MIME-Version: 1.0 Content-Location: file:///C:/2671C675/AP25.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Thrombolytic Screening Form (CVA)

Thrombolytic Screening Form (C= VA)

 

= 1.&n= bsp;      Patient Name: &nb= sp; _________________________________  _________________________________

(Last= name)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      (First name)

 

= 2.&n= bsp;      Patient Age / Sex:         __________________= _______________  _________________________________

(Sex)=         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;   (Age)

 

= 3.&n= bsp;      Past Medical History: _______________________________________________________________________

 

= 4.&n= bsp;      Current Medications: _______________________________________________________________________

 

= 5.&n= bsp;      Drug Allergies: ___________________________________________________________________________= _

 

= 6.&n= bsp;      Initial BP &= nbsp;           &nbs= p;         _______________        &= nbsp; _______________    /   _______________        &= nbsp;   ______________

(Righ= t Arm)        &= nbsp;           &nbs= p;         (Military Time)      &n= bsp;            = ;       (Left Arm)      &nb= sp;            =             &nb= sp;            =    (Military Time)      &n= bsp;  

        =    YES     &nb= sp;            = NO

= 7.&n= bsp;      Age < 18 years            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =            [  ]           &nb= sp;        [  ]

 

= 8.&n= bsp;      Patient was asleep when symptoms started         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          [  ]           &nb= sp;        [  ]

 

= 9.&n= bsp;      Onset of symptoms > 3 hours        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      [  ]           &nb= sp;        [  ]

 

= 10.&= nbsp;  Rapidly improving or minor symptoms        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;       [  ]           &nb= sp;        [  ]

 

= 11.&= nbsp;  History of intracranial hemorrhage        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p; [  ]           &nb= sp;        [  ]

 

= 12.&= nbsp;  Seizure at onset of symptoms            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;  [  ]           &nb= sp;        [  ]

 

= 13.&= nbsp;  Stroke or serious head injury < 3 month= s        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;  [  ]                &= nbsp;   [  ]

 

= 14.&= nbsp;  Major surgery or other serious trauma <= 2 weeks      &n= bsp;            = ;            &n= bsp;            = ;      [  ]           &nb= sp;        [  ]

 

= 15.&= nbsp;  GI or urinary tract hemorrhage < 3 week= s        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;           &= nbsp;   [  ]           &nb= sp;        [  ]

 

= 16.&= nbsp;  Systolic Blood Pressure > 185 mmHg        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      [  ]           &nb= sp;        [  ]

 

= 17.&= nbsp;  Diastolic Blood Pressure > 110 mmHg        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      [  ]           &nb= sp;        [  ]

 

= 18.&= nbsp;  Aggressive treatment to lower blood pressure (i.e= ., use of any vasodilators)    =          [  ]           &nb= sp;        [  ]

 

= 19.&= nbsp;  Blood glucose < 60             =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =     [  ]           &nb= sp;        [  ]

 

= 20.&= nbsp;  Blood glucose > 400             =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =   [  ]           &nb= sp;        [  ]

 

= 21.&= nbsp;  Symptoms of Subarachnoid hemorrhage (i.e., sudden severe headache     &nb= sp;            [  ]           &nb= sp;        [  ]

foll= owed by a brief loss of consciousness, most people wake up confused=

and<= /span> sle= epy.)

 

= 22.&= nbsp;  Arterial puncture at non-compressible site or lum= bar puncture < 1 week  &nbs= p;            &= nbsp;  [  ]           &nb= sp;        [  ]

 

= 23.&= nbsp;  Pregnant or lactating females            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;   [  ]           &nb= sp;        [  ]

 

= 24.&= nbsp;  If all of the Thrombolytic Screening Form (CVA= ) criteria are met (all NO’s), alert the receiving facility of a possible thrombolytic candidate as early as possible.  If not, then return to the appropr= iate treatment protocol.

 

2= 5.  Form Completed by: _________________________________________________________