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THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE FLOWSHEET
Date: _________________Arrival Time: ______________ page 1 of 4
Treatment Decision Time: tPA started at (date/time):Time elapsed since tPA started Baseline Dose Verified Bolus 15 min 30 min 45 min 1 hr 1hr 15 min 1hr 30min 1hr 45 min 2hrTIME
R L | | | | | | | | |Size React | | | | | | | | |
EOMRUE LUE | | | | | | | | |RLE LLE | | | | | | | | |RUE LUE | | | | | | | | |RLE LLE | | | | | | | | |
P=Present
A=Absent
Blood PressureRespirationsRR Vent| Spont | | | | | | | | | | |Fi02Sp02Temp every 4 hrs
Nurse Initials
LOC Pupils SensoryA=Alert: Opens eyes, stays awake, interacts in conversation Reaction
B = Brisk
S=Sluggish
0= None
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
Level of ConsciousnessOrientation
Sensory
S=Stuporous: Arouses to continuous or painful stimuli. Incomprehensible sounds.
Total Dose: __________
Bolus Dose: __________
Waste mL: __________
Infusion Dose: __________
x3 = Time
Facial
SymmetrySpeech
Alteration
S/S of Angioedema or Anaphylaxis
Baseline NIHSS:
L=Lethargic: Drowsy, awakens to stimulation, Follows commands and
O=Obtunded: Needs constantly/vigorous stimulation to awake and follow simple
commands. Confused
Pupils
Motor
Strength
Vital Signs and Neuro checks: Baseline before bolus, every 15 min x
2 hours, every 30 mins x 6hrs and every 1 hr x 16 hrs.
x4 = Situtation
I= Intact
N=Numbness
T = Tingling 0
= AbsentC=Comatose: No response to painful/continuous stimuli. May have a reflex response. No
verbal sounds
Orientationx1 = Person
x2 = Place
5=Normal Strength
4=Moves against resistance
3 = Overcomes gravity
2 = Can't overcome gravity
1 = Flicker of muscle
0 = No movement, flaccid
Motor Strength
Created 8/2014
THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE FLOWSHEET
Date: ________________
page 2 of 4Time elapsed since tPA started 2hr 30 min 3 hr 3hr 30 min 4 hr 4 hr 30 min 5 hr 5 hr 30 min 6 hr 6 hr 30 min 7 hr 7hr 30 minTIME
R L | | | | | | | | | |Size React | | | | | | | | | |
EOMRUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |RUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |
P = PresentA = AbsentBlood PressureRespirationsRR Vent| Spont | | | | | | | | | |Fi02Sp02Temp every 4 hrs
Nurse Initials
LOC Pupils SensoryA=Alert: Opens eyes, stays awake, interacts in conversation Reaction
B = Brisk
S=Sluggish
0= None
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
Vital Signs and Neuro checks: Baseline before bolus, every 15 min x 2
hours, every 30 mins x 6hrs and every 1 hr x 16 hrs.
I= Intact
N=Numbness
T = Tingling 0
= Absent
Level of ConsciousnessOrientation
Pupils
Motor
Strength
Sensory
Facial
Orientationx1 = Person
L=Lethargic: Drowsy, awakens to stimulation, Follows commands and x2 = Place
O=Obtunded: Needs constantly/vigorous stimulation to awake and follow simple
commands. Confusedx3 = Time
S=Stuporous: Arouses to continuous or painful stimuli. Incomprehensible sounds. x4 = Situtation
C=Comatose: No response to painful/continuous stimuli. May have a reflex response. No
verbal sounds
Motor Strength5=Normal Strength
4=Moves against resistance
3 = Overcomes gravity
2 = Can't overcome gravity
1 = Flicker of muscle
0 = No movement, flaccid
Speech
S/S of Angioedema or Anaphylaxis
Created 8/2014
THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE FLOWSHEET
Date: ________________
page 3 of 4Time elapsed since tPA started 8 hr 9 hr 10 hr 11 hr 12 hr 13 hr 14 hr 15 hr 16 hr 17 hr 18 hrTIME
R L | | | | | | | | | |Size React | | | | | | | | | |
EOMRUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |RUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |
P=PresentA=AbsentBlood PressureRespirationsRR Vent| Spont | | | | | | | | | |Fi02Sp02Temp every 4 hrs
Nurse Initials
LOC Pupils Sensory
A=Alert: Opens eyes, stays awake, interacts in conversation Reaction
B = Brisk
S=Sluggish
0= None
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
Motor Strength
Level of Consciousness
Vital Signs and Neuro checks: Baseline before bolus, every 15 min x 2
hours, every 30 mins x 6hrs and every 1 hr x 16 hrs.
Orientation
Pupils
Motor
Strength
Sensory
Facial Speech
S/S of Angioedema or Anaphylaxis
Orientation
x1 = Person
L=Lethargic: Drowsy, awakens to stimulation, Follows commands and
answers questions inatentively.x2 = Place
O=Obtunded: Needs constantly/vigorous stimulation to awake and follow simple
commands. Confusedx3 = Time
x4 = Situtation
C=Comatose: No response to painful/continuous stimuli. May have a reflex response. No
verbal sounds
5=Normal Strength
4=Moves against resistance
3 = Overcomes gravity
2 = Can't overcome gravity
1 = Flicker of muscle
0 = No movement, flaccid S=Stuporous: Arouses to continuous or painful stimuli. Incomprehensible sounds.
Withdraws from pain.
I= Intact
N=Numbness
T = Tingling 0
= Absent
Created 8/2014
THROMBOLYTIC THERAPY FOR ACUTE ISCHEMIC STROKE FLOWSHEET
Date: ________________
page 4 of 4
Time elapsed since tPA started 19 hr 20 hr 21 hr 22hr 23 hr 24hrTIME
R L | | | | | | | | | |Size React | | | | | | | | | |
EOM
RUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |RUE LUE | | | | | | | | | |RLE LLE | | | | | | | | | |
P=Present
A=AbsentBlood Pressure
Respirations
RR Vent| Spont | | | | | | | | | |Fi02
Sp02
Temp every 4 hrs
Nurse Initials
LOC Pupils Sensory
A=Alert: Opens eyes, stays awake, interacts in conversation Reaction
B = Brisk
S=Sluggish
0= None
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
RN Initials / Signature:___________________________________ RN Initials / Signature:___________________________________
Level of Consciousness
Orientation
Pupils
Motor
Strength
Vital Signs and Neuro checks: Baseline before bolus, every 15 min x 2
hours, every 30 mins x 6hrs and every 1 hr x 16 hrs.
Additional Assessment
x4 = Situtation
C=Comatose: No response to painful/continuous stimuli. May have a reflex response. No
verbal sounds
Sensory
Facial Symmetry
Speech Alteration
S/S of Angioedema or Anaphylaxis
Orientation Motor Strength5=Normal Strength
4=Moves against resistance
3 = Overcomes gravity
2 = Can't overcome gravity
1 = Flicker of muscle
0 = No movement, flaccid
I= Intact
N=Numbness
T = Tingling 0
= Absent
x1 = Person
L=Lethargic: Drowsy, awakens to stimulation, Follows commands and
answers questions inatentively.x2 = Place
O=Obtunded: Needs constantly/vigorous stimulation to awake and follow simple
commands. Confusedx3 = Time
S=Stuporous: Arouses to continuous or painful stimuli. Incomprehensible sounds.
Withdraws from pain.
Created 8/2014
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