House-wide Policy Template



The Stroke Program Orders and Policies are based on the American Stroke Guidelines for Acute Ischemic Stroke

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Vital signs and basic neuro checks are required per the Guidelines AND Hospital Policy. They are ordered:

Q15 min x 2 hrs, Q30 min x 6 hours, then Q 1 hour x 16 hours.

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A complete NIHSS MUST be completed:

Prior to tPA administration, upon completion of tPA infusion, 12 hours and 24 hours after tPA infusion.

|[pic] |Effective Date: 9/14 |Number: CCU101610 |

|CRITICAL CARE UNIT | | |

|Policy and Procedures | | |

| |Supersedes: 12/11 |Page: 1 of 2 |

| |Prepared by and manual to be contained in: |

| |Director/CCU |

| |Authority/Approved by: CNE/CCU Director |

|Title: Thrombolytic Therapy; Nursing Care of the Patient |

PURPOSE: To standardize the Care of patient on Thrombolytic Therapy.

POLICY STATEMENT:

Tissue Plasminogen Activator (TPA or Activase) is the only drug which is FDA approved for the treatment of acute ischemic stroke (AIS) within 3 hours of onset of symptoms. Streptokinase, Tissue Type Plasminogen Activator (TPA OR Activase) are current thrombolytic agents given during an acute myocardial infarction to reperfuse the coronary artery. Patients meeting established criteria may receive these agents upon order of the physician. The nurse will be responsible for administration of the drug and care of the patient following the infusion.

SCOPE: Nursing

KEY COLLABORATORS: Nursing, Cardiology

WHO MAY PERFORM: Critical Care Trained RNs, Emergency Department RNs

EQUIPMENT/SUPPLIES:

• Medication to be infused as ordered by the physician

• IV infusion pump

PROCEDURE:

1. Establish necessary IV lines prior to administration of the thrombolytic agent.

1. A separate line is required for infusion of thrombolytic medications.

2. Obtain lab studies as ordered by the physician.

1. Physician may order coagulation studies, CPK, troponin, fibrinogen levels, CBC prior to initiation.

2. For AIS, Code Stroke protocol will be activated and completed prior to order of TPA

3. Administer thrombolytic as ordered by the physician.

1. Patient will be on Heparin drip post thrombolytic infusion for acute myocardial infarction only.

4. Post “thrombolytic Precaution” sign at the head of the bed to alert all medical personnel to potential bleeding problems.

5. Post infusion, observe patient for signs of bleeding and instruct patient to notify RN if signs or symptoms should occur.

1. Watch for bleeding gums, vomiting blood, complaint of unusual back or leg pain, change in neurological status.

6. For AIS:

1. Monitor vital signs and neuro checks q15 min during infusion

2. Monitor vs and neuro checks q 15 min x 2 hours, q 30 min x 6 hours, q 1 hours x 16 hours post infusion

3. Repeat NIHSS 1, 12 and 24 hours post infusion

7. Monitor and treat any arrhythmias per standing orders

1. Coronary thrombolysis may result in arrhythmias associated with reperfusion.

2. Atrial fibrillation is a frequent cause of AIS

8. Monitor coagulation lab results (PTT or ACT) post infusion and report to physician as ordered.

1. Daily PTTs are usually ordered while patient is on heparin drip.

DOCUMENTATION: Document medication given on Medication Profile. Document patient response to medication, rhythm, and any adverse reactions on Nursing progress notes.

REFERENCES & RELATED DOCUMENTS:

| | |

|POLICY HISTORY |APPROVAL PATH |

| |P/P Committee: 12/11 |

|Revision Dates: 5/94, 6/97, 9/00, 4/03, 6/15 |Critical Care Committee: 12/11 |

| |Medical Executive Committee: 12/11 |

|Review Dates: 5/94, 6/97, 9/00, 4/03, 12/05, 7/08, 12/11, 9/14 |CHW Board 12/11 |

| |PCC 1/15 |

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