ED Stroke Management Process

Nursing Protocol

Suspected or Confirmed Stroke*

These guidelines will be used to initiate the care and treatment of patients with symptoms of suspected stroke or confirmed stroke. *Stroke refers to any of three main types: arterial ischemic stroke, cerebral venous thrombosis, or intracranial hemorrhage from aneurysm or arteriovenous malformation.

If patient has unstable vital signs, unstable airway, ventilation, circulation or altered mental status, expedite physician assessment. Otherwise:

  1. Initiate cardio-respiratory monitoring. Vital signs upon admission and then hourly, if stable. Neuro checks hourly.
  2. Obtain pulse ox. Administer humidified oxygen via the route best tolerated by the patient and notify the physician immediately if the pulse ox is <95% or if mental status is depressed or perfusion or oxygenation are compromised.
  3. Check dextrose stick on admission and every 2 hours. Immediately notify physician if < 60 or >150.
  4. Administer Acetaminophen per rectum every 6 hours for fever > 37 ° C
  5. Restrict activity to bed rest with the head of bed flat. Do not allow child to ambulate or sit upright for toileting or transfer from ED to radiology. Not needed for neonates and non-mobile infants (<6 months).
  6. Child must be NPO pending determination about need for sedation, and assessment of aspiration risk by speech therapy if there is any cranial nerve deficit.
  7. Discuss with patient and parents the need to place an IV and send laboratory studies to aid in evaluation and treatment.
  8. Obtain the following labs with IV placement:
    1. CBC with differential
    2. Platelet count
    3. PT
    4. PTT
    5. INR
    6. Basic metabolic panel
  9. Assess the need for a normal saline bolus.
  10. Start maintenance fluids as soon as possible.

February 2006
Reviewed: June 2011