acute stroke & transient ischaemic attack

7/26/2019 Acute Stroke & Transient Ischaemic Attack

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Acute Stroke & Transient Ischaemic Attack Patient’ Name _____________________________ MRN_ __________ Clinical Pathway / Blacktown Hospital @WSLHD

Admission Day / /Day 0-1 (1st 24hrs) > ED to Stroke Unit

Day 2 / / Acute Stroke Unit


Goals/ Outcomes Identify acute ischaemic / haemorrhagic / TIA/ others……

Document time and date of symptoms onset ___________________________________

Scandinavian Stroke Scale…………………..

Swallowing screening / Safe swallowing

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………..

Neuro status stabilised / improving / deteriorating

Avoid complications

Diagnostic tests documented

Rehabilitation therapies continued as appropriate.

Patient / Family understands stroke causes and risk factors

Pathology/Diagnostic Tests

Brain CT scan without contrast

FBC, PT / APTT / INR, ESR, EUC, LFT, BSL

ECG / CXR / UA

Consider: ● MRI CTA ●TOE / TTE ● Carotid Doppler

Fasting Lipid / Glucose / HBA1c

Follow up abnormal test results

APTT daily if therapeutic on heparinPT / INR daily if on Warfarin

If patient received thrombolysis, CT brain without contrast.

APTT daily if therapeutic on heparin

PT / INR daily if on Warfarin

Follow up abnormal test resultsConsider: ● Repeat CT (if stroke not yet confirmed )

Treatment IV - N/S if NBM or dehydrated

BP management as per Consultant / medication ordered

Febrile ≥37.5˚C Paracetamol; ≥ 38˚C→ 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 PRConsider: ● Anticoagulation > Consultant decision

● Avoid Heparin & ClexaneConsider: ● Thrombolysis ( IV < 4.5h ) ● Nicotine patch

Review / cease IV fluids

Assess BP management adequacy and medications

Febrile ≥37.5˚C Paracetamol; ≥38˚C→ septic work -up

BSL 5-10mmol/L > q6h ; BSL: > 10mmol/L→ Insulin infusion

Bowel regimeConsider: ● anticoagulation > Consultant decisionSecondary stroke prevention ● ACEI ● Statins ● Nicotine patchThrombolysis ● after 24hrs > CT scan, then begin antiplatelets

Review / cease IV fluids

Management plan for hypertension

Febrile ≥37.5˚C Paracetamol; ≥38˚C→ septic work -up

BSL 5-10mmol/L > q6h ; BSL: > 10mmol/L→ Insulin infusion

Bowel regimeConsider: ● Anticoagulation > Consultant decision

Nursing Care Neuro obs and vital signs q4h, (or as per protocol ifthrombolysed)

Stroke telemetry – BP, HR, T, SaO², 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 / addressedConsider: ● Fine bore NG for medication & early nutrition

Neuro obs and vital signs q4h (or as per protocol ifthrombolysed)

Stroke telemetry – BP, HR, T, SaO² , cardiac rhythm

BSL q6h→ before meals & bedtime

Bowel / Bladder assessment & management

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

Neuro obs and vital signs q4h

Stroke telemetry may be ceased if stable

BSL q6h→ before meals & bedtime Bowel / Bladder assessment & management

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


Nutrition /Hydration

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

Advance diet as per Speech Pathologist or NBM ifdysphagia / Safe swallowing precautions

Fine bore NG tube and feeds, goal rate set

Advance diet as per Speech Pathologist recommendation

NBM if dysphagia / Safe swallowing precautions

Fine bore NG tube and feeds – monitor goal rate foradequate nutrition

Activity Functional assessment, encourage participation infunctional activities.

Increase activity / exercises of hemiparetic limbs, as perPhysio and OT assessment

Functional assessment, encourage participation infunctional activities

Increase activity / exercises of hemiparetic limbs as per Physioand OT assessment

Functional assessment, encourage participation in functionalactivities

Increase activity / exercises of hemiparetic limbs as per PT & OT

Electrical stimulation if appropriate

Referrals /Consults

Stroke CNC Social Worker

Physiotherapist Occupational Therapist

Speech Pathologist Diabetic Educator

Pharmacist OrthoptistConsider: ● Cardiology ● Neurosurgery ● Endocrinology

Completion of consults from Day 1

Rehabilitation referral

Dietitian

Social Work / counsellingConsider: ● Vascular Surgery

Completion of consults from Day 2

Referral to Smoking cessation Clinic

Others………………………………

Patient/ FamilyEducation

Orientate to stroke unit

Education about tests / monitoring / planned care

Education about stroke risk factors and complications

Education about tests, diet and care of hemiparetic limbs

Reinforce stroke education / secondary stroke prevention

Discuss plans / goals for rehabilitation

Ongoing stroke education

Medication education, eg. Warfarin /ACEI /Statin / Antiplatelet

DischargePlanning

Evaluation of pre-existing function and home environment

Case discussion and planning at multidisciplinary meeting

Discussion with family re: aim for discharge as appropriate

Case discussion and planning at multidisciplinary meeting.

Rehabilitation waiting list as appropriate

Case discussion and planning at multidisciplinary meeting

TIA patient may be discharged as appropriate

7/26/2019 Acute Stroke & Transient Ischaemic Attack

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Acute Stroke & Transient Ischaemic Attack Patient’ Name _____________________________ MRN_ __________ Clinical Pathway / Blacktown Hospital @WSLHD



Day 6 or Discharge Day / /Step Down from Stroke Unit

Goals/ Outcomes Neuro status stabilised / improving

Avoid complications

Rehabilitation therapies continued as appropriate.

Patient / Family understands stroke causation & riskfactors

Neuro status stabilised / improving

Complications avoided

Rehab therapies continued as appropriate.

Discharged planning finalised

Aware of risk factors modification

Neuro status stabilised / improving

Complications avoided

Aware of sings and symptoms of stroke

Follow up post discharge organised.

Pathology/Diagnostic Tests


INR daily if on warfarin



INR daily if on Warfarin



INR daily if on Warfarin

Treatment IV if required – N/S Only +/- electrolytes

Medication review

Diabetes management plan

Antiplatelets / anticoagulation long-term planning

Continue management plan Review medication prior to discharge

● Reinforce Secondary Stroke Prevention

Anticoagulation / antiplatelet plan

BP managementLifestyle changes; eg smoking c essation, ETOH, weight↓

Diabetes Hyperlipidemia

Nursing care Neuro obs and vital signs q4h

Bowel / Bladder assessment / training


HOB up 30o / Safe swallowing precautions

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


Neuro and vital obs q4h



HOB up 30o/ Safe swallowing precautions






Vitals as required


HOB up 30o/ Safe swallowing precautions






Nutrition /Hydration

Diet advanced / maintained as per Speech

Pathologist recommendation

Continue nutrition requirements as per Dietitian

Maintain NG tube feeds at goal rate.

Diet advanced / maintained as per Speech Pathologist


Maintain NG tube feeds at goal rate.

Diet maintained / advanced as per Speech Pathologist


Maintain NG tube feeds at goal rate

Activity Encourage independence and participation in functionalactivities

Increase activity / exercises of hemiparetic limbs as per

Physio and OT assessment

Encourage independence and participation in functionalactivities



Encourage independence and participation in functionalactivities



Rankin Score……………….

Referrals /Consults

Rehabilitation inpatient / outpatient

Stroke Outreach Service

Consider: ● Long term feeding options ● Gastro review

● OT home visitFollow up Post-Acute Stroke Support Clinic

Follow up Neurovascular Clinic

Appointment Geriatrics Medicine / Neurology

Patient/ FamilyEducation

Reinforce stroke risk factors education

Medication education, eg. Warfarin, antiplatelet agents

Discuss / finalise plans for rehabilitation / discharge

Reinforce stroke / medication education, eg. Warfarin

Education for skills to manage patient at home

Discharge as appropriate

Ensure knowledge of stroke signs and symptoms

Reinforce risk factor modification / lifestyle adaptation

Reinforce medication management plansEducation re: rehabilitation goals & needs

Contact details for support and follow up given

DischargePlanning

● 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

Discharge instructions confirmed re: medication, diet, equipment

Discharge Barthel Index……………………

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

http://www.strokefoundation.com.au/



acute stroke & transient ischaemic attack

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