What are the initial management and admitting orders for an adult patient with no contraindications presenting with an ischemic stroke?

Basic Ischemic Stroke Admitting Orders

All patients with acute ischemic stroke should be admitted to a specialized stroke unit with continuous monitoring capabilities, as this intervention provides mortality and morbidity benefits comparable to IV thrombolysis itself. 1, 2

Admission Location and Monitoring

• Admit to dedicated stroke unit with monitored beds for at least the first 24 hours 2, 3
• Stroke unit care should include a geographically defined facility staffed by skilled physicians, nurses, and rehabilitation personnel with regular communication and coordinated care 1
• Frequent neurological assessments using NIHSS every 15 minutes during thrombolysis, then hourly for 6 hours, then every 2 hours for 18 hours 2, 3
• Continuous cardiac monitoring to detect arrhythmias, particularly atrial fibrillation 2

Vital Signs Management

Blood Pressure

• For patients who received IV tPA: Maintain BP <180/105 mmHg for at least 24 hours post-thrombolysis 4
• For patients who did NOT receive thrombolysis: Only treat if systolic BP >220 mmHg or diastolic >120 mmHg 4
• Check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 2

Temperature

• Monitor temperature every 4 hours for first 48 hours 4
• Treat fever aggressively if temperature exceeds 37.5°C (99.5°F) with acetaminophen and cooling measures, as hyperthermia worsens neurological damage 3, 4

Oxygen

• Maintain oxygen saturation >94% 2
• Supplemental oxygen only if hypoxic; avoid routine oxygen in normoxic patients 1

NPO Status and Swallowing Assessment

• Keep patient NPO until formal swallowing assessment completed 1, 2
• Perform bedside swallowing screen (water swallow test) within 24 hours before allowing any oral intake 1, 4
• Patients with brainstem infarctions, multiple strokes, major hemispheric lesions, depressed consciousness, dysphonia, cranial nerve palsies, or high NIHSS scores are at highest aspiration risk 1
• A preserved gag reflex does NOT guarantee safe swallowing 1

Nutrition and Hydration

• Maintain euvolemia with IV normal saline at maintenance rate (typically 75-100 mL/hr) until swallowing cleared 1
• Dehydration increases risk of deep vein thrombosis and may slow recovery 1
• If swallowing impaired beyond 24-48 hours, consider nasogastric tube or early PEG placement 1

Mobilization and Activity

• Begin early mobilization within 24 hours if patient stable 2, 4
• Initial bed rest with head of bed flat or at 30 degrees (avoid extreme head elevation which may reduce cerebral perfusion) 1
• Close observation during transition to sitting/standing as some patients experience neurological worsening with upright posture 1
• Frequent turning every 2 hours and use of alternating pressure mattresses to prevent pressure ulcers 1
• Fall precautions with bed alarm and assistance for all transfers 1

Venous Thromboembolism Prophylaxis

• Intermittent pneumatic compression devices to both legs within 24 hours 2, 3
• Consider subcutaneous heparin 5000 units every 8-12 hours or enoxaparin 40 mg daily after 24 hours if no hemorrhagic transformation on repeat imaging 4
• Do NOT use anti-embolism stockings alone as they are ineffective 4

Laboratory Monitoring

Initial Labs (if not done in ED)

• Complete blood count, comprehensive metabolic panel 2
• PT/INR, aPTT 2
• Lipid panel, HbA1c 2
• Troponin and BNP (cardiac biomarkers) 2

Glucose Management

• Check fingerstick glucose every 6 hours for first 24 hours 2
• Maintain glucose 140-180 mg/dL; treat if >180 mg/dL with sliding scale insulin 2
• Avoid hypoglycemia (<70 mg/dL) which worsens brain injury 2

Medications

Antiplatelet Therapy (if NOT receiving thrombolysis)

• Aspirin 325 mg daily (or 160-300 mg) should be started within 24-48 hours 3
• If patient received IV tPA, delay aspirin for 24 hours and obtain repeat head CT to exclude hemorrhage before starting 3

Statin Therapy

• High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg daily) regardless of baseline LDL 2

Avoid Routine Medications

• No prophylactic anticonvulsants unless seizure occurs 4
• No neuroprotective agents (none proven effective) 1
• No routine antibiotics unless infection documented 1

Repeat Imaging

• Repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation, especially if thrombolysis given 2, 3
• Earlier imaging if any neurological worsening 2

Rehabilitation

• Physical therapy, occupational therapy, and speech therapy consultations within 24 hours 1, 2
• Early rehabilitation lessens complications including pneumonia, DVT, pulmonary embolism, pressure sores, contractures, and orthopedic complications 1

Common Pitfalls to Avoid

• Do not aggressively lower blood pressure in acute stroke unless criteria met above; permissive hypertension allows cerebral perfusion to penumbra 4
• Do not give oral medications, food, or water before swallowing assessment—aspiration pneumonia significantly worsens outcomes 1
• Do not delay mobilization beyond 24 hours unless contraindicated; prolonged immobility increases complications 1, 4
• Do not use subcutaneous heparin in first 24 hours after thrombolysis due to bleeding risk 3