Acute Stroke & Transient Ischaemic Attack

Acute Stroke & Transient Ischaemic Attack
Clinical Pathway / Blacktown Hospital @WSLHD

Goals/ Outcomes
Pathology/
Diagnostic Tests
Treatment
Nursing Care
Nutrition /
Hydration
Activity
Referrals /
Consults
Patient/ Family
Education
Discharge
Planning
Admission Day
/
/
Day 0-1 (1st 24hrs) > ED to Stroke Unit
Identify acute ischaemic / haemorrhagic / TIA / others
Document time and date of symptoms onset
___________________________________
Scandinavian Stroke Scale..
Swallowing screening / Safe swallowing
Brain CT scan without contrast
FBC, PT / APTT / INR, ESR, EUC, LFT, BSL
ECG / CXR / UA
Consider: MRI CTA TOE / TTE Carotid Doppler
IV - N/S if NBM or dehydrated
BP management as per Consultant / medication ordered
Febrile 37.5C Paracetamol; 38C septic work-up
BSL 5-10mmol/L > q6h ; BSL: > 10mmol/L Insulin inf.
Evaluate prior medications / Continue pre-existing meds
Bowel regime
AntiplateletS / oral or PR
Consider: Anticoagulation > Consultant decision
Avoid Heparin & Clexane
Consider: Thrombolysis ( IV < 4.5h ) Nicotine patch
Neuro obs and vital signs q4h, (or as per protocol if
thrombolysed)
Stroke telemetry BP, HR, T, SaO, cardiac rhythm
BSL q6h before meals & bedtime
Bowel / Bladder assessment & management
Avoid indwelling catheter / Post voiding scanning
HOB up 30 / Turn q4h or prn if on bed rest
Positioning of hemi-paretic limb / Protect & Support
Institute Falls Risk precautions
Waterlow Pressure Area risk assessed / addressed
Consider: Fine bore NG for medication & early nutrition
NBM or diet as recommended by Speech Pathologist
IV fluids N/S Only +/- K+
Nutritional support via fine bore NG
Diabetic diet if Diabetes Mellitus
Functional assessment, encourage participation in
functional activities.
Increase activity / exercises of hemiparetic limbs, as per
Physio and OT assessment
Stroke CNC
Social Worker
Physiotherapist
Occupational Therapist
Speech Pathologist
Diabetic Educator
Pharmacist
Orthoptist
Consider: Cardiology Neurosurgery Endocrinology
Orientate to stroke unit
Education about tests / monitoring / planned care
Education about stroke risk factors and complications
Evaluation of pre-existing function and home environment
Case discussion and planning at multidisciplinary meeting
Patient Name_____________________________MRN___________
Day 2
/
/
Acute Stroke Unit
Neuro status stabilised / improving / deteriorating
Avoid complications -aspiration, infection, DVT / PE, falls
Initial diagnostic test results documented.
Rehab therapies initiated / continued / Rehab goals set/documented
Barthel Index..
Fasting Lipid / Glucose / HBA1c
Follow up abnormal test results
APTT daily if therapeutic on heparin
PT / INR daily if on Warfarin
If patient received thrombolysis, CT brain without contrast.
Review / cease IV fluids
Assess BP management adequacy and medications
BSL 5-10mmol/L > q6h ; BSL: > 10mmol/L Insulin infusion
Bowel regime
Consider: anticoagulation > Consultant decision
Secondary stroke prevention ACEI Statins Nicotine patch
Thrombolysis after 24hrs > CT scan, then begin antiplatelets
Neuro obs and vital signs q4h (or as per protocol if

thrombolysed)
Stroke telemetry BP, HR, T, SaO , cardiac rhythm
Avoid indwelling catheter / Post-voiding scanning
Trial of voiding
HOB up 30o / Turn q4h or prn if patient on bed rest
Positioning of hemi-paretic limbs / Protect & Support
Pressure area risk / Falls Risk
Assess NG tube patency / positioning q8h
Advance diet as per Speech Pathologist or NBM if
dysphagia / Safe swallowing precautions
Fine bore NG tube and feeds, goal rate set
Functional assessment, encourage participation in
functional activities
Increase activity / exercises of hemiparetic limbs as per Physio
and OT assessment
Completion of consults from Day 1
Rehabilitation referral
Dietitian
Social Work / counselling
Consider: Vascular Surgery
Education about tests, diet and care of hemiparetic limbs
Reinforce stroke education / secondary stroke prevention
Discuss plans / goals for rehabilitation
Discussion with family re: aim for discharge as appropriate
Case discussion and planning at multidisciplinary meeting.
Day 3
/
/
Acute Stroke Unit
Neuro status stabilised / improving / deteriorating
Avoid complications
Diagnostic tests documented
Rehabilitation therapies continued as appropriate.
Patient / Family understands stroke causes and risk factors
PT / INR daily if on Warfarin
Consider: Repeat CT (if stroke not yet confirmed )
Review / cease IV fluids
Management plan for hypertension
BSL 5-10mmol/L > q6h ; BSL: > 10mmol/L Insulin infusion
Bowel regime
Consider: Anticoagulation > Consultant decision
Neuro obs and vital signs q4h

Stroke telemetry may be ceased if stable
Avoid indwelling catheter/ Trial of voiding / Bladder scanning
HOB up 30o / Safe swallowing precautions
Turn q4h or prn if patient on bed rest
Pressure area risk / Falls Risk
Advance diet as per Speech Pathologist recommendation
NBM if dysphagia / Safe swallowing precautions
Fine bore NG tube and feeds monitor goal rate for
adequate nutrition
Functional assessment, encourage participation in functional
activities
Increase activity / exercises of hemiparetic limbs as per PT & OT
Electrical stimulation if appropriate
Completion of consults from Day 2
Referral to Smoking cessation Clinic
Others
Ongoing stroke education

Medication education, eg. Warfarin /ACEI /Statin / Antiplatelet
Rehabilitation waiting list as appropriate
Case discussion and planning at multidisciplinary meeting
TIA patient may be discharged as appropriate
Acute Stroke & Transient Ischaemic Attack

Clinical Pathway / Blacktown Hospital @WSLHD
Goals/ Outcomes
Pathology/
Diagnostic Tests
Treatment
Nursing care
Nutrition /
Hydration
Activity
Day 4
/
/
Acute Stroke Unit
Neuro status stabilised / improving
Avoid complications
Rehabilitation therapies continued as appropriate.
Patient / Family understands stroke causation & risk
factors
INR daily if on warfarin
IV if required N/S Only +/- electrolytes
Medication review
Diabetes management plan
Antiplatelets / anticoagulation long-term planning
Neuro obs and vital signs q4h

Bowel / Bladder assessment / training
BSL daily or q6h if > 10mmol
Turn q4h or prn if patient mobility restricted
Positioning of hemiparetic limbs / Protect & Support
Pressure area risk / Falls Risk assessment / addressed
Diet advanced / maintained as per Speech
Pathologist recommendation
Continue nutrition requirements as per Dietitian
Maintain NG tube feeds at goal rate.
Encourage independence and participation in functional
activities
Increase activity / exercises of hemiparetic limbs as per
Referrals /
Consults
Rehabilitation inpatient / outpatient
Patient/ Family
Education
Stroke Outreach Service

Reinforce stroke risk factors education
Medication education, eg. Warfarin, antiplatelet agents
Discuss / finalise plans for rehabilitation / discharge
Discharge
Planning
Confirm discharge plan

Inpatient Rehabilitation / Outpatient Rehabilitation
Placement in Nursing Home / Hostel
Home + Community Support
Informal - family Formal - Specify..
Home independent
Transfer to other wards; eg. AGU / Med / CSDU / TCU
Patient Name_____________________________MRN___________
Day 5
/
/
Acute Stroke Unit
Complications avoided
Rehab therapies continued as appropriate.
Discharged planning finalised
Aware of risk factors modification
INR daily if on Warfarin
Continue management plan
Neuro and vital obs q4h

HOB up 30o/ Safe swallowing precautions
Diet advanced / maintained as per Speech Pathologist
Maintain NG tube feeds at goal rate.
activities
Consider: Long term feeding options Gastro review
OT home visit
Reinforce stroke / medication education, eg. Warfarin
Education for skills to manage patient at home
Discharge as appropriate
Discharge instructions confirmed re: medication, diet, equipment

Discharge Barthel Index
Day 6 or Discharge Day

/
Step Down from Stroke Unit
Complications avoided
Aware of sings and symptoms of stroke
Follow up post discharge organised.

INR daily if on Warfarin
Review medication prior to discharge
Reinforce Secondary Stroke Prevention
Anticoagulation / antiplatelet plan
BP management
Lifestyle changes; eg smoking cessation, ETOH, weight
Diabetes
Hyperlipidemia
Vitals as required
Diet maintained / advanced as per Speech Pathologist
Maintain NG tube feeds at goal rate
activities
Rankin Score.
Follow up Post-Acute Stroke Support Clinic
Follow up Neurovascular Clinic
Appointment Geriatrics Medicine / Neurology
Ensure knowledge of stroke signs and symptoms
Reinforce risk factor modification / lifestyle adaptation
Reinforce medication management plans
Education re: rehabilitation goals & needs
Contact details for support and follow up given
Discharge as appropriate
Follow up arrangements by Allied Health
Discharge Barthel Index
Version 5 / November 2013
Source: Clinical Guidelines for Stroke Management 2010. www.strokefoundation.com.au

Acute Stroke & Transient Ischaemic Attack

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Acute Stroke & Transient Ischaemic Attack

Diunggah oleh

Hak Cipta:

Format Tersedia

Acute Stroke & Transient Ischaemic Attack

Clinical Pathway / Blacktown Hospital @WSLHD

Neuro obs and vital signs q4h (or as per protocol if

Neuro obs and vital signs q4h

Ongoing stroke education