STROKE GUIDELINES

SCOPE: Evaluation and treatment of acute stroke for inpatient care.

DEFINITION: Admitting diagnosis of acute stroke, which is based on clinical assessment in the emergency room or other sources of admission (clinic or
other service). Excluding: Subarachnoid hemorrhage, transient ischemic attacks, and intracerebral hemorrhage, subdural hematoma.
PURPOSE: To reduce unnecessary utilization of hospital resources.
Emergency Room
⇓
⇓ Acute CVA? - Determine time of onset by ER. In ER for patients who are to be admitted:
⇓ Order CXR, EKG, lytes, CBC, other indicated labs.
Neurology consult - Discussion between neurology and ER Initiate IV
⇓ regarding decision to admit patient CT scan - ordered STAT (high priority)
⇓ 1. Candidate for TPA.
home ⇐ ⇐ ♦ ⇒ ⇒ refer to another service for admission a. Deficit with known time of onset less than 3 hours
⇓ ⇓ ⇓ b. Not on anticoagulants
⇓ ⇓ ⇓ c. Not severely hypertensive
arrange for ⇓ follow-up by Neurology consults CT scan - ordered by ER physician for:
follow-up care. ⇓ 1. Large deficit (i.e., decrease level of consciousness).
⇓ CT scan - ordered by Neurology physician for:
Admit as inpatient for Neurology service 1. Patient to be anticoagulated.
⇓ ⇓ 2. Strong suspicion of cerebellar stroke.
UNSTABLE STABLE ♦ Need to document reason for CT scan.
⇓ ⇓ * Consider later if patient is stable and results of scan - waiting may
Intensive Care ⇓ improve diagnostic accuracy, and less likely to repeat.
⇓ ⇓ Upon Admission:
STABLE ⇒ ⇒ ⇒ ⇒ ⇒ ward History and physical completed - Routine labs recorded - Initial clinical
impression stated and plan identified - Complete physician orders -
Include social service consult - Notify primary care MD
Areas to consider in treatment:
1. Treatment of complications to stroke:
a. MD to assess swallowing - If taking po - Cap IV -OR ⇒ If not taking po ⇒ ⇒ NPO b. Aphasia ⇒ Speech Therapy
⇓ or unsure of ⇓ c. Motor, Sensory, Coordination
⇓ PO status ⇓ Deficits ⇒ PT/OT
⇓ ⇓ ⇓
Order diet Consider swallow study Consider Rehab consult
⇓ (through Social Service)
If taking adequate d. DVT prophylaxis -
PO for 12-24 hrs., If on bedrest ⇒ Consider SCDs or
DC IV. SQ Heparin, 5,000 Units, BID
2. Consider treatment to prevent another stroke: 1. Risk factor reduction-Tx of Hypertension, Diabetes, Hyperlipidemia, Smoking, etc.
2. ASA or Ticlid 250mg. po, BID.
3. Anticoagulation with Heparin/Coumadin.
4. Carotid Endarterectomy
5. Less common therapies (e.g., immunosuppression).
3. Definitive diagnostic workup to assess for etiology of stroke:
Diagnostic interventions: Criteria: (Ask: Will therapy be influenced by findings??)
Cardiology, Hematology, Internal Medicine consult: Cardiac disease, coagulopathy,, comorbidities.
Carotid Dopplers: Stroke in carotid artery distribution AND a surgical candidate or to rule out tandem disease
Echocardiogram: Evidence of heart disease on history/exam/CXR/EKG/ AND a candidate for anticoagulation
OR Young adult. Evidence for embolic CVA by history (E.g. CVA occurred while awake).
Repeat CT scan/MRI: Clinical deterioration, atypical course or therapy directly influenced by result of test.
MR Angiogram: Therapy directly influenced by result of test.
Transesophageal echocardiogram: Therapy directly influenced by result of test.
Cerebral Angiogram: Not a resource utilization problem due to risk of adverse event.
Transcranial dopplers, Lumbar puncture, EEG. ?

FOR CONTINUED HOSPITALIZATION: FOLLOW-UP:

1. NPO Status 2. Intravenous Medications 1. Neurology follow-up 2. Primary care follow-up
3. Progression of stroke 3. Special Care Unit stay 3. If on Coumadin, check PT in 1 - 2 weeks.
4. Angiogram/Arteriogram 4. If on Ticlid, check CBC in 2 weeks if newly started.

NOTE: The Clinical Practice Guideline/Critical Pathway is meant to serve as a guideline for routine patient care. When the condition of
the patient warrants, treatment decisions must be dictated by the skill and judgment of the health care professional.
IF PT CARD OR LABEL NOT AVAILABLE, WRITE DATE, NAME AND UH# IN SPACE BELOW

CVA CRITICAL PATHWAY

Department of Neurology

Medical Record Form 5629 - Neuro01- 4/15/98

The University of Texas Medical Branch Hospitals
Galveston, Texas

Original - Medical Record

INCLUSION CRITERIA: Ischemic Stroke. Patient has moderate to severe deficits, and patient would benefit from OT or PT or Speech
intervention, and will not achieve independence at discharge from acute care.
OUTCOMES
1. Improve consistency of care of stroke patients 4. Primary care follow up 6. PT in 1 - 2 weeks if on Coumadin
2. Decrease costs 5. Neurology follow up 7. CBC in 2 weeks if on Ticlopidine for less
3. Decrease length of stay than 3 months
DAY 1 DAY 2
PHYSICIAN Neurology consults to see patient. Admit to floor if DC IV if taking diet
stable, to ICU if unstable Carotid Doppler, ECHO, Holter monitor if indicated
INTERVENTIONS
NIH stroke scale PTT if Heparin therapy
CXR, ECG, and lab results on chart
C CT as determined by M.D. Nutrition Consult if:
R Order PT, OT, and speech evaluation and treatment - Tube feeds need to be initiated.
I M.D. assess swallow.
T P.O. diet is ordered per speech recommendation if
I patient has dysphagia.
NPO if patient has dysphagia.
C
Order speech pathology consult if pt has dysphagia.
A Determine need for anti coagulant, hypertensive, and
L home meds
Social Work consult
TREATMENT * Case Manager - screen * - Patient and family participate in goal setting.
- Evaluation complete.
- Consult to OT initiated. - Patient/family education initiated.
- Consult to speech is initiated. Specify speech and/or - Counsel patient/family for adjustment/ adaptation to
P swallow evaluation. illness, lifestyle changes, etc.
A - Consult Social Work initiated. - Educate patient/family about social/financial needs,
support, options.
T
Pharmacy (in conjunction with MD) - Make contingency plan if family’s first choice is not
H - Evaluate for appropriateness of antiplatelet therapy. available.
W - Recommend or concur with established antiplatelet/ Pharmacy
A Anticoagulant therapy. - Review patient’s current medication profile (Include OTC
Y - Review patient medication profile/practices for practices).
medications which may worsen cerebral flow. - Determine if drug therapy practices contributes to risk of
- If placed on coumadin, establish dose for target INR 2nd event or worsening of 1st event.
- Confirm request for anticoagulant therapy laboratory
monitoring post 48 hours from initiation of therapy
ACTIVITY VS q2 hours x 24; Neuro checks q2 hours x 24 VS q4 hours; Neuro ck’s q4 hours
Bedrest; TED Hose or SCD’s OOB to chair or bedrest; TED Hose or SCD’s
Eggcrate or Specialty Bed; Turn q2 hours Eggcrate or Specialty Bed; Turn q2 hours
BOWEL & BLADDER I&O’s q shift I&O’s q shift
Diaper/condom cath PRN; Stool Softener Diaper/condom cath PRN; Stool Softener
TEACHING Orient Pt/Family to unit/care Orient Pt/Family to unit/care
RN assessment of learning needs RN assessment of learning needs
Continued teaching as needed
OTHER Self Determination Act ; Spiritual needs
STATUS AND EXPECTED Initial Status: Goal Initial Status: Goal
Eating __ _5_ Bed Mobility __ __
OUTCOMES
Grooming __ _5_ Transfers __ __
Bathing __ _3_ Locomotion __ __
Toileting __ _3_ LE Strength/
Dressing __ _3_ ROM __ __
Equipment __ _√_ Equipment __ √_
Home Program __ _√_ Orthotics __ √_
Orthotics __ _√_ Patient/family
Patient/family education __ √_
education __ _√_ Other Home Pgm __ √_
Caregiver independent in Caregiver independent in
assisting patient. assisting patient.
Progress on track? Yes No _________ Yes No _________
Check / Initial initials initials

NOTE: The Clinical Practice Guideline/Critical Pathway is meant to serve as a guideline for routine patient care. When the condition of
the patient warrants, treatment decisions must be dictated by the skill and judgment of the health care professional.
IF PT CARD OR LABEL NOT AVAILABLE, WRITE DATE, NAME AND UH# IN SPACE BELOW

CVA CRITICAL PATHWAY

Department of Neurology

Medical Record Form 5629 - Neuro01- 4/15/98

The University of Texas Medical Branch Hospitals
Galveston, Texas

Original - Medical Record

INCLUSION CRITERIA: Ischemic Stroke. Patient has moderate to severe deficits, and patient would benefit from OT or PT or Speech
intervention, and will not achieve independence at discharge from acute care.
OUTCOMES
1. Improve consistency of care of stroke patients 4. Primary care follow up 6. PT in 1 - 2 weeks if on Coumadin
2. Decrease costs 5. Neurology follow up 7. CBC in 2 weeks if on Ticlopidine for less
3. Decrease length of stay than 3 months
DAY 3 DAY 4
PHYSICIAN Feeding guidelines per Speech Therapy Increase tube feeding (if present) per dietary
Consult dietary if tube feeding needed Discuss discharge destination with nursing, therapies,
INTERVENTIONS
Further tests/consults as needed and social service
Physical rehabilitation and medicine consult (if ppropriate)
TREATMENT - Moderate assist with eating. - Moderate assist with grooming and hygiene.
- Moderate assist with SROM & strengthening. - May assist in don/doff gown.
- Moderate verbal cues in scanning for ADL. - Discharge recommendations made to team.
- Patient/family education. - Equipment recommendations made team.
- Modified Barium swallow study if indicated. - Ambulation or wheelchair mobility.
- Bed mobility. - Home Program.
- Ambulation or wheelchair mobility. - Recommendations for equipment.
C
Nutrition Evaluation:
R - If po intake not tolerated <50% consumed or still npo. Social Work:
I Social Work: - Explore and pursue options of family’s choice.
T - Explore and pursue options of family’s choice. - Seek availability.
I - Seek availability. - Present information to family.
- Present information to family. - Reassess and modify plan as needed.
C - Reassess and modify plan as needed. - Consult, confer, and confirm with appropriate receiving
A - Consult, confer, and confirm with appropriate receiving facility SW/RN/D/C planner about long-term d/c plan.
L facility SW/RN/D/C planner about long-term d/c plan. - Execute choice of d/c plan.
- Execute choice of d/c plan. - Present proposed long-term d/c plan chosen by family.
- Present proposed long-term d/c plan chosen by family. Pharmacy:
Pharmacy: - Review pt clinical profile for drug associated risk factors
- Review pt clinical profile for drug associated risk factors contributing to worsening of cerebral ischemia.
P contributing to worsening of cerebral ischemia. - Monitor therapeutic response of current medication
A - Monitor therapeutic response of current medication profile.
profile. - Recommend continuation or adjustment of antiplatelet
T - Evaluate PT (INR) and/or a PTT. and/or anticoagulant dose.
H - Recommend continuation or adjustment of - If warfarin dose changed, recommend PT (INR)
W antiplatelet and/or anticoagulant dose. measurement in 48 hours.
A - If warfarin dose changed, recommend PT (INR) - Begin patient/care giver drug education interaction for
measurement in 48 hours. discharge planning.
Y
ACTIVITY - VS q4 hours - TED Hose or SCD’s - VS q4 hours - TED Hose or SCD’s
- Neuro ck’s q4 hours - Eggcrate or Specialty Bed - Neuro ck’s q4 hours - Eggcrate or Specialty Bed
- OOB to chair - Turn q2 hours - OOB to chair - Turn q2 hours
BOWEL & BLADDER I&O’s q shift; Diaper/condom cath PRN; Stool Softener I&O’s q shift; Diaper/condom cath PRN; Stool Softener

TEACHING -Orient Pt/Family to unit/care; -RN assessment of -Orient Pt/Family to unit/care; -RN assessment of
learning needs; -Teaching info given to pt/family learning needs; -Teaching info given to pt/family
OTHER Grief/Emotional Counseling

STATUS AND EXPECTED Initial Status: Goal Initial Status: Goal Initial Status: Goal Initial Status: Goal
Eating __ _5_ Bed Mobility __ __ Eating __ _5_ Bed Mobility __ __
OUTCOMES
Grooming __ _5_ Transfers __ __ Grooming __ _5_ Transfers __ __
Bathing __ _3_ Locomotion __ __ Bathing __ _3_ Locomotion __ __
Toileting __ _3_ LE Strength/ Toileting __ _3_ LE Strength/
Dressing __ _3_ ROM __ __ Dressing __ _3_ ROM __ __
Equipment __ _√_ Equipment __ √_ Equipment __ _√_ Equipment __ √_
Home Prgrm __ _√_ Orthotics __ √_ Home Prgrm __ _√_ Orthotics __ √_
Orthotics __ _√_ Patient/family Orthotics __ _√_ Patient/family
Patient/family education __ √_ Patient/family education __ √_
education __ _√_ Other Home Pgm __ √_ education __ _√_ Other Home Pgm __ √_
Caregiver independent in Caregiver independent in Caregiver independent in Caregiver independent in
assisting patient. assisting patient. assisting patient. assisting patient.
Progress on track? Yes No _________ Yes No _________
Check / Initial initials initials

NOTE: The Clinical Practice Guideline/Critical Pathway is meant to serve as a guideline for routine patient care. When the condition of
the patient warrants, treatment decisions must be dictated by the skill and judgment of the health care professional.
IF PT CARD OR LABEL NOT AVAILABLE, WRITE DATE, NAME AND UH# IN SPACE BELOW

CVA CRITICAL PATHWAY

Department of Neurology

Medical Record Form 5629 - Neuro01- 4/15/98

The University of Texas Medical Branch Hospitals
Galveston, Texas

Original - Medical Record

INCLUSION CRITERIA: Ischemic Stroke. Patient has moderate to severe deficits, and patient would benefit from OT or PT or Speech
intervention, and will not achieve independence at discharge from acute care.
OUTCOMES
1. Improve consistency of care of stroke patients 4. Primary care follow up 6. PT in 1 - 2 weeks if on Coumadin
2. Decrease costs 5. Neurology follow up 7. CBC in 2 weeks if on Ticlopidine for less
3. Decrease length of stay than 3 months
DAY 5 DAY 6
PHYSICIAN Increase tube feeding (if present) Discharge summary if needed
Chest x-ray if going to nursing home (if not done earlier)
INTERVENTIONS
TREATMENT - Minimum assist with SROM and strengthening. Moderate assist toileting.
- Home Program. ___ Standard
- Minimum assist with grooming and hygiene. ___ Raised
- Ambulation or wheelchair mobility.
- Minimum assist in rolling. - Standby assist with grooming and hygiene.
- Moderate assist supine to sit. - Minimum assist with upper extremity dressing.
C Social Work: (continue the following on DAY 6) - Moderate assist with lower extremity.
R - Explore and pursue options of family’s choice. - Moderate assist with bathing.
I - Seek availability. - Ambulation or wheelchair mobility.
- Present information to family. - Transfers.
T
- Reassess and modify plan as needed. - Family training/home program prior to D/C.
I - Consult, confer, and confirm with appropriate
C receiving facility SW/RN/D/C planner about long- Social Work:
A term d/c plan. - See DAY 5
L - Execute choice of d/c plan.
- Present proposed long-term d/c plan chosen by Pharmacy:
family. - Review patient clinical profile for drug associated risk
Pharmacy: factors contributing to worsening of cerebral ischemia.
- Review patient clinical profile for drug associated - Monitor therapeutic response of current medication
P risk factors contributing to worsening of cerebral profile.
A ischemia. - Recommend continuation or adjustment of antiplatelet
T - Monitor therapeutic response of current medication and/or anticoagulant dose.
H profile. - If warfarin dose changed, recommend PT (INR)
W - Recommend continuation or adjustment of measurement in 48 hours.
antiplatelet and/or anticoagulant dose. - Continue patient/care giver drug education interaction for
A - If warfarin dose changed, recommend PT (INR) discharge planning.
Y measurement in 48 hours. - Evaluate patient/care giver regarding drug education
- Continue patient/care giver drug education program.
interaction for discharge planning. - Reinforce drug compliance importance.
ACTIVITY - VS q4 hours - TED Hose or SCD’s - VS q4 hours - TED Hose or SCD’s
- Neuro ck’s q4 hours - Eggcrate or Specialty Bed - Neuro ck’s q4 hours - Eggcrate or Specialty Bed
- OOB to chair - Turn q2 hours - OOB to chair - Turn q2 hours
BOWEL & BLADDER I&O’s q shift; Diaper/condom cath PRN; Stool softener I&O’s q shift; Diaper/condom cath PRN; Stool Softener
TEACHING Orient Pt/Family to unit/care Orient Pt/Family to unit/care
RN assessment of learning needs RN assessment of learning needs
Teaching info given to pt/family Teaching info given to pt/family
Discharge teaching as needed Discharge teaching as needed
STATUS AND EXPECTED Initial Status: Goal Initial Status: Goal Initial Status: Goal Initial Status: Goal
Eating __ _5_ Bed Mobility __ __ Eating __ _5_ Bed Mobility __ __
OUTCOMES
Grooming __ _5_ Transfers __ __ Grooming __ _5_ Transfers __ __
Bathing __ _3_ Locomotion __ __ Bathing __ _3_ Locomotion __ __
Toileting __ _3_ LE Strength/ Toileting __ _3_ LE Strength/
Dressing __ _3_ ROM __ __ Dressing __ _3_ ROM __ __
Equipment __ _√_ Equipment __ √_ Equipment __ _√_ Equipment __ √_
Home Program __ _√_ Orthotics __ √_ Home Program __ _√_ Orthotics __ √_
Orthotics __ _√_ Patient/family Orthotics __ _√_ Patient/family
Patient/family education __ √_ Patient/family education __ √_
education __ _√_ Other Home Pgm __ √_ education __ _√_ Other Home Pgm __ √_
Caregiver independent in Caregiver independent in Caregiver independent in Caregiver independent in
assisting patient. assisting patient. assisting patient. assisting patient.
Progress on track? Yes No _________ Yes No _________
Check / Initial initials initials

NOTE: The Clinical Practice Guideline/Critical Pathway is meant to serve as a guideline for routine patient care. When the condition of
the patient warrants, treatment decisions must be dictated by the skill and judgment of the health care professional.
IF PT CARD OR LABEL NOT AVAILABLE, WRITE DATE, NAME AND UH# IN SPACE BELOW

CVA CRITICAL PATHWAY

Department of Neurology

Medical Record Form 5629 - Neuro01- 4/15/98

The University of Texas Medical Branch Hospitals
Galveston, Texas

Original - Medical Record

INCLUSION CRITERIA: Ischemic Stroke. Patient has moderate to severe deficits, and patient would benefit from OT or PT or Speech
intervention, and will not achieve independence at discharge from acute care.
OUTCOMES
1. Improve consistency of care of stroke patients 4. Primary care follow up 6. PT in 1 - 2 weeks if on Coumadin
2. Decrease costs 5. Neurology follow up 7. CBC in 2 weeks if on Ticlopidine for less
3. Decrease length of stay than 3 months
DAY 7
PHYSICIAN Discharge orders
Discharge summary signed
INTERVENTIONS
NIH stroke scale
Transportation form signed
Follow-up appointments as needed
TREATMENT - SBA Eating.
- Upper extremity orthotics provides as appropriate.
- Equipment recommended made.
C
- Caregiver competent in assisting patient.
R - Written Home Program and family education
I provided.
T - Equipment adjusted for discharge.
I - Lower extremity orthotics recommended as
C appropriate.
- Family training/home program prior to D/C.
A
- Nutrition recommendations and education as
L appropriate prior to D/C.
Social Work:
- Confirm and execute appropriate d/c plan to
appropriate facility.
P - D/C patient.
Pharmacy:
A
- Participate in discharge process as per request of
T medicine.
H - Discuss compliance potential/problems w PCP.
W - Be available for family questions regarding
A medication profile.
Y

TEACHING Reassess DC teaching for understanding

Discharge teaching as needed
STATUS AND EXPECTED Initial Status: Goal Initial Status: Goal Initial Status: Goal Initial Status: Goal
Eating __ _5_ Bed Mobility __ __ Eating __ _5_ Bed Mobility __ __
OUTCOMES
Grooming __ _5_ Transfers __ __ Grooming __ _5_ Transfers __ __
Bathing __ _3_ Locomotion __ __ Bathing __ _3_ Locomotion __ __
Toileting __ _3_ LE Strength/ Toileting __ _3_ LE Strength/
Dressing __ _3_ ROM __ __ Dressing __ _3_ ROM __ __
Equipment __ _√_ Equipment __ √_ Equipment __ _√_ Equipment __ √_
Home Program __ _√_ Orthotics __ √_ Home Program __ _√_ Orthotics __ √_
Orthotics __ _√_ Patient/family Orthotics __ _√_ Patient/family
Patient/family education __ √_ Patient/family education __ √_
education __ _√_ Other Home education __ _√_ Other Home
Program __ √_ Program __ √_

Caregiver independent in Caregiver independent in Caregiver independent in Caregiver independent in

assisting patient. assisting patient. assisting patient. assisting patient.
Progress on track? Yes No _________ Yes No _________
Check / Initial initials initials

NOTE: The Clinical Practice Guideline/Critical Pathway is meant to serve as a guideline for routine patient care. When the condition of
the patient warrants, treatment decisions must be dictated by the skill and judgment of the health care professional.
IF PT CARD OR LABEL NOT AVAILABLE, WRITE DATE, NAME AND UH# IN SPACE BELOW

CVA CRITICAL PATHWAY

Department of Neurology

Medical Record Form 5629 - Neuro01- 4/15/98

The University of Texas Medical Branch Hospitals
Galveston, Texas

Original - Medical Record