Process
If symptoms are captured when EMS calls, a pre-alert to ETC is activated and overhead “stroke alert eval” EMS ETA in min, get tele monitor to bedside. Once pt arrives, we follow the same process to hallway 18, place in a weighted stretcher, stroke team (ED, and stroke MD, RN, Charge RN, paramedic, pharmacy), obtain, PIV x1, collect labs, take weight, and bgl, then directly to CT with tele monitor, TS may continue to eval pt in CT. team also collects family contact from EMS if available.
What is the stroke alert process for patients that arrive via EMS?
Prior to first po intake
What is a dysphagia screen?
RN accesses the provider notification flowsheet in EPIC for a Blood Pressure of 220/105
What is documenting provider notification of assessment outside parameters?
Bottle of Sterile water 100ml.
What is the dilutant used for alteplase reconstitution?
Over one minute
What is the amount of time to IV push the tPA bolus given?
Aspirin administered rectally
What is the alternative to PO route for Aspirin/antithrombotic administration?
Performed on arrival or upon noticing stroke symptoms, on handoff, and anytime there is a change in LOC
What is an NIHSS assessment?
Same infusion rate as alteplase infusion.
What is the rate of infusion for the 50ml Normal Saline flush post TPA?
Alteplase 90mg – any pt over 100kg
What is the max dose for alteplase?
60 min from start to finish.
What is the length of time the tPA infusion and NS 50ml flush run for?
SPO2 of at least 95% or greater.
What is the minimum required 02 sat for stroke patients?
Q1H - for 72 hrs while in the ED
What is the ESI level for Brain bleeds?
Neuro and vital assessments q15min x2 hrs; q30min x6 hrs; q1h x 16hrs
What is the neurological and vital signs assessment documentation frequency for post IV TPA patients?
RN, ANM, OR Charge Nurse must accompany the patient from the ED and conduct bedside handoff NIHSS with the IP RN.
What roles can transport a stroke alert patient?
Less than 30 minutes from arrival.
What is the goal DTN time?
Neg CTH, 2 PIV, BP within parameter
What are three things the nurse must ensure prior to administering tPA?
Similar to the post alteplase frequency: q15min x2 hrs; q30min x6 hrs; q1h x 16hrs.
What is the thrombolytic adverse reaction assessment and reassessment frequency?
The time Normal Saline flush bag was started post TPA, and rate of flush.
What is the TPA Normal Saline flush MAR documentation?
Blood Pressure 180/105
What is the max/ceiling BP parameter post tPA?
Within 15 min prior to Alteplase administration.
What is the time requirement for the pre alteplase vitals/neuro assessment to be completed?
Overhead page, take patient to HW 18, place in a weighted stretcher, stroke team (ED, and stroke MD, RN, Charge RN, paramedic, pharmacy), obtain, PIV x1, collect labs, take weight and bgl, then directly to CT with tele monitor, TS eval pt in CT.
What is the process for activating a stroke evaluation on walk-in patients?
Level 2
What is the ESI level for Stroke/TIA patients?
Neuro “X”, LOC, Orientation, cognition, speech, facial symmetry, pupil (size, shape, reaction, description, movement). Hand grasp, motor response, motor strength, sensation. GCS, NIHSS.
What are the required neurological assessment documentation components?
Stroke alert patients, stroke work up patient, any patient with neurological deficit, patient with head Ct ordered, patient with incidental stroke finding.
What are the indications to perform a dysphagia screen on a patient?
Blood Pressure of 185/110 or greater prior to TPA. Could try labetalol push first, cardene if IV push doesn’t lower BP.
What is the max ceiling BP parameter prior to TPA and the medications that can be administered to lower BP outside parameter?