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Microsoft word - admit orders-acute stroke - post t-pa 2012 rev.doc

Acute Stroke Post t-PA
Admit Orders
Admit to: 1HOSPITALIST SERVICE and/or 1Dr. __________________________
Secondary diagnosis:______________________________________________________________________________ Admit to: 1 Observation Status or 1 Inpatient Status in ICU (see Critical Care Authorization Sheet) Condition: 1stable 1fair 1guarded 1critical Allergies: 1NKA 1Penicillin 1Sulfa 1Other_______________________________________________________
Code Status: (See Goldenrod) Advance Directives: 1on chart 1completed at office - please call for copy 1unknown REFERRALS
⌧ Notify PCP of Patient Admission: Notified @ ___:___ by ___________ 1Done in ER ⌧ Request Medication Records and Problem List from PCP: Requested @ ___:____ by _________ 1Done in ER ⌧ Notify neurologist of patient admit – Nursing to call @ 0700 on the morning after admit. ⌧ Stroke Rehab Evaluation 1Dysphagia 1Discharge Planning 1Financial Services 1Wound/Ostomy Care RN 1Social Services 1Other:Integrative Health: 1Integrative Medical Consult 1All OK PRN pt request 1Acupuncture 1Music Care 1Guided Imagery/Hypnosis 1Massage therapy 1Osteopathy NURSING CARE
VS and neuro assessment every 15 minutes X 2 hours then every 30 minutes X 6 hours then hourly X 16 hours and then per unit policy I&O 1Weigh daily Activity: 1Bed rest 1 BRP 1OOB to chair every _________ 1Ambulate as tolerated 1Notify physician if: HR <60 or >120 ■SBP <100 or >185 ■DBP ≥100 ■RR <8 ■Temp >101.5 ■SpO2 <90% ■Urine Output <20 ml/hr X 2 hours OR 1 Notify physician if: ■HR <_ ____ or > _____ ■SBP < _____ or > _____ ■DBP < _____ or > _____ ■RR < _____ or > _____ ■Temp > _____________ ■ SpO2< _____% ■Urine Output < _______ ml/hr ⌧ Bleeding precautions – no tooth brushing for 24º
Notify physician of signs or symptoms of systemic bleeding or neurological deterioration including but not limited to:
Nausea, vomiting, severe new onset headache
Sudden increase in BP (≥40mm Hg)
Worsening neurological status (ie increased weakness, confusion, pupillary dilatation, etc.)
On admit (if not done in ED): ⌧ Cardiac Panel 1 CBC (auto diff) ⌧ CMP 1 Magnesium 1 PTT 1 Protime/INR ⌧ Lipid Panel (Fasting) 1 ABG 1 Other________________________________________ 1 AM Labs: CBC, CMP (Fasting), Magnesium 1CXR portable if not done in ER 1To dept for PA and lateral ⌧Bilateral carotid ultrasound/doppler ⌧ 2D echocardiogram 1Bilateral leg ultrasounds 1MRI brain scan without gadolinium contrast 1Non-contrast CT brain scan 1MR angiogram 1Other: Prevention of
1NPO (including medications) ⌧HOB elevated 450 Aspiration
⌧Swal ow Screening by RN today prior to first drink of water. Call physician for diet order if patient passes this test. 1Swal owing evaluation and diet per dysphagia therapist recommendations (patient must be able to maintain alertness for 15 minutes, follow simple commands, and sit at least 60 degrees upright for this evaluation to take place). INFECTION
MRSA NARES SCREEN ON ADMIT if: Discharged from an acute care hospital within past 30 days; OR
Transferred from a nursing facility; OR Admission to ICU (one screen per hospital stay)
1Positive MRSA History—Obtain a nasal screen and place in Gloves Precautions while awaiting results. If screen comes back negative, discontinue precautions. If positive continue Glove Precautions. MRSA NARES SCREEN ON DAY OF DISCHARGE if Palm Drive LOS > 10 days AND patient was in ICU.
CULTURES: 1wound 1aspiration closed wound 1sputum (PNA) 1U/A with UTI symptoms/Hx 1Blood
DIARRHEA: NOTIFY I.P. x4352 and send first stool for C-Difficile and place on Contact Plus precautions.
Other etiologies: 1Bacterial (stool culture) 1Norovirus 1Parasites x3 (O&P) rate 1Other: NOTE: EMPIRIC ANTIBIOTIC GUIDELINES to be attached to this order set.
G:\FORMS\Forms for EMR\BAR CODED Forms\ORDER\Admit Orders-Acute Stroke - Post t-PA 2012 Rev.doc Last printed 2/5/2013 3:27:00 PM APPROVED 7/2007 REVISED 2/11
Acute Stroke Post t-PA
Admit Orders

1 Foley catheter - Criteria for insertion: (Must check at least ONE)
1acute urinary retention or obstruction 1neurogenic bladder 1incontinence with stage 3 or 4 perineal or sacral pressure ulcer 1Accurate I&O in critically ill patient 1immobilization for trauma or surgery 1comfort with end-of-life care 1chronic catheter use 1peri-operative use in selected surgeries ⌧ UA dip to Lab with insertion ⌧ Foley Catheter Removal Protocol 1 Notify physician prior to removal of foley catheter. If physician wants to keep catheter, obtain new order and RESPIRATORY
1EKG if not done in ER; notify physician of ST-segment elevation or new LBBB 1Saline Lock 1NS at ________ml per hour 1add ________mEq KCL/L IV ORDERS
⌧ NPO until Nurse Swallow Evaluation 1Clear Liquids 1Full Liquids 1Regular 1Encourage fluids
1 Cardiac 1 NAS ___Gm Sodium 1 ADA ______Calories 1 ADA - NAS _______ Calories 1 Pureed 1 Soft 1 Mechanical Soft-Diced 1 Mechanical Soft-Ground Liquids consistency for Dysphagia: 1 “Honey” Thick 1 ”Nectar” Thick 1 “Pudding” thick 1Other:____________________________________________________ 1Dietary Consult
1Crush all meds and administer with applesauce or pudding if patient has passed swallow evaluation or cleared by speech. Pharmacy review drug regimen for non-crushable meds and contact physician for alternative. 1TPN per protocol 1 per tube feeding – follow jejunal protocol
⌧To begin 24º post t-PA (Start med ordered below @ exactly 24º post t-PA)
1Aspirin 81mg PO daily OR Aspirin 300mg PR daily if patient has not passed swal ow evaluation.
1Aspirin 25mg / Dipyridamole 200 mg (Aggrenox) one tab PO BID 1Warfarin (Coumadin) _______mg today, then per Pharmacy protocol, target INR 1Enoxaparin (Lovenox) 1mg/kg subQ BID Pharmacy to adjust. LIPID LOWERING
1Simvastatin (Zocor) PO daily: 1 5mg 1 20mg ⌧If fasting AM blood sugar >140, notify MD, order a nutrition consult and a Hemoglobin A1C if not already GLYCEMIC
1Sliding Scale Insulin (see order sheet) or
1 Intensive Insulin Protocol (ICU only - see order sheet) 1Pantoprazole (Protonix) 40 mg PO / IV daily (circle route) ? PEPTIC ULCER
Ischemic Stroke BP Management: If SBP > 185 or DBP > 110 Target SBP is ≥ 120 and ≤ 180 and DBP is ≥ 60 and ≤ 105 Hemorrhagic Stroke BP Management: Target SBP is < 140 and DBP is < 90 mm Hg. For both Ischemic and for Hemorrhagic Stroke use:
1 Labetalol 10 mg IV; May repeat every 10 minutes X3 doses. If unresponsive to Labetolol or other contraindications to beta blocker effect (asthma or bradycardia) give:
1Nicardipine (0.2mg/ml) by continuous IV infusion. Start at 5mg/hour. May increase 2.5mg/hour every 5 – 15 ANTIBIOTICS
Antibiotics must be ordered on “Empiric Antibiotic Guidelines” order set PROPHYLAXIS
No antithrombotics/anticoagulants for 24 hours: No aspirin, ASA & Dipyridamole (Aggrenox),
Clopidogrel (Plavix), heparin, low molecular weight heparin (Lovenox) or other antithrombotic agents such as
NOTE: EMPIRIC ANTIBIOTIC GUIDELINES to be attached to this order set.
G:\FORMS\Forms for EMR\BAR CODED Forms\ORDER\Admit Orders-Acute Stroke - Post t-PA 2012 Rev.doc Last printed 2/5/2013 3:27:00 PM APPROVED 7/2007 REVISED 2/11
Acute Stroke Post t-PA
Admit Orders

Intracranial Hemorrhage Management Guidelines During and After t-PA Infusion
If clinical suspicion of ICH present: Notify physician immediately. Order: • CT Head STAT - Reason: R/O CNS bleed S/P tPA • CBC,PT,INR,PTT, Fibrinogen STAT • T&C 4 units PRBCs, 5 units cryoprecipitated fibrinogen, 2 Units FFP(Use Blood Transfusion Order Sheet) If CT Head shows hemorrhage and clinical situation justifies, then: • If Fibrinogen < 50, administer 4 Units Cryoprecipitated fibrinogen • If PT > 24sec or PTT > 50sec, and fibrinogen > 80mg, then administer 2 Units FFP • If platelets < 50,000, administer 1 Unit Platelet Pheresis Pack If any blood product administered, order PT, PTT Contact stroke neurologist to evaluate for transfer. 1Acetaminophen (Tylenol) 650 mg PO / PR every 4 hours PRN mild pain (3/10 or less), temp ≥ 99.6 F (37.5º C). TEMPERATURE
or if NPO or otherwise cannot tolerate po meds, then
1 Acetaminophen (Ofirmev) ___________mg IV every 6 hours PRN temp ≥ 99.6°F (37.5º)
(recommended dose: • >13 years and > 50 kg = 1000mg every 6 hours, • < 50kg = 15mg/kg every 6 hours 1 Other: _______________________________________ 1Dolasetron (Anzemet) 12.5mg IV every 6 hrs PRN nausea or vomiting, may repeat x 1 in 30 min VOMITING
1Ondansetron (Zofran) 4mg IV every 6 hrs PRN nausea or vomiting (do NOT repeat if first does ineffective) 1 Promethazine (Phenergan) 25mg every 6 hrs PRN N/V PO / PR / IM 1Metoclopramide (Reglan) 10mg IV every 6 hrs PRN nausea or vomiting BOWEL CARE
Senna 1 tab PO daily for pts on narcotics (in addition to DSS) MOM 30 ml PO daily hs PRN constipation Bisacodyl (Dulcolax) Supp 10 mg PR daily PRN constipation
Fleets Enema daily PRN constipation
1Temazepam (Restoril) 15mg PO every HS PRN insomnia MR X1 in 1 hour 1 7.5 mg(rec. for ≥65 years) 1Zoldipem (Ambien) 5mg PO HS PRN insomnia MR X1 in 1 hour as needed 1 ALPRAzolam (Xanax) 0.25 mg PO every 6 hours PRN anxiety or 1 LORAzepam (Ativan)__________mg IV / PO (circle one) every _________hrs PRN anxiety 1Nicotine Patch: 17 mg daily 114 mg daily 121 mg daily CESSATION
Influenza vaccine: per Influenza Vaccination Screening & Administration Protocol Pneumonia vaccine: per Pneumococcal Vaccination Screening & Administration Protocol 1Adult Potassium & Magnesium Replacement Protocol MEDICATIONS
1Magnesium/Aluminum Hydroxide/Simethicone (Maalox) 30 ml PO every 4 hrs PRN indigestion 1Adult multivitamin with minerals 1 PO every day 1 1 1 1____________________________________________________________________________________________ Physician Signature:_______________________________________ Date:_________________ Time:____________________ Transcriber Signature: _____________________________________ Date:_________________ Time:____________________ NOTE: EMPIRIC ANTIBIOTIC GUIDELINES to be attached to this order set.
G:\FORMS\Forms for EMR\BAR CODED Forms\ORDER\Admit Orders-Acute Stroke - Post t-PA 2012 Rev.doc Last printed 2/5/2013 3:27:00 PM APPROVED 7/2007 REVISED 2/11


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