Ischemic Stroke Admitting Orders
Admit all acute ischemic stroke patients to a dedicated stroke unit or intensive care unit for the first 24-72 hours, with specific monitoring protocols based on whether they received reperfusion therapy. 1, 2
Admission Location
- Stroke unit admission is mandatory for all acute ischemic stroke patients, ideally within 3 hours of symptom onset 3
- ICU admission is required for:
- General stroke unit (not ICU) is appropriate for:
Vital Signs Monitoring Protocol
For Patients Who Received rtPA:
Blood pressure monitoring schedule: 1, 7
- Every 15 minutes for 2 hours from start of rtPA
- Every 30 minutes for next 6 hours
- Every hour for 16 hours thereafter
Blood pressure targets post-rtPA: 8, 7
- Maintain BP ≤180/105 mm Hg
- If systolic BP 180-230 mm Hg or diastolic BP 105-120 mm Hg:
- Labetalol 10 mg IV bolus followed by continuous infusion 2-8 mg/min, OR
- Nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h)
- If diastolic BP >140 mm Hg: consider IV sodium nitroprusside 8
Neurological assessments: 1
- Every 15 minutes during rtPA infusion
- Every 30 minutes for 6 hours after infusion
- Hourly until 24 hours post-treatment
For Patients NOT Receiving Thrombolysis:
Blood pressure monitoring: 3
- At least every 4 hours for first 48 hours
- Then per ward routine based on clinical stability
Blood pressure management (non-thrombolysis candidates): 8, 7
- Do NOT routinely lower BP unless:
- Systolic BP >220 mm Hg or diastolic BP >120 mm Hg
- Evidence of end-organ damage (aortic dissection, acute MI, pulmonary edema, hypertensive encephalopathy)
- When lowering is indicated:
Temperature Management (FeSS Protocol)
Monitor temperature at least 4 times daily for first 3 days 2, 3
Treat fever >37.5°C (99.5°F) with: 2, 3
- Acetaminophen/paracetamol (IV, rectal, or oral) within 1 hour
- Investigate for infection source (pneumonia, UTI) 9
- Initiate antimicrobial therapy if infection identified 9
Glucose Management
- Formal venous glucose on admission
- Finger-stick glucose at least 4 times daily for first 3 days
Treatment targets: 2
- Treat glucose >180 mg/dL (10 mmol/L) with insulin
- Maintain glucose 140-180 mg/dL (7.8-10 mmol/L) 2
- Avoid hypoglycemia <60 mg/dL (3.3 mmol/L) 2
Swallowing Assessment
Perform swallowing screen within 24 hours of admission using validated tool by trained nurse or speech pathologist before any oral intake (food, fluids, or medications) 2, 3
If swallowing screen failed: refer immediately to speech pathologist for formal assessment 3
NPO status until swallowing cleared 2, 3
Intravenous Fluids
Initiate maintenance IV fluids to maintain euvolemia: 8
- Use isotonic normal saline (0.9% NaCl) 2
- Avoid hypotonic solutions
- Avoid volume expanders for hemodilution 2
- Correct hypovolemia urgently if present 8
Antiplatelet Therapy
Aspirin 325 mg within 24-48 hours of stroke onset 10, 2
Critical timing restrictions: 1, 2
- Delay aspirin for 24 hours if rtPA was given
- Administer only after swallowing screen/assessment completed
- If unable to swallow, may give aspirin rectally 2
Do NOT use urgent anticoagulation for acute ischemic stroke (increases hemorrhage risk without proven benefit) 10
Venous Thromboembolism Prophylaxis
Initiate within 24 hours: 9
- Intermittent pneumatic compression (IPC) devices to both legs 9
- Continue until independently mobile, at discharge, or 30 days (whichever first) 9
- Assess skin integrity daily 9
Add pharmacologic prophylaxis: 9, 2
- Low-molecular-weight heparin (enoxaparin) for high-risk patients
- Unfractionated heparin if renal failure present 9
Do NOT use anti-embolism stockings alone (not effective) 9, 2
Catheter Management
Avoid indwelling urinary catheters due to infection risk 9, 2
If catheter required: 9
- Assess daily for removal
- Remove as soon as possible
- Implement strict pericare and infection prevention
Delay placement of: 1
- Nasogastric tubes
- Indwelling bladder catheters
- Intra-arterial pressure catheters (especially in first 24 hours post-rtPA)
Mobilization
Do NOT mobilize within first 24 hours (associated with worse outcomes) 9, 2
Begin mobilization between 24-48 hours if no contraindications: 9, 2
- Contraindications: arterial puncture site, unstable medical condition, low oxygen saturation, lower limb fracture
Rehabilitation assessment within 48 hours by physical/occupational therapy 9
Seizure Management
Do NOT give prophylactic anticonvulsants 10
Treat recurrent seizures as per standard protocols 10
Imaging Follow-up
Obtain follow-up CT scan at 24 hours before starting anticoagulants or antiplatelet agents (if rtPA was given) 1
If patient develops severe headache, acute hypertension, nausea, or vomiting: 1
- Discontinue rtPA infusion immediately if still running
- Obtain emergency CT scan
Medications to Hold
Temporarily discontinue or reduce premorbid antihypertensive medications at stroke onset due to: 8
- Impaired swallowing
- Unpredictable responses during acute stress
- Risk of hypotension
Restart antihypertensive therapy after initial 24 hours in most patients 8
Additional Orders
- Maintain head of bed position: 2
- Consider flat (0°) for large artery occlusions with fluctuating symptoms
- Elevate to 30° for hemorrhagic transformation risk or increased intracranial pressure
- Ensure adequate nutrition: nasoenteric tube feeding if unable to swallow safely for 2-3 weeks (preferred over PEG initially) 2
- Early hydration and mobilization to prevent VTE 9
- Patient/family education regarding stroke, prognosis, and rehabilitation 2