"
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Ischemic Stroke
1.Admit to:
2.Diagnosis: Ischemic stroke
3.Condition:
4.Vital Signs: Vital signs and neurochecks q30minutes
for 6 hours, then q60 minutes for 12 hours. Call
physician if BP >185/105, <110/60; P >120, <50;
R>24, <10; T >38.5 C; or change in neurologic status.
5.Activity: Bedrest.
6.Nursing: Head-of-bed at 30 degrees, turn q2h when
awake, range of motion exercises qid. Foley catheter,
eggcrate mattress. Guaiac stools, inputs and outputs.
Bleeding precautions: check puncture sites for
bleeding or hematomas. Apply digital pressure or
pressure dressing to active compressible bleeding
sites.
7.Diet: NPO except medications for 24 hours, then
dysphagia ground diet with thickened liquids.
8.IV Fluids and Oxygen: 0.45% normal saline at 100
cc/h. Oxygen at 2 L per minute by nasal cannula.
9.Special Medications:
Ischemic Stroke <3 hours:
a.Tissue plasminogen activator (t-PA, Alteplase) is
indicated if the patient presents within 3 hours of
onset of symptoms and the stroke is non-
hemorrhagic; 0.9 mg/kg (max 90 mg) over 60 min.
Give 10% of the total dose as an initial bolus over 1
minute.
b.Repeat CT scan or MRI 24 hours after completion
of tPA. Begin heparin if scan results are negative
for hemorrhage.
c.Heparin 12 U/kg/h continuous IV infusion, without a
bolus. Check aPTT q6h to maintain 1.2-1.5 x
control.
Completed Ischemic Stroke >3 hours:
-Aspirin enteric coated 325 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd OR
-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab
PO bid OR
-Aspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75
mg PO qd
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Omeprazole (Prilosec) 20 mg PO bid or qhs.
-Docusate sodium (Colace) 100 mg PO qhs
-Bisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR
prn.
-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn
temp >38°C or headache.
11. Extras: CXR, ECG, CT without contrast or MRI with
gadolinium contrast; carotid duplex scan; echo-
cardiogram, 24-hour Holter monitor; swallowing stud-
ies. Physical therapy consult for range of motion
exercises; neurology and rehabilitation medicine
consults.
12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile
VDRL, ESR; drug levels, INR/PTT, UA. Lupus
anticoagulant, anticardiolipin antibody.
Transient Ischemic Attack
1.Admit to:
2.Diagnosis: Transient ischemic attack
3.Condition:
4.Vital Signs: q1-4h with neurochecks. Call physician if
BP >160/90, <90/60; P >120, <50; R>25, <10; T
>38.5 C; or change in neurologic status.
5.Activity: Up as tolerated.
6.Nursing: Guaiac stools.
7.Diet: Dysphagia ground with thickened liquids or
regular diet.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
-Aspirin 325 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd OR
-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab
PO bid.
-Heparin (only if recurrent TIAs or cardiogenic or
vertebrobasilar source for emboli) 700-800 U/h (12
U/kg/h) IV infusion without a bolus (25,000 U in
500 mL D5W); adjust q6-12h until PTT 1.2-1.5 x
control.
-Warfarin (Coumadin) 5.0-7.5 mg PO qd for 3d, then
2-4 mg PO qd. Titrate to INR of 2.0-2.5.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Docusate sodium (Colace) 100 mg PO qhs.
-Milk of magnesia 30 mL PO qd prn constipation.
11. Extras: CXR, ECG, CT without contrast; carotid
duplex scan, echocardiogram, 24-hour Holter monitor
Physical therapy, neurology consults.
12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile
VDRL, drug levels, INR/PTT, UA.
Subarachnoid Hemorrhage
1.Admit to:
2.Diagnosis: Subarachnoid hemorrhage
3.Condition:
4.Vital Signs: Vital signs and neurochecks q1-4h. Call
physician if BP >185/105, <110/60; P >120, <50;
R>24, <10; T >38.5 C; or change in neurologic status
5.Activity: Bedrest.
6.Nursing: Head-of-bed at 30 degrees, turn q2h when
awake. Foley catheter to closed drainage, eggcrate
mattress. Guaiac stools, inputs and outputs.
7.Diet: NPO except medications.
8.IV Fluids and Oxygen: 0.45% normal saline at 100
cc/h. Oxygen at 2 L per minute by nasal cannula.
-Keep room dark and quiet; strict bedrest. Neurologic
checks q1h for 12 hours, then q2h for 12 hours,
then q4h. Call physician if abrupt change in
neurologic status.
-Restrict total fluids to 1000 mL/day; diet as tolerated.
9.Special Medications:
-Nimodipine (Nimotop) 60 mg PO or via NG tube q4h
for 21d, must start within 96 hours.
-Phenytoin (seizures) load 15 mg/kg IV in NS (infuse
at max 50 mg/min), then 300 mg PO/IV qAM (4-6
mg/kg/d) OR
-Valproic acid (Depakene) 500-1000 mg IV q6h.
Hypertension:
-Nitroprusside sodium, 0.1-0.5 mcg/kg/min (50 mg in
250 mL NS), titrate to control blood pressure OR
-Labetalol (Trandate) 10-20 mg IV q15min prn or 1-2
mg/min IV infusion.
10. Extras: CXR, ECG, CT without contrast; MRI an-
giogram; cerebral angiogram. Neurology,
neurosurgery consults.
11. Labs: CBC, SMA 7&12, VDRL, UA.
Seizure and Status Epilepticus
1.Admit to:
2.Diagnosis: Seizure
3.Condition:
4.Vital Signs: q6h with neurochecks. Call physician if
BP >160/90, <90/60; P >120, <50; R>25, <10; T
>38.5 C; or any change in neurological status.
5.Activity: Bed rest
6.Nursing: Finger stick glucose. Seizure precautions
with bed rails up; padded tongue blade at bedside.
EEG monitoring.
7.Diet: NPO for 24h, then regular diet if alert.
8.IV Fluids: D5 ½ NS at 100 cc/hr; change to heparin
lock when taking PO.
9.Special Medications:
Status Epilepticus:
1. Maintain airway.
2. Position the patient laterally with the head down.
The head and extremities should be cushioned to
prevent injury.
3. A bite block or other soft object may be inserted
into the mouth to prevent injury to the tongue.
4. Give 100% O
by mask. Obtain brief history and a
2
fingerstick glucose.
5. Secure IV access and draw blood for glucose
analysis. Give thiamine 100 mg IV push, then
dextrose 50% 50 mL IV push.
6.Initial Control:
Lorazepam (Ativan) 6-8 mg (0.1 mg/kg; not to
exceed 2 mg/min) IV at 1-2 mg/min. May repeat
6-8 mg q5-10min (max 80 mg/24h) OR
Diazepam (Valium), 5-10 mg slow IV at 1-2
mg/min. Repeat 5-10 mg q5-10 min prn (max
100 mg/24h).
Phenytoin (Dilantin) 15-20 mg/kg load in NS at 50
mg/min. Repeat 100-150 mg IV q30min, max 1.5
gm; monitor BP.
Fosphenytoin (Cerebyx) 20 mg/kg IV/IM (at 150
mg/min), then 4-6 mg/kg/day in 2 or 3 doses
(150 mg IV/IM q8h). Fosphenytoin is metabolized
to phenytoin; fosphenytoin may be given IM.
If seizures persist, administer phenobarbital 20
mg/kg IV at 50 mg/min, repeat 2 mg/kg q15min;
additional phenobarbital may be given, up to max
of 30-60 mg/kg.
7.If seizures persist, intubate the patient and give:
- Midazolam (Versed) 0.2 mg/kg IV push, then 0.045
mg/kg/hr; titrate up to 0.6 mg/kg/hr OR
-Propofol (Diprivan) 2 mg/kg IV push over 2-5 min,
then 50 mcg/kg/min; titrate up to 165 mcg/kg/min
OR
-Phenobarbital as above.
-Induce coma with pentobarbital 10-15 mg/kg IV over
1-2h, then 1-1.5 mg/kg/h continuous infusion.
Initiate continuous EEG monitoring.
8.Consider Intubation and General Anesthesia
Maintenance Therapy for Epilepsy:
Primary Generalized Seizures – First-Line Therapy:
-Carbamazepine (Tegretol) 200-400 mg PO tid [100,
200 mg]. Monitor CBC.
-Phenytoin (Dilantin) loading dose of 400 mg PO,
followed by 300 mg PO q4h for 2 doses (total of 1
g), then 300 mg PO qd or 100 mg tid or 200 mg bid
[30, 50, 100 mg].
-Divalproex (Depakote) 250-500 mg PO tid-qid with
meals [125, 250, 500 mg].
-Valproic acid (Depakene) 250-500 mg PO tid-qid with
meals [250 mg].
Primary Generalized Seizures -- Second Line
Therapy:
-Phenobarbital 30-120 mg PO bid [8, 16, 32, 65, 100
mg].
-Primidone (Mysoline) 250-500 mg PO tid [50, 250
mg]; metabolized to phenobarbital.
-Felbamate (Felbatol) 1200-2400 mg PO qd in 3-4
divided doses, max 3600 mg/d [400, 600 mg; 600
mg/5 mL susp]; adjunct therapy; aplastic anemia,
hepatotoxicity.
-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max
1800 mg/day [100, 300, 400 mg]; adjunct therapy.
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy .
Partial Seizure:
-Carbamazepine (Tegretol) 200-400 mg PO tid [100,
200 mg].
-Divalproex (Depakote) 250-500 mg PO tid with meals
[125, 250, 500 mg].
-Valproic acid (Depakene) 250-500 mg PO tid-qid with
meals [250 mg].
-Phenytoin (Dilantin) 300 mg PO qd or 200 mg PO bid
[30, 50, 100].
-Phenobarbital 30-120 mg PO tid or qd [8, 16, 32, 65,
100 mg].
-Primidone (Mysoline) 250-500 mg PO tid [50, 250
mg]; metabolized to phenobarbital.
-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max
1800 mg/day [100, 300, 400 mg]; adjunct therapy.
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy.
-Topiramate (Topamax) 25 mg PO bid; titrate to max
200 mg PO bid [tab 25, 100, 200 mg]; adjunctive
therapy.
Absence Seizure:
-Divalproex (Depakote) 250-500 mg PO tid-qid [125,
250, 500 mg].
-Clonazepam (Klonopin) 0.5-5 mg PO bid-qid [0.5, 1,
2 mg].
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy.
10. Extras: MRI with and without gadolinium or CT with
contrast; EEG (with photic stimulation,
hyperventilation, sleep deprivation, awake and asleep
tracings); portable CXR, ECG.
11. Labs: CBC, SMA 7, glucose, Mg, calcium, phos-
phate, liver panel, VDRL, anticonvulsant levels. UA,
drug screen.
1.Admit to:
2.Diagnosis: Ischemic stroke
3.Condition:
4.Vital Signs: Vital signs and neurochecks q30minutes
for 6 hours, then q60 minutes for 12 hours. Call
physician if BP >185/105, <110/60; P >120, <50;
R>24, <10; T >38.5 C; or change in neurologic status.
5.Activity: Bedrest.
6.Nursing: Head-of-bed at 30 degrees, turn q2h when
awake, range of motion exercises qid. Foley catheter,
eggcrate mattress. Guaiac stools, inputs and outputs.
Bleeding precautions: check puncture sites for
bleeding or hematomas. Apply digital pressure or
pressure dressing to active compressible bleeding
sites.
7.Diet: NPO except medications for 24 hours, then
dysphagia ground diet with thickened liquids.
8.IV Fluids and Oxygen: 0.45% normal saline at 100
cc/h. Oxygen at 2 L per minute by nasal cannula.
9.Special Medications:
Ischemic Stroke <3 hours:
a.Tissue plasminogen activator (t-PA, Alteplase) is
indicated if the patient presents within 3 hours of
onset of symptoms and the stroke is non-
hemorrhagic; 0.9 mg/kg (max 90 mg) over 60 min.
Give 10% of the total dose as an initial bolus over 1
minute.
b.Repeat CT scan or MRI 24 hours after completion
of tPA. Begin heparin if scan results are negative
for hemorrhage.
c.Heparin 12 U/kg/h continuous IV infusion, without a
bolus. Check aPTT q6h to maintain 1.2-1.5 x
control.
Completed Ischemic Stroke >3 hours:
-Aspirin enteric coated 325 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd OR
-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab
PO bid OR
-Aspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75
mg PO qd
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Omeprazole (Prilosec) 20 mg PO bid or qhs.
-Docusate sodium (Colace) 100 mg PO qhs
-Bisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR
prn.
-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn
temp >38°C or headache.
11. Extras: CXR, ECG, CT without contrast or MRI with
gadolinium contrast; carotid duplex scan; echo-
cardiogram, 24-hour Holter monitor; swallowing stud-
ies. Physical therapy consult for range of motion
exercises; neurology and rehabilitation medicine
consults.
12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile
VDRL, ESR; drug levels, INR/PTT, UA. Lupus
anticoagulant, anticardiolipin antibody.
Transient Ischemic Attack
1.Admit to:
2.Diagnosis: Transient ischemic attack
3.Condition:
4.Vital Signs: q1-4h with neurochecks. Call physician if
BP >160/90, <90/60; P >120, <50; R>25, <10; T
>38.5 C; or change in neurologic status.
5.Activity: Up as tolerated.
6.Nursing: Guaiac stools.
7.Diet: Dysphagia ground with thickened liquids or
regular diet.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
-Aspirin 325 mg PO qd OR
-Clopidogrel (Plavix) 75 mg PO qd OR
-Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab
PO bid.
-Heparin (only if recurrent TIAs or cardiogenic or
vertebrobasilar source for emboli) 700-800 U/h (12
U/kg/h) IV infusion without a bolus (25,000 U in
500 mL D5W); adjust q6-12h until PTT 1.2-1.5 x
control.
-Warfarin (Coumadin) 5.0-7.5 mg PO qd for 3d, then
2-4 mg PO qd. Titrate to INR of 2.0-2.5.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Docusate sodium (Colace) 100 mg PO qhs.
-Milk of magnesia 30 mL PO qd prn constipation.
11. Extras: CXR, ECG, CT without contrast; carotid
duplex scan, echocardiogram, 24-hour Holter monitor
Physical therapy, neurology consults.
12. Labs: CBC, glucose, SMA 7&12, fasting lipid profile
VDRL, drug levels, INR/PTT, UA.
Subarachnoid Hemorrhage
1.Admit to:
2.Diagnosis: Subarachnoid hemorrhage
3.Condition:
4.Vital Signs: Vital signs and neurochecks q1-4h. Call
physician if BP >185/105, <110/60; P >120, <50;
R>24, <10; T >38.5 C; or change in neurologic status
5.Activity: Bedrest.
6.Nursing: Head-of-bed at 30 degrees, turn q2h when
awake. Foley catheter to closed drainage, eggcrate
mattress. Guaiac stools, inputs and outputs.
7.Diet: NPO except medications.
8.IV Fluids and Oxygen: 0.45% normal saline at 100
cc/h. Oxygen at 2 L per minute by nasal cannula.
-Keep room dark and quiet; strict bedrest. Neurologic
checks q1h for 12 hours, then q2h for 12 hours,
then q4h. Call physician if abrupt change in
neurologic status.
-Restrict total fluids to 1000 mL/day; diet as tolerated.
9.Special Medications:
-Nimodipine (Nimotop) 60 mg PO or via NG tube q4h
for 21d, must start within 96 hours.
-Phenytoin (seizures) load 15 mg/kg IV in NS (infuse
at max 50 mg/min), then 300 mg PO/IV qAM (4-6
mg/kg/d) OR
-Valproic acid (Depakene) 500-1000 mg IV q6h.
Hypertension:
-Nitroprusside sodium, 0.1-0.5 mcg/kg/min (50 mg in
250 mL NS), titrate to control blood pressure OR
-Labetalol (Trandate) 10-20 mg IV q15min prn or 1-2
mg/min IV infusion.
10. Extras: CXR, ECG, CT without contrast; MRI an-
giogram; cerebral angiogram. Neurology,
neurosurgery consults.
11. Labs: CBC, SMA 7&12, VDRL, UA.
Seizure and Status Epilepticus
1.Admit to:
2.Diagnosis: Seizure
3.Condition:
4.Vital Signs: q6h with neurochecks. Call physician if
BP >160/90, <90/60; P >120, <50; R>25, <10; T
>38.5 C; or any change in neurological status.
5.Activity: Bed rest
6.Nursing: Finger stick glucose. Seizure precautions
with bed rails up; padded tongue blade at bedside.
EEG monitoring.
7.Diet: NPO for 24h, then regular diet if alert.
8.IV Fluids: D5 ½ NS at 100 cc/hr; change to heparin
lock when taking PO.
9.Special Medications:
Status Epilepticus:
1. Maintain airway.
2. Position the patient laterally with the head down.
The head and extremities should be cushioned to
prevent injury.
3. A bite block or other soft object may be inserted
into the mouth to prevent injury to the tongue.
4. Give 100% O
by mask. Obtain brief history and a
2
fingerstick glucose.
5. Secure IV access and draw blood for glucose
analysis. Give thiamine 100 mg IV push, then
dextrose 50% 50 mL IV push.
6.Initial Control:
Lorazepam (Ativan) 6-8 mg (0.1 mg/kg; not to
exceed 2 mg/min) IV at 1-2 mg/min. May repeat
6-8 mg q5-10min (max 80 mg/24h) OR
Diazepam (Valium), 5-10 mg slow IV at 1-2
mg/min. Repeat 5-10 mg q5-10 min prn (max
100 mg/24h).
Phenytoin (Dilantin) 15-20 mg/kg load in NS at 50
mg/min. Repeat 100-150 mg IV q30min, max 1.5
gm; monitor BP.
Fosphenytoin (Cerebyx) 20 mg/kg IV/IM (at 150
mg/min), then 4-6 mg/kg/day in 2 or 3 doses
(150 mg IV/IM q8h). Fosphenytoin is metabolized
to phenytoin; fosphenytoin may be given IM.
If seizures persist, administer phenobarbital 20
mg/kg IV at 50 mg/min, repeat 2 mg/kg q15min;
additional phenobarbital may be given, up to max
of 30-60 mg/kg.
7.If seizures persist, intubate the patient and give:
- Midazolam (Versed) 0.2 mg/kg IV push, then 0.045
mg/kg/hr; titrate up to 0.6 mg/kg/hr OR
-Propofol (Diprivan) 2 mg/kg IV push over 2-5 min,
then 50 mcg/kg/min; titrate up to 165 mcg/kg/min
OR
-Phenobarbital as above.
-Induce coma with pentobarbital 10-15 mg/kg IV over
1-2h, then 1-1.5 mg/kg/h continuous infusion.
Initiate continuous EEG monitoring.
8.Consider Intubation and General Anesthesia
Maintenance Therapy for Epilepsy:
Primary Generalized Seizures – First-Line Therapy:
-Carbamazepine (Tegretol) 200-400 mg PO tid [100,
200 mg]. Monitor CBC.
-Phenytoin (Dilantin) loading dose of 400 mg PO,
followed by 300 mg PO q4h for 2 doses (total of 1
g), then 300 mg PO qd or 100 mg tid or 200 mg bid
[30, 50, 100 mg].
-Divalproex (Depakote) 250-500 mg PO tid-qid with
meals [125, 250, 500 mg].
-Valproic acid (Depakene) 250-500 mg PO tid-qid with
meals [250 mg].
Primary Generalized Seizures -- Second Line
Therapy:
-Phenobarbital 30-120 mg PO bid [8, 16, 32, 65, 100
mg].
-Primidone (Mysoline) 250-500 mg PO tid [50, 250
mg]; metabolized to phenobarbital.
-Felbamate (Felbatol) 1200-2400 mg PO qd in 3-4
divided doses, max 3600 mg/d [400, 600 mg; 600
mg/5 mL susp]; adjunct therapy; aplastic anemia,
hepatotoxicity.
-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max
1800 mg/day [100, 300, 400 mg]; adjunct therapy.
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy .
Partial Seizure:
-Carbamazepine (Tegretol) 200-400 mg PO tid [100,
200 mg].
-Divalproex (Depakote) 250-500 mg PO tid with meals
[125, 250, 500 mg].
-Valproic acid (Depakene) 250-500 mg PO tid-qid with
meals [250 mg].
-Phenytoin (Dilantin) 300 mg PO qd or 200 mg PO bid
[30, 50, 100].
-Phenobarbital 30-120 mg PO tid or qd [8, 16, 32, 65,
100 mg].
-Primidone (Mysoline) 250-500 mg PO tid [50, 250
mg]; metabolized to phenobarbital.
-Gabapentin (Neurontin), 300-400 mg PO bid-tid; max
1800 mg/day [100, 300, 400 mg]; adjunct therapy.
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy.
-Topiramate (Topamax) 25 mg PO bid; titrate to max
200 mg PO bid [tab 25, 100, 200 mg]; adjunctive
therapy.
Absence Seizure:
-Divalproex (Depakote) 250-500 mg PO tid-qid [125,
250, 500 mg].
-Clonazepam (Klonopin) 0.5-5 mg PO bid-qid [0.5, 1,
2 mg].
-Lamotrigine (Lamictal) 50 mg PO qd, then increase
to 50-250 mg PO bid [25, 100, 150, 200 mg];
adjunct therapy.
10. Extras: MRI with and without gadolinium or CT with
contrast; EEG (with photic stimulation,
hyperventilation, sleep deprivation, awake and asleep
tracings); portable CXR, ECG.
11. Labs: CBC, SMA 7, glucose, Mg, calcium, phos-
phate, liver panel, VDRL, anticonvulsant levels. UA,
drug screen.
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