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VS/Neuro check/puncture site/neurovascular check:

Every 15 min x 4

Every 30 min x 2

Every 1 hr x 4

Then q 2h or as ordered

Post thrombectomy or Carotid stent:
Maintain SBP < 140 unless otherwise ordered to prevent hyperperfusion syndrome which causes ICH.

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Stroke pts are at high risk for aspiration.

Pt. must pass BSS by nurse or SLP prior to ANY PO intake including meds. (Notify provider if pt. fails)

Do BSS on arrival if BSS not done in our ED or transferred from another facility.

Once BSS completed, may not repeat unless:

Patient fails only do to low GCS

Patient improves post tPA or thrombectomy.

May not repeat BSS once pt. has been seen by SLP.

If provider orders PO med on pt. who has failed BSS, inform provider of results.  Then OK to give med with notation that provider aware of BSS result.

Do not document meds given enterally as PO. Order must be changed to reflect correct route.

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To start thrombolytic: BP must be less than 185/110

Then maintain BP less than 180/105

Check with provider for BP parameters!!

Monitor VS and neuro checks:

Every 15 mins X 2 hours

Every 30 min X 6 hours

Every hour X 16 hours

Watch BP cuff site for hematoma formation

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Early identification of neuro changes determines patient outcomes.

Always perform neuro checks as ordered or more frequently

Notify provider immediately of ANY neuro change, even if subtle.

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On arrival and at discharge

Jointly at any hand-off and BID at shift change to obtain baseline for your shift.

24 hrs post tPA or thrombectomy and if there is any blood on f/u imaging.

Do a complete NIHSS if you identify any neuro change.

Notify provider for any change of 2 or more.

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Provide the booklet Stroke: A Patient Guide.

Initiate Ischemic or Hemorrhagic Stroke Care plan

Document education every shift

Educate patient and family/caregiver if present

Document patient's individual risk factors

Enter Ischemic or Hemorrhagic Stroke education in Patient Pass

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- NIHSS/mRS on arrival and discharge
- BSS prior to any PO intake (must document correct route meds are given even if new order must be entered)
- Antithrombotic (antiplatelet or anticoagulant) by day after arrival and at discharge
- VTE prophy by day after arrival
- Draw lipid profile within 48 hours of arrival
- Statin ordered
- All consults (PT, OT, SLP, Psych, Care Manager) completed
- Patient education
- Documented q shift (include individual risk factors)
'BHU Stroke Discharge' in depart
Also as appropriate:
BHU Discharge Instructions for Carotid Stenting
BHU Discharge instructions for Carotid Endarterectomy

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Dorothy Adair 863-944-9243

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B = BALANCE Sudden trouble walking, dizziness, loss of balance or coordination.

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- Check ABCs - Vital Signs
- POC Glucose
- NIHSS or neuro check
- Determine when last seen at baseline

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Inadequate BP Management could result in death.

Always clarify BP parameters with provider each shift: do not rely on powerplan orders alone.

Maintain BP within desired limits. Use PRNs, then drips.  Notify provider if unable to maintain BP with ordered meds.

Document follow up BP within 15 minutes after IV BP meds given or titrated.

Document follow up BP within 1 hour after PO BP meds given

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Pre-securement re-bleed

Keep SBP < 140-160

Vasospasm causes DCI (delayed ceredbral ischemia):

Monitor for very subtle neuro changes

May require intervention

May require higher BP

Hydrocephalus: monitor EVD

Seizures:

Sub clinical sz may present as just decreased LOC. Identified on continuous EEG.

Takotsubo: temporary heart failure "broken heart syndrome" cardiomyopathy.

Severe persistent headache:

Use multimodal pain management

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NIHSS every 2 years.

Enter in People soft

Provide manager with copy for file

Stroke First Responder annually
BSS annually
Complete assigned modules to complete total of 8 hours of Stroke Education annually

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Maintain SBP < 140 unless otherwise ordered to prevent hyperperfusion syndrome which causes ICH.

Assess VS, neuro check (including CN IX-XII), wound and neck circumference:

Every 15 min x 4

Every 30 min x 2

Every 1 hr x 4

Then q 2h or as ordered

(CN IX-XII includes 'Swallow' and 'Shoulder/Head' movement in Neuroscience band

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Notify provider If unable to give any med (antithrombotic, nimodipine, etc.)

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Notify provider If unable to give any med (antithrombotic, nimodipine, etc.)

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Some medications can not be held and require dose adjustment or NGT placed.

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Same frequency as BP monitoring

If symptoms worsen or patient has decreased LOC or vomiting (signs of increased ICP):

Stop alteplase

Notify provider

Stat non contrast CT head

Provider may resume alteplase if CT neg for blood

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Consults- All stroke pts must be assessed by the following:

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Consults- All stroke pts must be assessed by the following:

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PT/OT/ SLP as indicated.

Psychology for depression screen and cognitive decline.

If unable to have psych consult,  complete Stroke Depression Screen (ad hoc form)

Case Manager/Social Worker for discharge planning.

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NIHSS Scoringcheat sheet-abbreviated with mRS 

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Initiate Carotid Revascularization Care Plan.

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Kristin Davies 904-707-5719

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E = EYESIGHT Sudden trouble seeing in one or both eyes

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Call 7777 to initiate a Rapid Response for Code Stroke.
Call 202-STROke (2-7876) for stat consultation with Stroke Neurologist

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Ischemic Stroke no intervention:

Permissive HTN with max BP 220/120 (1st 24-48 hrs)

Ischemic stroke post thrombolytic:

Permissive HTN with max BP 180/105

Ischemic Stroke post endovascular intervention or CEA:

Maintain SBP less than 140

ICH or SAH:

Maintain SBP < 140 or < 160 per MD order

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Apply/document SCD’s for VTE prophy

24 hours after alteplase:

Perform NIHSS

Obtain NCCT Head (or other brain imaging) to r/o bleeding.

If imaging negative for blood: start antithrombotic (ASA, plavix, etc) and start SQ lovenox or heparin for VTE prophy if indicated

If any head imaging post tPA is  head positive for blood: perform another NIHSS

If MRI negative, may downgrade to W5 after 12 hours.

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Cheryl Lewis 904-860-4066

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F = Face Droop  Sudden weakness or numbness of the face

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- Use Code Stroke powerplan.
- If only CT head requested order: Code Stroke CT
Goal: get to CT stat with patient on transport monitor for HR, BP, and sPO2.

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Internal bleeding

ICH, retroperitoneal, GI, GU, respiratory

Superficial bleeding

All skin puncture sites (hold pressure to control)

Oral-lingual angioedema

Usually within 1st 2 hrs, monitor for swelling of lips and tongue

If this occurs, notify provider STAT, pt may require rapid intubation

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Kirstin Del Pizzo 609-661-0868

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A =  ARM DRIFT Sudden weakness or numbness of the arm and/or leg, especially on one side of the body

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- Taking anticoagulants? If so, when was last dose?
- Taking sedating meds? If so, when was last dose?
- Recent surgery/procedure? Any recent severe bleeding?
- Any history of intracranial hemorrhage?
- Other pertinent history?

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Dorothy Adair 863-944-9243

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S= SPEECH Sudden confusion, trouble speaking or understanding

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Wendy Camp

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T = TIME TIME IS BRAIN!  Call 7777 for a Rapid Response/Code Stroke

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All Ischemic stroke, and non traumatic ICH and SAH are considered "stroke patients"

Baptist Neuroscience Institute moto: Treat every patient as you would expect your loved one to be treated.