Remake of Stroke: Inpatient Units by Odalys Gregory https://padlet.com/osoto1013/wklh8q6memp8l5jx Because Time is Brain en-us 2022-08-10 14:12:56 UTC 2022-08-10 14:12:58 UTC hello@padlet.com https://vtnews.vt.edu/content/dam/vtnews_vt_edu/articles/2013/03/images/030113-vtc-brain.jpg osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234312 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234312 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234314 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234314 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234315 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234315 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234317 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234317 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234318 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234318 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234319 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234319 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234320 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234320 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234321 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
]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234321 Possible complications: osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234322
  • 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



    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234322     BP Management osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234323
  • 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
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234323     BP GOALS osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234324 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

    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234324     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234325 - Check ABCs - Vital Signs
    - POC Glucose 
    - NIHSS or neuro check
    - Determine when last seen at baseline]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234325     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234326 Call 7777 to initiate a Rapid Response for Code Stroke.
    Call 202-STROke (2-7876) for stat consultation with Stroke Neurologist]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234326     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234327 - 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.]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234327     History osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234328 - 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? ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234328     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234329 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234329 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234330 B = BALANCE Sudden trouble walking, dizziness, loss of balance or coordination. ]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234330 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234331 E = EYESIGHT Sudden trouble seeing in one or both eyes]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234331 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234332 F = Face Droop  Sudden weakness or numbness of the face]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234332 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234333 A =  ARM DRIFT Sudden weakness or numbness of the arm and/or leg, especially on one side of the body]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234333 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234334 S= SPEECH Sudden confusion, trouble speaking or understanding]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234334 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234335 T = TIME TIME IS BRAIN!  Call 7777 for a Rapid Response/Code Stroke]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234335 osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234336 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.  ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234336     Downtown osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234338 Dorothy Adair 863-944-9243

    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234338     South osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234339 Kristin Davies 904-707-5719]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234339 Beaches, Nassau, all FSEDs osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234340 Cheryl Lewis 904-860-4066]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234340 Stroke Educator osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234341 Kirstin Del Pizzo 609-661-0868]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234341 Stroke Navigator osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234342 Dorothy Adair 863-944-9243]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234342 Director osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234345 Wendy Camp]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234345 Ischemic Stroke Quality Measures osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234346 - 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

    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234346     Q shift Stroke Education osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234347
  • 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

    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234347     For Carotid Procedures: osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234348
    Initiate Carotid Revascularization Care Plan.


    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234348     NIHSS on all stroke Patients osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234349
  • 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.
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234349     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234350 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234350 Neuro checks osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234351
  • 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.
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234351     Consults- All stroke pts must be assessed by the following: osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234353
  •  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.
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234353     BP osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234354
  • 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
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234354     Neuro checks osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234355
  • 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
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234355     Follow up osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234357
  • 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.
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234357     Possible Complications osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234358
  •  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
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234358     Bedside Swallow Screen (BSS) osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234359
  • 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. 
    • ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234359     Notify provider If unable to give any med (antithrombotic, nimodipine, etc.) osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234360 Some medications can not be held and require dose adjustment or NGT placed.]]> 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234360 All Endovascular Cases: osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234361 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.
    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234361     Post CEA osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234362
  • 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

    ]]>     2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234362     osoto1013 https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234363 2022-08-10 14:12:56 UTC https://padlet.com/osoto1013/wklh8q6memp8l5jx/wish/2258234363