with atrial fibrillation) is
unclear; usually started day 2-14 of ischemic
stroke, after asymptomatic ICH has been ruled out;
or started immediately for patients with TIA and
atrial fibrillation)
• Dabigatran and Rivaroxaban are non-formulary.
Re-ly and Rocket-AF trials did not enroll patients
within first 14 days of stroke, nor first 3-6 months of
severe stroke
DRAFT
Patient Data
REGIONAL
Acute Ischemic Stroke/TIA Orders
Bar Code Area
Bar Code Area
Page: 3 of 4
Rev: 30JA12
DRUG & FOOD ALLERGIES
Bullets are active orders*. Cross out orders not indicated (initial), place (9) in boxes as appropriate.
POST_________________
t-PA TREATMENT FOR ISCHEMIC
STROKE –
Date:
Time:_________
FIRST 24 HOURS
MEDICATIONS (continued): Blood Glucose Management:
•
Glucometer qid (ac tid + hs). If on enteral feeds, glucometer Q6H
INSULIN Regimen as at home (Specify): _______________________________________________
_________________________________________________________________________________
INSULIN Basal:
NPH ________________________________ (dose and times)
Other ________________________________
INSULIN REGULAR HUMAN subcutaneously (per dosing specified below) tid ac at 0730h, 1130h, 1630h
(NOT qhs unless specified below)
Serum Glucose
(mmol/L)
Less than 4
4-10
10.1-12
12.1-14
14.1-16
16.1-18
18.1-20
Greater than 20
□ Standard Regimen
□ Resistant Regimen
□ Other Regimen
No insulin; initiate Hypoglycemia Protocol; notify MD
0
0
2 units
5 units
4 units
8 units
6 units
10 units
8 units
12 units
10 units
14 units
12 units & call MD
16 units & call MD
□ HS Insulin
units
units
units
units
units
units
__units & call MD
Standard Regimen: suggested starting point for most patients (thin, elderly, or on steroids, insulin and oral hypoglycaemic medications)
Resistant Regimen: suggested starting point for overweight/previously high insulin requirement patients
DIET:
•
•
•
Screen for swallowing impairment using Regional Stroke Swallowing Screening Tool
NPO until swallow screening completed
If swallowing is impaired, order a swallowing assessment and keep patient NPO.
If swallowing is normal, initiate diet as appropriate:
□ NPO
□ DAT
□ Diabetic _______ kcal
□ Dysphagia ________________
□ Other _________________
•
Call Physician if: patient becomes NPO or when enteral feeding is initiated or stopped; persistent nausea and
vomiting unresponsive to treatment, a change in level of consciousness.
Physician Signature: ___________________________
Physician Printed Name: _____________________________
DRAFT
REGIONAL
Acute Ischemic Stroke/TIA Orders
Bar Code Area
Patient Data
Bar Code Area
Rev: 30JA12
Page: 4 of 4
DRUG & FOOD ALLERGIES
Bullets are active orders*. Cross out orders not indicated (initial), place (9) in boxes as appropriate.
Date: _________________
Time:_________
POST t-PA TREATMENT FOR ISCHEMIC STROKE –
FIRST 24 HOURS
INVESTIGATIONS
(only if not already completed):
•
•
•
•
•
Urinalysis
Troponin I
Hemoglobin A1c (glycosylated hemoglobin)
Chest X-ray: □ portable □ PA
Other _____________________
CT Head non-contrast
CT Angio
Other __________________
ECG (12 lead)
CBC, electrolytes, BUN, SCr, random blood glucose, INR, PTT, TSH, CK
Fasting blood glucose (minimum 12 hour fasting period)
Fasting lipid profile (minimum 12 hour fasting period)
Carotid Doppler ultrasound
Echocardiogram
Holter Monitor
MONITORING:
•
•
•
•
•
Vital signs, SpO2 and Neurovital signs [Glasgow coma scale, pupil and motor strength assessments] q2h or
q ___h for first 24h, then q4h x 24h, then q8h x 24h.
Notify Physician if Glasgow Coma Scale changes by more than 1 POINT or signs of neurological
deterioration.
Titrate 02 to keep Sp02 saturations greater than or equal to 92% or ____ %
Braden Scale on admission then daily x4days then reassess; discontinue when patient ambulating
Glucometer qid (ac tid + hs). If on enteral feeds, glucometer Q6H
Cardiac Monitor (Telemetry) x 24 hours then reassess
ACTIVITY:
AAT
Head of Bed Up (not to exceed 30 degrees): ____
Bedrest
Other ___________
REFERRALS:
•
•
•
•
•
Physiotherapist
Occupational Therapist
Speech Language Pathologist
Dietitian
Transition Planning
Patient/Family Counselling
Psychosocial Assessment
Social Worker:
Pharmacist:
Medication history/review
Education
Other _____________________
Physician Signature: _________________________
Physician Printed Name: ________________________