Saint Luke’s Care

Saint Luke’s Health System

Clinical Path – Transient Ischemic Attack

Problem: Disrupted Cerebral Perfusion

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to cerebral ischemia
Initiated Date: ___________________ Modified: __________________ Resolved: _______________
Key Outcome Statement: Cerebral perfusion will remain adequate as evidenced by:
Expected Outcome: 1. Neuro function IER (in expected range) – LOC/motor/sensory/visual/cognitive
2. Patient free of signs and symptoms of increased ICP
3. Vital Signs remain in prescribed range
4. Pt will not demonstrate seizure activity

Nursing Assessment/
Intervention
(Practice Interventions)
1. Assess neuro status/function trends-LOC, motor (movement, muscle tone, drift) sensory, pupil size, shape,
symmetry, reactivity), cognition – every 4 hours
2. Assess VS-BP, HR, respiratory rate and pattern, temp, O2 sat – every 4 hours
3. Maintain body alignment in midline and avoid neck flexion or head rotation – ongoing
4. Plan nursing care, procedure for energy conservation to minimize increased ICP – every 12 hours
5. Prevent accumulation of tracheobronchial secretions – every 4 hours
6. Administer prescribed medications/fluids (volume expanders, vasoactive medication, anticoagulants, sedative,
analgesics, etc.) to maintain hemodynamic parameters and optimize cerebral perfusion – as ordered

Problem: Disrupted Peripheral Perfusion

Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to reduction / interruption of venous / arterial blood flow
Initiated Date: ___________________ Modified: __________________ Resolved: _______________
Key Outcome Statement: Peripheral tissue perfusion is adequate to nourish the tissue as evidenced by:
Expected Outcome: 1. Peripheral perfusion IER (color/temp/capillary refill/pulses)
2. Skin intact
3. Absence or peripheral edema
4. Absence of localized extremity pain
5. Sensation level IER
6. Motor function IER

Nursing Assessment/
Intervention
(Practice Interventions)
1. Assess peripheral perfusion, i.e. peripheral pulses, color, temperature, capillary refill – every 8 hours
2. Inspect skin for tissue breakdown or ulcers – every 12 hours
3. Assess pain level – every 12 hours
4. Assess sensation and motor function – every 8 hours
5. Maintain TED hose/SCD’s-collaborate with physician – once
6. Assess for signs of peripheral ischemia – ongoing
7. Implement appropriate wound care; consider need for multidisciplinary consult i.e. skin nurse, pharmacy – once

Path intermediate/discharge goals reviewed with patient/SO and mutually agreed upon.
Date: _______________ RN Signature: ____________________________________
SAINT LUKE’S HEALTH SYSTEM
Saint Luke’s Care
The suggested plan represents the initial desired course of treatment
and goals of recovery. These are representative or average guidelines
only and should be reviewed periodically by the attending physician
and other involved disciplines. Deviations are generally expected and
revisions to the plan should be made as warranted

Patient Label

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SYS-199 (Rev. 09/22/08)
 Saint Luke’s Care
Saint Luke’s Health System
Clinical Path – Transient Ischemic Attack

Problem: Decreased Knowledge

Nursing Diagnosis: Knowledge Deficit related to unfamiliarity with information / resources
Initiated Date: ___________________ Modified: __________________ Resolved: _______________
Key Outcome Statement: Pt/SO demonstrates knowledge and / or skills needed to practice health behaviors as evidenced by:
Expected Outcome: 1. Pt/SO verbalized understanding of procedures and disease process
2. Pt/SO verbalizes/demonstrates ability to care for self/pt
3. Pt/SO sets realistic goals

Nursing Assessment/ 1. Assess pt/so current knowledge level – daily

Intervention 2. Provide individualized instruction on specific aspect of care – daily
(Practice Interventions) 3. Review, reinforce and modify teaching methods as needed – daily
4. Assess readiness and ability to learn – daily
5. Collaborate with PT/SO to develop realistic learning objectives – daily
6. Evaluate Pt/SO ability to verbalize/demonstrate understanding of information/instruction taught – once

Problem: Inability to Eat

Nursing Diagnosis: Imbalanced Nutrition, Less Than Body Requirements related to biologic / physiologic factors
Initiated Date: ___________________ Modified: __________________ Resolved: _______________
Key Outcome Statement: Nutrient intake meets metabolic needs as evidenced by:
Expected Outcome: 1. Pt/SO/Family/ caregiver expresses understanding of nutritional deficit/plan
2. Fluid and food intake IER
3. Blood glucose IER
4. Pt/SO/caregiver demonstrates ability to maintain adequate nutritional intake

Nursing Assessment/ 1. Record percent of meal eaten – TID

Intervention 2. Assess weight – as ordered but at least weekly
(Practice Interventions) 3. Collaborate with dietitian on nutritional assessment, counseling and/or plan – once
4. Assess blood glucose – per orders and PRN
5. Assess abdomen, bowel sounds, and bowel elimination – every 12 hours
6. Assess Pt/SO/family/caregiver ability to maintain adequate nutrition – daily
7. Assess Pt/SO/family understanding of nutritional deficit/plan – daily

Patient Label

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SYS-199 (Rev. 09/22/08)
 Saint Luke’s Care
Saint Luke’s Health System
Clinical Path – Transient Ischemic Attack
Diagnostic – Evaluation
NURSING DIAGNOSIS/ DATE: _________________ to __________________
OUTCOME STATEMENT INITIAL Explain unmet EOs
W1 W2 Indicate time and nursing diagnosis with key word
Nursing Diagnosis: Ineffective cerebral Intervention: _________________________
tissue perfusion related to cerebral [ ] InitiateTIA orders
ischemia or cerebral hemorrhage [ ] [ ] Neuro Assess and VS Q 2hr x 4, then Q 4hr, report changes _________________________
NEURO / COGNITIVE PSYCH

Baseline O2 Sat _______ _________________________

Outcome Statement: Cerebral perfusion
will be adequate as evidenced by:
Nursing Diagnosis: Altered peripheral
tissue perfusion related to
reduction/interruption of blood flow
CARDIO / PULMONARY
[ ] Unit admit NIHSS _______
[ ] Hold Metformin for 48 hours post contrast dye _________________________
(CT/CTA/angio) _________________________
Expected Outcomes: _________________________
____ ____Vital signs in prescribed range, HR > 60 & < 120
____ ____O2 Sat > 92% _________________________
____ ____Neuro assessment IER or improving _________________________
____ ____If neuro status decreases, neurologist is notified
____ ____No seizure activity _________________________
____ ____Diagnostic tests completed or ordered _________________________
Intervention: _________________________
[ ] Dressing change to site as needed
[ ] Antithrombotic started within 24 – 48 hours _________________________

[ ] Evaluate need for DVT prophylaxis _________________________

Outcome Statement: Tissue Perfusion
will remain adequate as evidenced by:
Nursing Diagnosis: Imbalanced
nutrition, less than required related to
disease process
GI/GU/NUTRITION
[ ] [ ] Up with assistance
Expected Outcomes: _________________________
____ ____Arteriogram site without hematoma & distal pulses _________________________
palpable _________________________
____ ____No edema or pain at incision site or lower extremity
____ ____Motor function and sensation IER for lower extremity _________________________
____ ____SCDs ordered, applied, if indicated _________________________
____ ____Antithrombotic treatment held for prescribed time
____ ____Participates in ADLs without symptoms _________________________
Intervention: _________________________
[ ] PBG on admission, then Q 4hr if NPO or AC & HS if eating _________________________
[ ] If PBG >140 initiate sliding scale insulin orders per TIA

Outcome Statement: Nutrient intake
meets needs AEB:
Nursing Diagnosis: Knowledge Deficit,
related to unfamiliarity with
information/resources
TEACHING
orders _________________________
[ ] Assess Pt/SO ability to maintain adequate nutrition _________________________
[ ] Last BM _______, give laxative if > 48 hours
Expected Outcomes: _________________________
____ ____Pt/SO verb understanding of nutrition plan _________________________
____ ____Fluid and food intake IER
____ ____Glucose < 140
_________________________
____ ____Lipid lowering medication ordered for LDL >100 _________________________
Intervention: _________________________
[ ] Assess Pt/SO current knowledge level, readiness/ability
to learn _________________________
[ ] Assess Pt/SO knowledge of disease process _________________________
[ ] Assess Pt/SO knowledge of diagnostic tests/procedures
[ ] Provide Stroke Education Booklet
_________________________
[ ] Initiate Stroke Risk Reduction Plan _________________________

[ ] Provide smoking cessation packet _________________________

Outcome Statement: Pt/SO demonstrates Expected Outcomes:
knowledge/ skills needed to practice health ____ ____Pt/SO verb understanding of disease process _________________________
behaviors AEB: ____ ____Pt/SO verbalizes/demonstrates ability to care for self/pt _________________________
____ ____Pt/SO sets realistic goals
____ ____Pt/SO verb understanding of tests/procedures
_________________________
____ ____Pt/SO verb understanding of Risk Reduction Plan _________________________
____ ____Pt/SO understand the need to know stroke warning signs _________________________
(Act FAST) (Face Arm Speech Time)
A a in a [ ] indicates intervention done
SYMBOL KEY: ____ = Expected Outcome “Initials” on a line means Expected Outcome
A “o” in a [ ] or on a line indicates the item was not pertinent
[ ] = Interventions done and findings as expected
A “*” in a [ ] or on a line indicates the item was not done as expected

Init. Signature PATIENT LABEL

_______ ____________________
_______ ____________________
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SYS-199 (Rev. 09/22/08)
 Saint Luke’s Care
Saint Luke’s Health System
Clinical Path – Transient Ischemic Attack
Discharge Phase
NURSING DIAGNOSIS/ DATE: _________________ to __________________
OUTCOME STATEMENT INITIAL Explain unmet EOs
W1 W2 Indicate time and nursing diagnosis with key word
Nursing Diagnosis: Altered cerebral Intervention: _________________________
tissue perfusion related to cerebral [ ] [ ] Neuro assess Q 4h
_________________________
NEURO / COGNITIVE PSYCH

ischemia or cerebral hemorrhage [ ] [ ] Discharge NIHSS _______

Outcome Statement: Cerebral
perfusion will be adequate as evidenced
by:
Nursing Diagnosis: Altered peripheral
tissue perfusion related to
CARDIO / PULMONARY
[ ] [ ] Vitals Q 4hr _________________________
_________________________
Expected Outcomes:
____ ____Neuro status IER
_________________________
____ ____If Decreased neuro status, reported to neurologist _________________________
____ Patient on antithrombotic at discharge _________________________
____ ____BP in desired range according to orders
____ ____Cardiac Rhythm stable with HR >60 & <120 _________________________
_________________________
Intervention: _________________________
[ ] [ ] DC saline lock

reduction/interruption of blood flow [ ] [ ] Assess groin site, if applicable

Outcome Statement: Tissue Perfusion
will remain adequate as evidenced by:
Nursing Diagnosis: Imbalanced
nutrition, less than required related to
disease process
GI / GU / NUTRITION
_________________________
_________________________
Expected Outcomes: _________________________
____ ____Arteriogram groin site IER
____ ____Peripheral perfusion IER, skin intact, sensation and
_________________________
motor function IER _________________________
_________________________
Intervention:
[ ] HgbA1C & lipid panel results on Risk Reduction Sheet
_________________________
[ ] Nutrition screening completed _________________________

[ ] Diabetes education completed, if applicable _________________________

Outcome Statement: Nutrient intake
meets needs AEB:
Nursing Diagnosis: Deficient
knowledge related to unfamiliarity with
information/resources
TEACHING
_________________________
Expected Outcomes:
____ ____Pt/SO verb understanding of HgbA1C & lipid profile _________________________
findings _________________________
____ ____Pt/SO verb understanding of any dietary _________________________
changes/restrictions
_________________________
Intervention: _________________________
[ ] Complete Stroke Risk Reduction Plan & give copy to _________________________
pt/SO
[ ] Discuss plan to prevent stroke (meds/risks) _________________________
[ ] Give discharge f/u plan (Dr. appointments, lab test, etc) _________________________
[ ] Reinforce stroke warning signs (Act FAST) _________________________

[ ] Instructed to call 911 if have stroke warning signs (Act

FAST) _________________________
_________________________
Outcome Statement: Pt/SO demon Expected Outcomes: _________________________
knowledge/ skills needed to practice ____ ____Pt/SO verb understanding of disease process
health behaviors AEB: ____ ____Pt/ SO verb understanding of discharge plan (risk _________________________
factors, meds, DC f/u needs, stroke warning signs _________________________
and to call 911 if s/s occur) _________________________
A a in a [ ] indicates intervention done
SYMBOL KEY: ____ = Expected Outcome “Initials” on a line means Expected Outcome
A “o” in a [ ] or on a line indicates the item was not pertinent
[ ] = Interventions done and findings as expected
A “*” in a [ ] or on a line indicates the item was not done as expected

Init. Signature PATIENT LABEL

_______ ____________________
_______ ____________________

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SYS-199 (Rev. 09/22/08)