Microsoft word - 3.3.5 sample plng & intervention guide tia

EMERGENCY SERVICES
ED Planning and Intervention Guide for
Stroke and TIA
CEREBROVASCULAR DISORDERS (Stroke/TIA)
PLANNING / INTERVENTION OPTIONS ( ____* if initialed, requires further documentation)
Done N/A
NPO: Evaluate airway, lung sounds and skin colour. (see nursing assessment)
Have suction and airway available and ready for use. Administer oxygen / suction as indicated. (see treatment sheet) Monitor vital signs including BP, TPR. and O2 Sat. as indicated. (see vital signs sheet) Evaluate neurologic parameters (see nursing assessment Stroke / TIA sheet)
Apply cardiac monitor and obtain rhythm strip. (see vital signs sheet) Measure random capillary blood glucose and document results (see nursing assessment)) Initiate IV therapy and/or give meds as ordered. (see treatment sheet) Prepare patient / assist with CT Scan / lumbar puncture. (see treatment sheet)
Report patient's condition and document observations. (see nursing assessment) Patient Last Seen Well Date: _ August 21 / 09__
_ _____ Time: __
_ 0730___ Unknown:
ASSESSMENT
COMMENTS
BEO __3___ BVR ___6__ BMR __5___ GCS Total = __14 Result ____5.2______ (Normal Range 3.9 – 7.8) Slurred speech/dysphagia screen completed Signature: W. Kirenko RN(EC) Initials: WK Signature: ______________________________ Initials: ____________ CEREBROVASCULAR DISORDERS PLANNING/INTERVENTION EMERGENCY SERVICES
Cerebrovascular Disorders (Stroke / TIA)


Suspected Acute Stroke signs & symptoms:
• Sudden weakness, numbness or tingling in the face, arm or leg
• Sudden trouble speaking or understanding speech
• Sudden loss of vision, particularly in one eye or double vision
• Sudden severe and unusual headache associated with the above symptoms
• Sudden loss of balance, dizziness, or lack of coordination, especially with any of the above

ANALYSIS / PROBLEM STATEMENT
Risk for altered cerebral perfusion related to cerebral edema or increased intracranial pressure as evidenced
by headache, vomiting, altered level of consciousness, seizures, pupillary changes, motor sensory deficits,
and impaired memory or thought processes.
EXPECTED OUTCOME / EVALUATION
Early detection and reporting of altered cerebral tissue perfusion during patient stay in E.D.
ANALYSIS / PROBLEM STATEMENT
Risk for injury from seizures related to cerebral irritation or edema as evidenced by involuntary, repetitive
motor / sensory movement or spasticity, changes in alertness, orientation or motor response.
EXPECTED OUTCOME / EVALUATION
Reduce the potential for physical injury during patient stay in E.D.

Copyright 1995 by the Emergency Department Nursing Staff, Public General Hospital, Chatham, Ontario.
Form # 9604

Source: http://otn.ca/sites/default/files/sample_ping__intervention_guide.pdf