Stroke
ICH/SAH
TNK
Medications
Documentation
100

BP parameter <140/<90

Goal for patient with Spontaneous ICH/SAH

100

Pt. with subdural hematoma post fall

Traumatic Bleed

100

Q 15 min assessment of VS, NIHSS, complete neuro, and  Thrombolytic reaction

Post TNK documentation

100

antihypertensive medication drip in stroke

Nicardipine second line

100

Eye Opening - Spontaneous

Verbal Response- Oriented

Motor Response- Obeys commands

Glascow Coma Scale score 15

200

Complications to monitor post TNK

Bleeding

Angioedema

200

Pt. with hx HTN, no trauma with Intracerebral hemorrhage

Spontaneous ICH

200

Change in LOC

new HA

N/V

NIHSS increase greater or equal to 3 points

Criteria to notify MD

200

Labetalol 10mg every 10 min. x2

First line antihypertensive with in strokes

200

GCS

Pupils

Grips, pushes, and pulls

Complete neuro exam

300

20 minutes

Door to CT Goal

300

BP <140/<90

Spontaneous hemorrhage BP goal

300

lips swelling 

Angioedema

300

Benadryl epi pepcid solumedrol

treatment for angioedema

300

NIHSS, Neuro, VS Q30 x4

Documentation for code 20

400

LKW <4.5 h PTA alert

Code Neuro

400

Bed position in pt. with Intracerebral hemorrhage

>30 degree's

400

pt. is at increased risk for angioedema

Pt. taking ace inhibitors

400

Diuretic used to decrease intracranial pressure

Mannitol

400

Every stroke TIA, Ischemic, and bleed requires a

Swallow screen

500

LKW 16 hr with weakness and aphasia

Positive VAN score-code neuro- Large Vessel Occlusion Candidate

500

220/110 BP

Permissable HTN in Ischemic stroke, no TNK

500

Team pause prior to administering TNK

Time out

500

prophylactic medication to prevent seizures

Keppra
500

document document documment

all delays for CT, Blood, TNK

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