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Order Sets for Hospitals

The following are recommended order sets for use by hospitals within the StrokeCareNow Network (SCNN).

  • Call is made to the SCNN Physician
    • Stroke Onset Time Determined
    • National Institutes of Health Stroke Scale (NIHSS) completed with the SCNN Physician

Stroke Activate Orders Initiated:

  • Place 2 large (20g or larger) bore IVs - one in the antecubital if not already present.
  • Labs: CBC with differential, APTT, INR, Protime, Basic Metabolic Panel, Creatinine Kinase, Magnesium, SGOT, Total Bilirubin, Alkaline Phosphatase, Sed Rate, Troponin (need to bundle these together to decrease time for drawing and processing) Serum pregnancy test for all pre-menopausal women. Items that have to be complete before giving tPA (Activase/Alteplase): PTT, PT/INR, H&H and platelets.
  • Non-contrast CT of the head  STAT.  Indication:  Stroke
  • CT perfusion and CTA of head/neck  STAT.  Indication:  Stroke.  (If available)
  • Maintain O2 saturation greater than 94%
  • EKG stat
  • IV fluids:
    • 0.9% Sodium Chloride IV at ______ml/hr.
    • 0.45% Sodium Chloride IV at ______ml/hr.
    • Saline Lock.
    • Other:__________________________at ________ml/hr.
  • Medications:
    • Hold any Metformin-containing products for 48 hours following CT perfusion.
    • Labetalol 10-20 mg IV push over 1-2 minutes. May repeat times 1 for systolic B/P greater than 180 or diastolic B/P greater than 105.
    • Cardene(Nicardipine) 25 mg/250 ml Sodium Chloride IV infusion 5 mg/hour (50 ml/hr). Titrate 2.5 mg/hr every 5-15 minutes to keep systolic B/P 170-190 or diastolic B/P 90-110. Maximum dose 15 mg/hour (150 ml/hour) Once B/P range is obtained, titrate Cardene(Nicardipine) to 3 mg/hour (30 ml/hour).
  • Obtain weight
  • B/P, pulse respirations and neuro checks every 15 minutes

Characteristics of Patients with Ischemic Stroke who Could be treated with tPA (Activase/Alteplase)

▢ Diagnosis of ischemic stroke causing measurable neurological deficit
▢ Neurological signs should not be clearing spontaneously
▢ Neurological signs should not be minor and isolated
▢ Caution should be exercised in treating a patient with major deficits
▢ Symptoms of stroke should not be suggestive of subarachnoid hemorrhage
▢ Onset of symptoms less than 3 hours before beginning treatment (up to 4.5 hours in select patients)
▢ No head trauma or prior stroke in previous 3 months
▢ No myocardial infarction in the previous 3 months
▢ No gastrointestinal or urinary tract hemorrhage in previous 21 days
▢ No major surgery in the last 14 days
▢ No arterial puncture at a noncompressible site in the previous 7 days
▢ No history of previous intracranial hemorrhage
▢ Blood pressure not elevated (systolic less that 185 mm Hg and diastolic less than 110 mm Hg)
▢ No evidence of active bleeding or acute trauma (fracture) on examination
▢ Not taking an oral anticoagulant or, if anticoagulant being taken, INR less than or equal to 1.5
▢ If receiving heparin in previous 48 hours, aPTT must be in normal range
▢ Platelet count greater than or equal to 100,000 mm3
▢ Blood glucose concentration greater than or equal to 50 mg/dl (2.5 mmol/L)
▢ No seizure with postictal residual neurological impairments
▢ CT does not show a multilobar infarction (hypodensity greater than 1/3 cerebral hemisphere)
▢ Patient or family understands the potential risks and benefits from treatment

tPA (Activase/Alteplase) Stroke orders

  • Initiate tPA Vital Sign/Neurocheck form
  • Begin transfer process to hub hospital.
  • Place foley cath
  • NG tube placement if speech or swallowing ability questioned
  • Patient weight: _________Kg
  • Bolus dose (0.09 mg/Kg)_______________(maximum bolus 9 mg) IVP over one minute.
  • Infusion dose (0.81mg/kg): ______________(maximum infusion dose 81 mg) over one hour.
  • Total dose (0.9 mg/Kg): __________ maximum dose 90 mg.
  • Have 0.9 Normal Saline ready for infusion post tPA infusion (to flush line from the spike down).

Drip and ship orders:

  • Transfer to Hub Hospital:
  • ALS transport to Hub hospital
  • Monitor for bleeding
  • VS and Neuro checks q 15 minutes during transport
  • Maintain NPO

Community Hospital Admission Orders

* items indicate Quality measures

  • Height and weight on admission
  • Vital signs and neuro checks every 2 hours times 4, then every 4 hours
  • I&O
  • Cardiac monitoring
  • Anchor NG tube and connect to low intermittent suction
  • Anchor urinary catheter
  • Bedside glucose before and after meals
  • Maintain O2 Saturation greater than 94%
  • Respiratory therapy to evaluate and treat
  • Keep head of bed elevated to 30 degrees
  • Turn patient every 2 hours while in bed if unable to move self
  • Passive range of motion to affected extremities three times daily
  • *Swallow evaluation by nursing prior to first oral intake including medications
  • NPO until swallow evaluation
  • *Provide Stroke Education packet, review information with patient and family and document
  • *Provide smoking cessation if patient has smoked within the last 12 months
  • *Intermittent pneumatic compression devices with graduated compression stockings on at all times while in bed
  • Monitor/evaluate bowel function daily
  • Physical therapy to evaluate and treat
  • *Occupational therapy to evaluate and treat
  • Speech therapy to evaluate and treat
  • *Make referral to Rehabilitation facility
  • Swallow evaluation by Speech therapy
  • Lifestyle interventions
  • Activity orders
  • Labs: *Lipid profile
  • Special tests: CT of head, MRI, EEG, Carotid ultra sound, Echocardiogram, Chest X-ray
  • *Antiplatelet Agent: ASA, Plavix, Aggrenox
  • *Lipid altering agent: Zocor, Lipitor, Crestor, Zetia