NURSING RESPONSIBILITIES - STROKE/TIA

IN-PATIENT UNITS

1. When getting report from the ED- get the following information:
a. Swallow screen results. If the patient failed the swallow screen in the ED, is there an order for a swallow
evaluation? If not obtain an order. During the weekends (Friday 4pm-Sunday 1pm) make sure the on-call
SLP was called regarding the failed swallow screen
b. NIHSS- this number is found in the ED physician’s documentation
c. CT results-just because it is negative that does not mean the patient did not have a stroke/TIA.

2. Stroke Admission Orders

Make sure the following are ordered on all stroke/TIA patients unless contraindicated:
a. PT eval (need an eval order, not just a functional screen)
b. Lipid profile if not completed in the ED
c. Antithrombotic (if ischemic stroke/TIA)
d. VTE prophylaxis. Document SCD application on admission
e. Swallow eval and treat for failed swallow screens

3. Nursing Documentation
a. If the swallow screen was not documented, make sure this assessment is documented before anything p.o
is given to the patient
b. Add the TIA/ Ischemic Stroke Pathway (In Plan of Care) into your worklist. This is a five day
documentation and must be done each day. If anything is “No” it needs to be followed up on.
c. Teaching must be done daily. Teach:stroke education. It covers the 5 items all stroke/TIA patients must
be educated on:
a. Activation of EMS
b. Warning signs
c. Personal Risk Factors
d. Following up with a physician
e. Medications the patient is on
d. If the patient smoked (even one cigarette) in the past 12 months- use Teach:smoking Cessation
Education to document the education
e. A repeat NIHSS must be done on day 2
f. On Discharge-pull in Stroke Discharge Instructions into the Stand Alone Forms and complete it. You must
enter the antithrombotic and statin onto this form as well as anticoagulant if the patient has A Fib/flutter

4. Reminders
a. VTE prophylaxis is mechanical (SCD) or pharmacological. AE hose does not count for stroke patients.
b. ASA and Plavix are not VTE prophylaxis
c. Antithrombotic must be given by hospital Day 2
d. Hospital day 1 is the day the patient ARRIVED and hospital day 2 is the following day (i.e. if the patient
arrived 4/27/16 at 23:55 that is day 1; day 2 is 4/28/16 at 00:01 through 23:59)
e. VTE prophylaxis should start at admission

5. Any questions?
You can call me during the day with any questions. Gerri Kiefer-Necklen- work cell: 201-469-5963 office x8564