Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient
2009; Lippincott Williams & Wilkins; Volume: 40; Issue: 8 Linguagem: Inglês
10.1161/strokeaha.109.192362
ISSN1524-4628
AutoresDebbie Summers, Anné Leonard, Deidre Wentworth, Jeffrey L. Saver, Jo Simpson, Judith Spilker, Nanette Hock, Elaine Miller, Pamela H. Mitchell,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeStrokeVol. 40, No. 8Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBComprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke PatientA Scientific Statement From the American Heart Association Debbie Summers, MSN, RN, FAHA, Anne Leonard, MPH, RN, FAHA, Deidre Wentworth, MSN, RN, Jeffrey L. Saver, MD, FAHA, Jo Simpson, BSN, RN, Judith A. Spilker, BSN, RN, Nanette Hock, MSN, RN, FAHA, Elaine Miller, DNS, RN, FAHA, Pamela H. Mitchell, PhD, RN, FAHA and Debbie SummersDebbie Summers , Anne LeonardAnne Leonard , Deidre WentworthDeidre Wentworth , Jeffrey L. SaverJeffrey L. Saver , Jo SimpsonJo Simpson , Judith A. SpilkerJudith A. Spilker , Nanette HockNanette Hock , Elaine MillerElaine Miller , Pamela H. MitchellPamela H. Mitchell and and on behalf of the American Heart Association Council on Cardiovascular Nursing and the Stroke Council Originally published28 May 2009https://doi.org/10.1161/STROKEAHA.109.192362Stroke. 2009;40:2911–2944is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 28, 2009: Previous Version 1 Ischemic stroke represents 87% of all strokes.1 As worldwide initiatives move forward with stroke care, healthcare providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) charged a panel of healthcare professionals from several disciplines with developing a practical, comprehensive overview of care for the patient with acute ischemic stroke (AIS). This article focuses on educating nursing and allied healthcare professionals about the roles and responsibilities of those who care for patients with AIS.Nurses play a pivotal role in all phases of care of the stroke patient. For the purposes of this article, the writing panel has defined 2 phases of stroke care: (1) The emergency or hyperacute care phase,2,3 which includes the prehospital setting and the emergency department (ED), and (2) the acute care phase, which includes critical care units, intermediate care units, stroke units, and general medical units.Stroke is a complex disease that requires the efforts and skills of all members of the multidisciplinary team. Nurses are often responsible for the coordination of care throughout the continuum.4–9 Coordinated care of the AIS patient results in improved outcomes, decreased lengths of stay, and decreased costs.10In developing this comprehensive overview, the writing panel applied the rules of evidence and formulation of strength of evidence (recommendations) used by other AHA writing groups11 (Table 1). We also cross-reference other AHA guidelines as appropriate. Download figureDownload PowerPointTable 1. Applying Classification of Recommendations and Levels of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level.Overview of StrokeIt is important that nurses understand the burden of stroke as a public health issue in the United States. This will guide them in developing appropriate skills to care for AIS patients and to educate patients and families about secondary stroke prevention.Epidemiology of StrokeThe AHA estimates that ≈780 000 strokes occur each year; 600 000 of these are new strokes, and ≈180 000 are recurrent strokes.1 Eighty-seven percent are ischemic strokes, 10% are intracranial hemorrhages (ICH), and 3% are subarachnoid hemorrhages (SAH). In 2007, the overall mortality rate from stroke was 273 000, which makes stroke the third-leading cause of death in the United States.1 Between 1979 and 2005, the annual number of hospital discharges with stroke as the diagnosis was ≈900 000.1 Direct and indirect costs associated with stroke are estimated to be approximately $65.5 billion.1 Direct costs are attributed to the initial hospitalization, skilled nursing care, physician and nursing care, medications and durable medical equipment, home health care, and acute rehabilitation. Indirect costs include loss of productivity (loss of future earnings) due to morbidity and mortality and loss of esteem (place in family and society) due to disability.Demographics of StrokeEach year, women experience ≈60 000 more strokes than men do.1 American Indian/Alaskan Native persons have the highest prevalence of stroke (6.7%), followed by persons of multiple races (4.6%). Black men and women have twice the prevalence of stroke as whites (4.0% versus 2.3%).1 Blacks lead all races or ethnic groups for first-ever stroke. The prevalence of stroke in Hispanic or Latino populations is 3.1% for men and 1.9% for women compared with 2.4% for non-Hispanic white men and 2.7% for non-Hispanic white women.1 Epidemiologists note the increasing risk of stroke with advancing age, comparable to the risk of Alzheimer's disease. Unless individuals change modifiable risk factors, the large aging American population is faced with rising stroke morbidity and a greater than ever public healthcare burden.9Etiology of Stroke (Stroke Subtypes)Strokes caused by blocked blood vessels to the brain, or ischemic strokes, lead to cerebral infarction, whereas hemorrhagic strokes caused by ruptured vessels in and around the brain lead to ICH and SAH. The AHA has published guidelines for the medical management of patients with ischemic stroke12,13 and strokes caused by ICH14 and SAH.15 Nursing and allied health management is not provided in these guidelines and thus is outlined here.Ischemic strokes are commonly caused by atherosclerotic disease of extracranial or intracranial vessels that circulate blood to the brain. Approximately 20% of ischemic strokes are caused by large-vessel atherosclerosis (extracranial or intracranial segments of carotid or vertebrobasilar arteries), and ≈25% of ischemic strokes are due to penetrating artery disease (small-vessel disease) that causes lacunar or subcortical strokes. Another 20% are caused by cardiogenic embolism, most frequently from atrial fibrillation.16 Approximately 30% of ischemic strokes are termed cryptogenic, for which the exact cause of stroke remains unknown.16Hemorrhagic stroke is commonly caused by either primary ICH or SAH. Overall, ICH accounts for ≈10% of all strokes and SAH for ≈3%.1 Common causes and risk factors for ICH are hypertension (the number 1 cause), bleeding disorders, African-American ethnicity, aging, vascular malformations, excessive use/abuse of alcohol, and liver dysfunction.17–20 The primary cause of SAH is a ruptured cerebral aneurysm.Crossing the Continuum of CarePhase 1 of stroke care, the emergency or hyperacute phase, encompasses the first 3 to 24 hours after onset of stroke. This phase generally incorporates the prehospital (activation of emergency medical services [EMS]/9-1-1 and response) and ED care protocols. The focus is on identifying stroke symptoms and infarct location, assessing the patient for risk of acute and long-term complications, and determining treatment options.Phase 2 includes acute care, which encompasses the period from 24 to 72 hours after onset of stroke. In this phase, the focus is on clarifying the cause of stroke, preventing medical complications, preparing the patient and family for discharge, and instituting long-term secondary prevention modalities.The Emergency or Hyperacute Phase of AIS CareOptimal management of the AIS patient in the emergency or hyperacute phase of AIS care requires an accurate and systematic evaluation that is coordinated and timely. Once a potential stroke is suspected, EMS personnel and nurses must determine the time at which the patient was last known to be well (last known well time). This time is the single most important determinant of treatment options during the hyperacute phase.The Nurse's RoleIn the prehospital setting, the leading healthcare team member is the emergency medical technician (EMT) or paramedic. Nurses may work as EMTs and paramedics, radio providers of online medical control to EMS personnel from base stations, and educators who teach EMS personnel about stroke and the care of stroke patients.The key elements of prehospital care are stabilization of the airway, breathing, and circulation (the ABCs); identification of signs and symptoms of stroke; establishment or verification of the last known well time; provision of supplemental oxygen to patients with hypoxemia; checking the blood glucose level; avoidance of the administration of glucose-containing fluids (unless the patient is hypoglycemic); rapid initiation of transport (load and go); and delivery of patients to receiving centers capable of rapidly caring for acute stroke.21 When recombinant tissue plasminogen activator (rtPA) was approved as the first acute treatment for AIS, the paradigm of care of the stroke patient shifted, and emergency care of the stroke patient in the field emerged.22 The role of time in determining treatment eligibility and patient outcome has generated a body of literature and knowledge about appropriate care for AIS patients,22–35,37–45 from which healthcare providers have developed measures to quickly and easily identify and assess stroke patients.46,47 Textbooks and training courses for EMTs and paramedics discuss stroke pathophysiology and identify stroke as a medical emergency. Understanding and recognizing specific stroke symptoms can be challenging.22–24,28,47–50 Evaluation of EMS practices has shown that stroke-specific knowledge has been deficient38 but that both overall knowledge28 and identification of stroke symptoms by EMTs and paramedics can be improved with additional stroke-specific education.19–25,28,31,47–50In many community and academic institutions, education of EMS providers has become a function of the nurse educator, a role that has expanded to the community. The most widely available stroke teaching tool for this purpose21 is chapter 9 of the AHA stroke module.44,51 Educational videos and other tools are also available for the EMS audience.52Before beginning an EMS stroke education program, the nurse educator should verify local policies and regulations governing acceptable practice for paramedics and EMTs in that region or state. For example, in some communities, EMS providers are not permitted to perform some recommended practices for acute stroke care, such as determining finger-stick glucose levels and starting intravenous lines. In other communities, higher standards that require specific assessment skills have been developed for EMS to enable them to respond more aggressively to AIS.10,27,47As a part of their continuing education, EMS personnel must also be provided with accurate information about acute stroke care and treatment capabilities in their community.47 EMS units should know which hospitals are equipped to provide specific emergency stroke care, such as those certified by the Joint Commission or their state health agencies.10,53–56Continuing education of EMS personnel is challenging and requires frequent updates. The nurse educator should keep in mind that a typical EMS provider cares for 4 to 10 stroke patients in a given year.44 As a result, field experience may be limited, and reinforcement of knowledge and practice in caring for acute stroke patients will be necessary. One study concluded that the knowledge gained from stroke training decreased by ≈50% over 1 year57; therefore, educational programs about stroke might be repeated from 1 to several times per year. In some states with mandated stroke systems of care, EMS updates in stroke education will be required.21 The National Institutes of Health (NIH) proceedings Improving the Chain of Recovery for Acute Stroke in Your Community is a useful resource for planning and organizing stroke educational programs.47Education Regarding Prehospital Assessment for Acute StrokeAlthough accurate identification of stroke symptoms is a critical success factor in early stroke treatment, the nurse educator needs to include additional aspects of prehospital stroke patient management.28,58,59 Recognition of stroke symptoms is an important factor in successful delivery of proven acute therapies. Prehospital assessment tools have been developed to help enhance recognition of stroke symptoms and improve the ability to identify stroke patients in the field (Table 2). The most common and well-investigated tools are the Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen.22,30,32,60 Newer stroke identification tools include the Face Arm Speech Test61 (Table 3), which is similar to the Cincinnati Prehospital Stroke Scale, and the Melbourne Prehospital Stroke Scale,62–64 which is similar to the Los Angeles Prehospital Stroke Screen. Tools to rate stroke severity in the field have been developed, including a shortened version of the NIH Stroke Scale (NIHSS)65 and the Los Angeles Motor Scale.34 If a specific tool has not been identified for use within a community, the nurse educator should review the common signs and symptoms of stroke such as those identified on the Brain Attack Coalition's World Wide Web site (http://www.stroke-site.org/index.html). These tools may also be used to teach a quick stroke screening evaluation to hospital personnel, because in-hospital strokes also require prompt recognition and action. Table 2. Components of Selected Prehospital Assessment ToolsCincinnati Prehospital Stroke Scale32Los Angeles Prehospital Stroke Screen60Los Angeles Motor Scale34Face Arm Speech Test61SNIHSS-565SNIHSS indicates shortened National Institutes of Health Stroke Scale.Facial droopFacial weaknessFacial weaknessFacial palsyRight leg motorArm weaknessArm strengthArm strengthArm weaknessLeft leg motorSpeechGripGripSpeech impairmentGazeScreening criteria (4 items)Visual fieldsBlood glucoseLanguageTable 3. Sample Face Arm Speech Test (FAST)61RT indicates right side; LT, left side.Facial palsy affected sideYes RT LTNoUnknownArm weakness affected sideYes RT LTNoUnknownSpeech impairmentYesNoUnknownTime of onsetEMS personnel have long understood the implications of time to treatment for myocardial infarction and trauma, but the concept of time dependency in AIS is relatively new. The nurse educator must emphasize the importance of obtaining the last known well time.Stroke education should emphasize that stroke requires high-priority status and that the load-and-go philosophy has now become a part of mainstream acute stroke care in the field.41 rtPA is the only treatment for AIS approved by the US Food and Drug Administration, and it ideally is administered within 3 hours of symptom onset.13,59,66,67 On-site stroke patient assessments should be performed expeditiously, and transport should be initiated as soon as the patient's condition is assessed as stable.44,66,68,69 Although the symptoms listed in the formal prehospital stroke assessment tools are classic, other stroke symptoms should also be described to EMS personnel. Table 4 lists neurological symptoms associated with strokes that occur in the different cerebral territories. Table 4. The 5 Key Stroke Syndromes: Classic Signs Referable to Different Cerebral AreasLeft (dominant hemisphere) Left gaze preference Right visual field deficit Right hemiparesis Right hemisensory lossRight (nondominant hemisphere) Right gaze preference Left visual field deficit Left hemiparesis Left hemisensory loss neglect (left hemi-inattention)Brainstem Nausea and/or vomiting Diplopia, dysconjugate gaze, gaze palsy Dysarthria, dysphagia Vertigo, tinnitus Hemiparesis or quadriplegia Sensory loss in hemibody or all 4 limbs Decreased consciousness Hiccups, abnormal respirationsCerebellum Truncal/gait ataxia Limb ataxia, neck stiffnessHemorrhage Focal neurological deficits as in AIS Headache (especially in SAH) Neck pain Light intolerance Nausea, vomiting Decreased level of consciousnessRecommendationsClass ITo increase the number of stroke patients who receive timely treatment, educational programs for physicians, hospital personnel, and EMS personnel are recommended (Class I, Level of Evidence B).Stroke education of EMS personnel should be provided on a regular basis, perhaps as often as twice per year, to ensure proper recognition, field treatment, and delivery of patients to appropriate facilities (Class I, Level of Evidence C).Education Priorities for Assessment and Treatment in the FieldNeurological assessment of the AIS patient should always include the ABCs, vital signs, cardiac monitoring during transport, and baseline neurological assessment. Because the field neurological examination will serve as a baseline for assessment of neurological improvement or worsening, the use of a prehospital stroke scale is recommended.EMS personnel on the scene should ask the patient's family or bystanders when the patient was last known to be normal or without neurological deficits, ie, the last known well time. Documentation of this report of onset can be helpful in establishing an accurate time of stroke symptom onset.44,46,47,69 Ideally, standardized definitions should be developed in EMS systems to define the specific onset date and time. The date and time should be defined as the time when the stroke symptoms that brought the patient to the hospital first occurred. A specific time can be identified within a reasonable amount of certainty within ±15 minutes. When possible, the information should be obtained directly from the patient. If the patient is unable to give this information, EMS personnel should look to another reliable source for this information.70 If the time of onset of stroke symptoms is not identifiable, a standard method of time parameters should be used, such as morning (6:00 am to 11:59 am), afternoon (noon to 5:59 pm), evening (6:00 pm to 11:59 pm), and overnight (midnight to 5:59 am).70 EMS providers must emphasize to families the importance of traveling to the hospital with the patient, particularly if symptom onset is within the time frame for rtPA administration and the patient's language or decision-making capability is compromised. When family members cannot accompany the patient, EMS personnel should document the family's contact information and provide it to the emergency physician.13The current guidelines recommend the use of continuous cardiac monitoring during transport of a suspected stroke patient to determine the presence of cardiac arrhythmias.13 If there is no standing field protocol for management of cardiac conditions, EMS personnel should contact the base station or receiving institution if the electrocardiogram demonstrates possible acute myocardial ischemia or atrial fibrillation. Blood pressure should be monitored every 15 minutes, or more often if severe hypertension (systolic blood pressure >200 mm Hg) or relative hypotension (systolic blood pressure 92%, additional oxygen is not needed.13 Transport with the head of the bed elevated ≈30° may help with oxygenation and may minimize the possibility of aspiration.44,71,72 To decrease the risk of aspiration, the patient should receive nothing by mouth (NPO).Hypoglycemia, a common stroke mimic, can be identified quickly by measuring blood glucose during transport. Finger-stick tests can be performed if the emergency vehicle is appropriately equipped and personnel are trained. Treatment of severe hypoglycemia should be instituted promptly by EMS personnel. Intravenous access can be established in the field, and non–glucose-containing intravenous fluids can be started if the patient is hypotensive. Establishment of intravenous access should not delay transport.44,46,47,57,69,71Finally, the nurse educator should emphasize the value of early notification of the receiving ED of the arrival of a potential acute stroke patient. Historic cardiac trials have shown that prearrival notification of the ED enhances rapid diagnostic workup, reducing time between symptom onset and treatment.23,25,73RecommendationsClass IEMS personnel should be trained to administer a validated prehospital stroke assessment, such as the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen (Class I, Level of Evidence B).EMS personnel should be trained to determine the last known well time using standardized definitions to collect the most accurate information (Class I, Level of Evidence B).EMS personnel should use the neurological/stroke assessment approach to gather basic physiological information about the patient and communicate the patient's condition to the receiving hospital (Class I, Level of Evidence B).From the Field to the ED: Stroke Patient Triage and CareEmergency personnel initiate basic triage and care modalities in the field. Once the stroke patient arrives in the ED, patient triage is usually a function of nursing staff. The Emergency Nurses Association and the American College of Emergency Physicians recommend a 5-level Emergency Severity Index as a preferred system for triage in a busy ED.52 This index puts all stroke patients in the level 2 or "needs immediate assessment" category, the same as for an unstable trauma patient or a critical care cardiac patient.46,52,69 The emergency nurse must be able to recognize neurological symptoms that suggest stroke and rapidly assess the initial time of symptom onset or the last known well time.44,46,57The triage nurse should use specialized checklists, protocols, and other tools to identify stroke patients.10,44,47,57,74 Once stroke is confirmed, the nurse uses these procedures and protocols that define who contacts the acute stroke team or appropriate neurological consultant. Emergency nurses understand that time is critical and are trained in rapid assessment and treatment of stroke patients. Studies have shown that the sooner thrombolytic therapy is started, the greater the benefit.23,44,46,75 It is critical that all emergency nurses and other emergency professional staff know that the NIH-National Institute of Neurological Disorders and Stroke (NINDS) benchmark treatment time for AIS with intravenous rtPA is within 60 minutes of arrival in the ED46 (Table 5). In some cases, this time will need to be shortened to successfully initiate thrombolytic therapy within 3 hours of stroke onset, although there is growing evidence of safety and effectiveness beyond the 3-hour window from stroke onset.76,77 The AHA AIS Writing Committee has issued a Science Advisory stating that some eligible patients may be treated between the 3- and 4.5-hour window after stroke. The recommendation comes with several caveats and follows the inclusion criteria described in the ECASS III results. The exceptions include persons >80 years of age, those taking oral anticoagulants with an international normalized ratio of 25, and those with a history of stroke and diabetes.77aTable 5. NINDS Time Targets for Organized Triage of Acute Stroke Patients44: Key Evaluation Time Targets for the Potential rtPA CandidateMaximum intervals recommended by NINDSCT indicates computed tomography.*On-site or by transfer to another facility.Door-to–doctor first sees patient10 minDoor-to–CT completed25 minDoor-to–CT read45 minDoor-to–thrombolytic therapy starts60 minPhysician examination15 minNeurosurgical expertise available*2 hAdmitted to monitored bed3 hRecommendationsClass IEDs should establish standard operating procedures and protocols to triage stroke patients expeditiously (Class I, Level of Evidence B).Standard procedures and protocols should be established for benchmarking time to evaluate and treat eligible stroke patients with rtPA expeditiously (Class I, Level of Evidence B).Target treatment with rtPA should be within 1 hour of the patient's arrival in the ED (Class I, Level of Evidence A).Eligible patients can be treated between the 3- to 4.5-hour window when evaluated carefully for exclusions to treatment (Class I, Level of Evidence B).Emergency Nursing Interventions in the Emergency/Hyperacute Phase of StrokeThe First 24 HoursStroke symptoms typically begin suddenly (but can evolve over minutes to hours) and are referable to the affected region of the brain. Ischemic stroke symptoms are generally divided into those that affect the anterior and posterior cerebral circulation (Table 4). To properly triage patients for AIS therapies such as rtPA, emergency nurses should be familiar with both typical and unusual stroke presentations.As in the prehospital phase, initial patient assessments made by the emergency nurse are based on the principle of assessing the ABCs, vital signs, and neurological assessment. The majority of AIS patients will present to the ED in a hemodynamically stable condition; however, ischemic strokes involving the posterior circulation can require aggressive airway management, especially if the patient has an altered level of consciousness.26,78Circulatory collapse or cardiac arrest, although possible, is uncommon in isolated ischemic stroke.79 The occurrence of either may indicate other medical conditions such as acute myocardial infarction, atrial fibrillation, or congestive heart failure. Cardiac monitoring of all suspected stroke patients in the ED helps identify these conditions.69Initial ED documentation of the stroke patient begins with the recording of all information included in the neurological/stroke assessment. Vital signs, including temperature, may be measured frequently as clinically indicated but not less than every 30 minutes while the patient is in the ED. Hyperthermia is associated with poor outcome in stroke patients13,80–82; therefore, it is important to consider treating any fever >99.6°F. During the 60-minute infusion of thrombolytic therapy, pulse and blood pressure should be checked at least every 15 minutes. Table 6 summarizes nursing care associated with thrombolysis and nonthrombolysis treatment of patients with acute cerebral ischemia on the basis of the original NIH-NINDS study protocol and AHA/ASA guidelines.2,29,83–86Table 6. Schedule of Neurological Assessment and Vital Signs and Other Acute Care Assessments in Thrombolysis-Treated and Nonthrombolysis–Treated Patients2,29,83–86Thrombolysis-Treated PatientsNonthrombolysis–Treated PatientsBP indicates blood pressure; ICU, intensive care unit; N/A, not applicable; IV, intravenous; NS, normal saline; and MRI, magnetic resonance imaging.Neurological assessment and vital signs (except temperature) every 15 min for the first 2 h at the beginning of rtPA infusion, then every 30 min for 6 h, then every 60 min for 16 h (total of 24 h) Note: Frequency of BP assessments may need to be increased if systolic BP stays ≥180 mm Hg or diastolic BP stays ≥105 mm Hg. Temperature every 4 h or as required. Treat temperatures >99.6°F with acetaminophen as orderedIn ICU, every hour with neurological checks or more frequently if necessary. In non-ICU setting, depending on patient's condition and neurological assessments, at a minimum check neurological assessment and vital signs every 4 hCall physician if systolic BP >185 or 105 or <60 mm Hg; pulse 110 per min; respirations >24 per min; temperature >99.6°F; or for worsening of stroke symptoms or other decline in neurological statusCall physician for further treatment based on physician and institutional preferences/guidelines: Systolic BP >220 or 120 or <60 mm Hg; pulse 110 per min; temperature >99.6°F; respirations >24 per min; or for worsening of stroke symptoms or other decline in neurological statusFor O2 saturation <92%, give O2 by cannula at 2 to 3 L/minFor O2 saturation <92%, give O2 by cannula at 2 to 3 L/minMonitor for major and minor bleeding complicationsN/AContinuous cardiac monitoring up to 72 h or moreContinuous cardiac monitoring for 24 to 48 hMeasure intake and outputMeasure intake and outputBed restBed restIV fluids NS at 75–100 mL/hIV fluids NS at 75–100 mL/hNo heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 h, then start antithrombotic as orderedAntithrombotics should be ordered w
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