Clinical Data/medical History printable pdf download

Patient Name_________________________________________________________

Soc Sec#________________________ DOB______________________________

Admit Date/Time_________________ ED Physician_______________________

(Patient Label)

PROTOCOL for ACUTE STROKE: 0-3 hours symptom onset

Providence Spokane Admit Transfer

(or 3-4.5 hours after review of additional exclusion criteria)

Center: 1-877-323-5055

When was

ED Arrival

Transport to ER via:

CT Time:

Time of Call to Neurologist :

 Self/Family

patient last seen

Time:

Name:

 Ambulance

normal? D&T:

Call to Transport:

Arrival:

Depart:

______/______

PRESENTING CLINICAL DATA/MEDICAL HISTORY – ED Physician and RN to complete

Date:

Age:

M F

Wt:

Ht:

IV Contrast Allergy: [ ] Yes [ ] No

Discuss w/ Neurology for Pre-Tx

Allergies:

Medications:

Pt. Currently Taking:  Warfarin/Coumadin  ASA  Plavix  Lovenox/Fragmin/Arixtra  Aggrenox Other __________________

IV Access: Size:

Need second site prior to tPA administration

(Must be 18g or 20g for CTA) Must be in forearm or anticubital.

Vitals: T _______ P _______ R _______ BP ____________

ECG Rhythm: _______________________________________________

Current Fingerstick Glucose: __________________________

O2 Sats:________@_______liters

STROKE SYMPTOMS

Risk Factors:

Previous Stroke/TIA:  No  Yes

 Left /5 arm

 Right /5 arm /5 leg

Motor:

/5 leg



___ arm ___ leg

Dyslipidemia:  No  Yes

Diabetes:  No  Yes

Sensory:

Left

Right

A-Fib:



Yes

 No  Yes

HTN:

LOC:

NIHSS:



Yes

Smoking: 

Facial Palsy:

Dysarthria:

CAD:

Other: (Gaze deviation, visual field cut, etc.)

Medical History:

 No

 Yes

Contraindication to Lytics:

If yes, comment:

ORDER SECTION

LABS/X-RAY – DO NOT DELAY TRANSPORT FOR RESULTS

CBC w/ platelet

PTT

ECG

Head CT without contrast

BMP

PT/INR

CXR

Other:

MEDICATIONS/DOSE

Dosing comment

NOTES

TIME

INITIAL

For thrombolytic patients: (If goal SBP less than 185mmHg or DBP less than 110 mmHg

not achieved, do not provide thrombolytic therapy.) If BP outside goal range, give:

Labetalol (Trandate) 10 mg IV over 1 min. If goal BP not achieved within 10 min, give:

Labetalol (Trandate) 20 mg IV over 1 min. If goal BP not achieved within 10 min notify

MD. Maximum dose is 300 mg per 24hrs. First line agent

If Labetalol is contraindicated or HR less than 60 bpm or if Labetalol is ineffective give:

Nicardipine (Cardene) 40 mg in 200 mL 0.83% NS IV infusion. Initial dose 5 mg/hr.

May increase by 2.5 mg/hr q 5 min up to maximum rate of 15 mg/hr prn.

Keep BP less than 180/105 post tPA

For non-thrombolytic patients: Goal SBP 120-220 mmHg; Goal DBP is less than 120 mmHg

Administer via infusion pump.

IV tPA Alteplase (Activase): 0-3 hours symptom

For Thrombolytic

indications and

No other medication is to be

onset (or 3-4.5 hours after review of additional

contraindications

administered through the line.

exclusion criteria)

see back of this

tPA-Alteplase (Activase):

After bag is empty instill 50ml normal

sheet.

Use Ischemic Stroke Dosing for tPA

saline into bag to infuse tPA remaining

(Activase/Alteplase)

in tubing.

VS Prior to transport: T

Glucose

Family Contact:

Phone #:

Provider Signature:____________________________________________

RN Signature:_________________________________________________

WHEN FORM COMPLETE, FAX WITH LAB/EKG TO SHMC ED 509-474-3346 AND SEND FORMS WITH PATIENT

Transport VS: T

Transport Notes:

Send Completed NIH Stroke Scale with Patient

PATIENT TO REMAIN NPO

This information is intended only as a guideline. Please use your best judgment in the treatment of patients.

Clinical Data/medical History

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