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AREA: Emergency Department, ICU, MGH NeuroCare Unit
PURPOSE: To outline the nursing management of the acute stroke patient entered in the Thrombolytic Therapy in Acute Ischemic Stroke Trial.
LEVEL: Interdependent (* items require an MD order).
SUPPORTIVE DATA: Recombinant human tissue-type plasminogen activator (Activase or rt-PA) is a thrombolytic agent with properties that make it relatively clot-specific. This clot specificity should theoretically minimize the risk of hemorrhage. The drug can be given intravenously with rapid achievement of therapeutic levels and clot lysis can be effected within minutes. A recent study, sponsored by the National Institutes of Health and published in the Dec. 14, 1995, New England Journal of Medicine, clearly demonstrated that treatment of selected patients within three hours of onset with t-PA improved patient outcome. Overall, patients treated with t-PA had a 30% greater chance of having minimal or no disability three months after the stroke, when compared with patients who received a placebo. These benefits were seen despite the fact that 6% of the patients treated with t-PA had a serious brain hemorrhage caused by the medication. About half of those patients who had a hemorrhage went on to die. This study was pivotal in the ultimate approval of t-PA for acute stroke by the Food and Drug Administration in June 1996.
1. Upon arrival in ED and suspected diagnosis is that of an acute stroke:
— ascertain symptom onset time;
— age is > 18 years.
2. Page the stroke pager STAT.
3. STAT CT of the brain without contrast.
4. Start one IV with normal saline at 60 cc/hour and one saline loc (18-gauge needles).
5. Initiate t-PA for Acute Stroke Standing Orders.
6. Obtain actual or estimated patient weight.
7. Notify pharmacy of possibility of giving t-PA, and inform them of the weight of the patient.
8. Obtain portable chest X-ray after CT done.
9. Monitor blood pressure very closely. Inform MD of any BP > 185 systolic and/or >105 diastolic.
10. Call bed placement coordinator for possible admission to designated unit (ICU, neuro unit).
11. When transfer of care from one caregiver to another occurs, neuro assessment of patient will be done together.
1. Physician to explain procedure and obtain consent from either the patient or closest relative.
2. Original consent to be placed in the patient medical record.
1. Total t-PA dose to be calculated by the pharmacy based on 0.9 mg/kg body weight (maximum dose 90 mg).
2. 10% of total dose to be given IV BOLUS in the ED.
3. Remaining drug to be given over one hour IV regulated by an IVAC pump; this to be completed in the ED prior to transfer of patient to ICU/MGH NeuroCare Unit.
1. Blood pressure assessed every 15 minutes x 2 hours, every 30 minutes x 6 hours, every 1 hour x 16 hours after initiation of the drug, then every 2-4 hours based on unit protocol.
2. Neuro checks every 15 minutes x 2 hours, every 30 minutes x 6 hours, every 1 hour x 16 hours after initiation of the drug, then every 2-4 hours based on unit protocol.
3. Assess for bleeding:
• Monitor peripheral IV sites and gums for oozing.
• Monitor for hematuria.
• Hemooccult test suspected emesis and stool.
• Monitor for hallmark signs and symptoms of intracerebral hemorrhage (ICH); neurological deterioration, new onset of headache, acute hypertension, and/or nausea and vomiting.
1. No automatic blood pressure machines to be used.
2. When DCing an IV or saline loc, or after venipuncture, hold site for 30 minutes.
3. No arterial punctures during the first three days of this admission.
4. Place thrombolytic therapy alert card above head of bed.
If change in level of consciousness or neurological signs to include suspected ICH:
1. Call radiology for possible STAT CT brain scan, and notify MD immediately.
If severe bleeding occurs and the effects of the study drug need to be reversed:
1. STAT PT, PTT, fibrinogen, type, and crossmatch.
2. Prepare for administration of 6-8 units of cryoprecipitate or 6-8 units of platelets.
3. Obtain fibrinogen level and bleeding time one hour post-infusion of cryoprecipitate or platelets.
4. Titrate further administration of cryoprecipitate/platelets based on fibrinogen level.
Notify MD if any of the following occur:
1. Altered level of consciousness or change in neurological signs to include signs and symptoms of intracerebral hemorrhage (neurological deterioration, new onset of headache, acute hypertension, and/or nausea and vomiting).
2. Any evidence of other bleeding (i.e., hematuria, oozing gums, etc.).
3. Any other sign and symptom that is unexpected based on present diagnosis.
1. Document on appropriate nursing/medication record forms the t-PA bolus and initiation of the t-PA infusion.
2. Document any adverse events or notifications to MD.
3. Document any teaching related to this protocol.
4. Document implementation and discontinuation of this protocol.
Source: Mercy Healthcare Sacramento (CA).