What is the rationale for the initial admitting orders for an adult patient presenting with acute ischemic stroke?

Rationale for Initial Admitting Orders in Acute Ischemic Stroke

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

Admission Location and Monitoring Infrastructure

• Admit to a geographically defined stroke unit staffed by specialized physicians, nurses, and rehabilitation personnel with coordinated interprofessional communication, as stroke unit care reduces death and dependency at rates equivalent to thrombolytic therapy 1, 2
• Continuous cardiac and neurological monitoring for at least 24 hours is mandatory to detect early deterioration, arrhythmias (particularly atrial fibrillation), and complications 3, 2
• Frequent neurological assessments using NIHSS every 15 minutes during thrombolysis, then hourly for 6 hours, then every 2 hours for 18 hours to identify hemorrhagic transformation or neurological worsening 2

Blood Pressure Management Orders

The rationale for permissive hypertension differs dramatically based on whether the patient received thrombolysis:

For Patients Who Received IV Alteplase:

• Maintain BP <180/105 mmHg for 24 hours post-thrombolysis using rapid-acting, titratable agents (labetalol, nicardipine) to prevent hemorrhagic transformation 1, 3, 2
• Check BP every 15 minutes during infusion, then hourly for 6 hours, then every 2 hours 2

For Patients Who Did NOT Receive Thrombolysis:

• Do not treat BP unless systolic >220 mmHg or diastolic >120 mmHg, as permissive hypertension maintains collateral perfusion to the ischemic penumbra 1, 3, 2
• If BP exceeds 220/120 mmHg, lower by only 15% during the first 24 hours to avoid precipitating further ischemia 1
• Avoid hypotension (SBP <90 mmHg) at all costs, as it worsens cerebral perfusion and expands the infarct 3

NPO Status and Aspiration Prevention

• Keep patient strictly NPO until formal swallowing assessment completed within 24 hours, as aspiration pneumonia significantly worsens stroke outcomes and mortality 3, 2
• Perform bedside water swallow test before any oral intake, recognizing that patients with brainstem infarctions, depressed consciousness, dysphonia, cranial nerve palsies, or high NIHSS scores carry highest aspiration risk 2
• If swallowing impaired beyond 24-48 hours, place nasogastric tube or consider early PEG to maintain nutrition and hydration 2

Temperature Monitoring and Fever Management

• Check core temperature every 4 hours for the first 48 hours, then per ward routine 3, 2
• Treat fever aggressively if temperature exceeds 37.5°C (99.5°F) with acetaminophen and cooling measures, as hyperthermia worsens neurological damage and increases infarct size 4, 2

Oxygen and Respiratory Support

• Maintain peripheral oxygen saturation ≥92% using pulse oximetry and provide supplemental oxygen only when saturation falls below 94%, as both hypoxemia and unnecessary hyperoxia may worsen cerebral injury 4

Venous Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression devices to both legs within 24 hours as first-line VTE prophylaxis for immobilized patients 4, 3, 2
• Add subcutaneous heparin 5000 units every 8-12 hours or enoxaparin 40 mg daily after 24 hours if repeat imaging excludes hemorrhagic transformation, as immobility dramatically increases DVT and pulmonary embolism risk 3, 2
• Do not use subcutaneous heparin in the first 24 hours after thrombolysis due to bleeding risk 2

Antiplatelet Therapy Timing

The timing of aspirin initiation is critical and depends entirely on thrombolysis status:

For Patients Who Received IV Alteplase:

• Wait 24 hours after thrombolysis and obtain repeat head CT to exclude hemorrhage before starting aspirin, as early aspirin increases hemorrhagic transformation risk 4, 3, 2
• Then start aspirin 160-325 mg daily for moderate-to-severe stroke 4, 3, 2

For Patients Who Did NOT Receive Thrombolysis:

• Start aspirin 160-325 mg within 24-48 hours of symptom onset to reduce early recurrent stroke risk 4, 3, 2
• For minor stroke (NIHSS ≤3) or high-risk TIA, initiate dual antiplatelet therapy with aspirin 81 mg plus clopidogrel 75 mg within 12-24 hours 3

Statin Therapy

• Initiate high-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg daily) immediately, regardless of baseline cholesterol levels, as early statin therapy reduces recurrent vascular events 3, 2

Glucose Management

• Check capillary blood glucose immediately on arrival to exclude hypoglycemia as a stroke mimic 3
• Monitor fingerstick glucose every 6 hours for first 24 hours and maintain glucose 140-180 mg/dL 2
• Treat hyperglycemia if glucose >180 mg/dL with sliding scale insulin, as hyperglycemia worsens infarct size and functional outcomes 3, 2

Hydration and Nutrition

• Maintain euvolemia with IV normal saline at maintenance rate (75-100 mL/hr) until swallowing cleared, as dehydration increases DVT risk and may slow recovery 2

Early Mobilization Orders

• Begin mobilization within 24 hours if patient stable, with initial bed rest at head of bed flat or 30 degrees (avoid extreme head elevation which may reduce cerebral perfusion) 4, 3, 2
• Initiate frequent, brief out-of-bed activity involving active sitting, standing, and walking as early rehabilitation lessens complications including pneumonia, DVT, pulmonary embolism, pressure sores, and contractures 3, 2
• Close observation during transition to upright posture, as some patients experience neurological worsening with position changes 2

Repeat Imaging

• Order repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation, especially if thrombolysis given 2

Rehabilitation Consultations

• Order physical therapy, occupational therapy, and speech therapy consultations within 24 hours, as early rehabilitation improves functional outcomes and prevents complications 3, 2

Laboratory Monitoring

• Initial labs: complete blood count, comprehensive metabolic panel, PT/INR, aPTT, lipid panel, HbA1c, troponin, and BNP to identify comorbidities, assess bleeding risk, and detect cardiac disease 3, 2
• ECG to identify atrial fibrillation and other arrhythmias that require anticoagulation for secondary prevention 3

Seizure Management Orders

• Do not order prophylactic anticonvulsants, as they may negatively affect neurological recovery 3
• If seizure occurs, treat with short-acting benzodiazepines (lorazepam IV) if not self-limiting 3
• Do not start long-term anticonvulsants for a single, self-limiting seizure within 24 hours 3

Critical Pitfalls to Avoid

• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg, as permissive hypertension maintains penumbral perfusion 2
• Never give oral medications, food, or water before swallowing assessment, as aspiration pneumonia significantly worsens outcomes 2
• Never delay mobilization beyond 24 hours unless contraindicated, as prolonged immobility increases complications 2
• Never use full-dose therapeutic anticoagulation (heparin or LMWH) for acute stroke treatment, as it does not improve outcomes and increases hemorrhage risk 4