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ADMISSION ORDERS FOR INTRACEREBRAL HEMORRHAGIC STROKE (ICH)
DATE & TIME __________________  ADMIT ICU: INPATIENT STATUS  ADMIT CVU: INPATIENT STATUS
ATTENDING: ____________________________________
RESIDENT: ________________________________
DIAGNOSIS:_____________________________________
CONDITION: _______________________________
ALLERGIES/TYPE OF REACTION____________________________:_______________________________________
 HEIGHT: _______________
 WEIGHT: ___________________
 VITAL SIGNS AND NEURO CHECKS USING THE MEND EXAM
 CALL MD FOR VITAL SIGN CHANGES AND NEUROLOGICAL STATUS DECLINE
Systolic B/P greater than 180 or less than 110 mm Hg
Diastolic B/P greater than 110 or less than 60 mm Hg
Pulse less than 50 or greater than 110
 FOR ICU: VITAL SIGNS EVERY 1 HR X 24 HOURS THEN PER ICU PROTOCOL
 FOR ICU: MEND EXAM EVERY 1HR X 24 THEN EVERY 2 HOURS X 72 THEN EVERY 8 HOURS
 FOR CVU: VITALS SIGNS EVERY 4 HOURS
 FOR CVU: MEND EXAM EVERY 4 HOURS X 72 HOURS THEN EVERY 8 HOURS
 TELEMETRY MONITOR FOR ARRHYTHMIA MONITORING
 12 LEAD ECG UPON ARRIVAL: (IF NOT ALREADY OBTAINED)
OXYGENATION:
 NASAL O2 @ 2-4L/NC TO MAINTAIN OXYGEN SATURATION ABOVE 92%
 DISCONTINUE OXYGEN IF SATURATION IS ABOVE 92% ON ROOM AIR
DIET:
DYSPHAGIA SCREENING COMPLETED BY RN PRIOR TO ANY ORAL INTAKE INCLUDING PO MEDICATIONS:
 SCREENING FAILED: NPO, CONSULT SPEECH THERAPY FOR SWALLOWING EVALUATION AND TREAT
 SCREENING PASSED: DIET: CARDIAC DIET 1800 CALORIE DIABETIC DIET OTHER_______________
 SPEECH THERAPY EVALUATE AND TREAT TO DETERMINE DIET MODIFICATIONS
 INSERT DOBHOFF & CONSULT NUTRITIONAL SUPPORT FOR TUBE FEEDING ORDERS
 KUB TO CONFIRM DOBHOFF PLACEMENT: CALL HOUSE OFFICER TO VERIFY PLACEMENT
MD SIGNATURE: ____________________________________________
DATE &TIME: __________________________
NURSE SIGNATURE: _______________________________________
DATE & TIME: ___________________________
 VERBAL ORDER READ BACK AND VERIFY X 1
Admission Orders for Intracerebral
Hemorrhagic Stroke (ICH)
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ACTIVITY LEVEL:
AS TOLERATED
FALLS PRECAUTIONS
 TURN EVERY 2 HOURS  HOB ELEVATED 30 DEGREES
 NO LIFTING/PULLING ON AFFECTED SIDE
 MAINTAIN PROPER HEAD AND BODY ALIGNMENT
 INTAKE AND OUTPUT
ELIMINATION:
 DAILY WEIGHTS
BATHROOM PRIVILEDGES
 NO FOLEY CATHETER
BEDPAN BEDSIDE COMMODE
 CONDOM CATHETER
 BLADDER TRAINING PROGRAM: TOILET EVERY 2 HOURS WHILE AWAKE AND EVERY 4 HOURS AT NIGHT
 BOWEL PROGRAM: IF NO BM EVERY 3 DAYS CONTACT MD FOR STOOL SOFTENER OR LAXATIVE
 VTE PROPHYLAXIS: COMPLETE VTE SCREENING FORM AND START ON ARRIVAL TO UNIT
 APPLY BILATERAL SCD ON ARRIVAL TO UNIT UNLESS CONTRAINDICATION IS DOCUMENTED
 PNEUMOCOCCAL/INFLUENZA VACCINATION PROTOCOL
CONSULTS:
 PT/OT/SPEECH THERAPY EVALUATION & TREATMENT FOR STROKE (EXT 56784)
DATE & TIME DONE: ______________________________________________
 STROKE COORDINATOR (EXT 54243)
DATE & TIME DONE: _______________________________________________
 CASE MANAGEMENT FOR DISCHARGE PLANNING DAY 1 OF ADMISSION (EXT 54568)
DATE & TIME DONE: _______________________________________________
 NUTRITION SERVICES FOR EVALUATION, DIETARY EDUCATION & WEIGHT MANAGEMENT (EXT 54199)
DATE & TIME DONE: _______________________________________________
 CARDIAC/STROKE EDUCATOR FOR STROKE EDUCATION (EXT 54613)
DATE & TIME DONE: _______________________________________________
 ACUTE REHAB EVALUTION FOR PLACEMENT (EXT 54121) : DATE & TIME DONE: _______________________
 DAILY STROKE EDUCATION: Types of Stroke, Complications, Stroke Warning Signs and Symptoms; How to Activate EMS:
911; FAST; Personal Modifiable Stroke Risk Factors, Smoking Cessation; Heart Healthy Diet; Exercise Activities; Weight
Management; Prescribed Medications; Need for Follow up after Discharge.
MD SIGNATURE: ____________________________________________
DATE &TIME: __________________________
NURSE SIGNATURE: _______________________________________
DATE & TIME: ___________________________
 VERBAL ORDER READ BACK AND VERIFY X 1
Admission Orders for Intracerebral
Hemorrhagic Stroke (ICH)
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CONSULTS:
 INTERNAL MEDICINE: _________________________________________________________________
 CARDIOLOGY: ________________________________________________________________________
 NEUROLOGY: _________________________________________________________________________
 NEUROSURGERY:______________________________________________________________________
 ENDOCRINOLOGY_____________________________________________________________________
 OTHER: _______________________________________________________________________________
LABS: CHECK ED PROFILE PRIOR TO ENTERING
 CKMB & TROPONIN EVERY 8 HOURS X 3
 ________  _________ __________
 UA/C&S (IF NOT ALREADY OBTAINED IN ED)
 Hgb A1C (IF NOT ALREADY OBTAINED IN ED)
 PT/PTT/INR (IF NOT ALREADY OBTAINED IN ED)
 URINE DRUG SCREEN (IF NOT ALREADY OBTAINED IN ED)
 LIPID PROFILE (IF NOT ALREADY OBTAINED IN ED)
 COMPLETE METABOLIC PANEL (IF NOT ALREADY OBTAINED IN ED)
 CBC w/DIFF (IF NOT ALREADY OBTAINED IN ED)
 CBC w/DIFF  DAILY
 PT/PTT/INR  DAILY
 BMP
 DAILY
 OTHER:______________  OTHER:______________
OTHER: __________________
DIAGNOSTICS:
 CHEST XRAY (IF NOT ALREADY DONE IN ED)  PORTABLE
 PA/LATERAL
 OTHER:_________
 MRI BRAIN & MRA BRAIN & NECK WITHOUT CONTRAST: STROKE PROTOCOL
 MRI BRAIN WITHOUT CONTRAST: DIAGNOSIS STROKE
 CT OF BRAIN WITHOUT CONTRAST : DIAGNOSIS STROKE
 CTA BRAIN & NECK DIAGNOSIS STROKE
 CAROTID DUPLEX ULTRASOUND: DIAGNOSIS STROKE
 ECHOCARDIOGRAM DIAGNOSIS STROKE: (DR. _________________ TO READ)
 EEG TO EVALUATE FOR SEIZURE ACTIVITY
 VENOUS DOPPLER STUDIES TO R/O DVT
 BILATERAL UE’S
MD SIGNATURE: ____________________________________________
 BILATERAL LE’S  OTHER:____________
DATE &TIME: __________________________
NURSE SIGNATURE: _______________________________________
DATE & TIME: ___________________________
 VERBAL ORDER READ BACK AND VERIFY X 1  TELEPHONE ORDERS READ BACK AND VERIFY X 2
Admission Orders for Intracerebral
Hemorrhagic Stroke (ICH)
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MEDICATIONS:
 IV FLUIDS: NORMAL SALINE (0.9%) AT ___________________________ML/HR.
 R-tPA NOT INDICATED DUE TO ICH
 ANTIPLATELET THERAPY NOT INDICATED DUE TO ICH
 LORAZEPAM (ATIVAN®) 1MG IV EVERY 20-30 MINUTES PRIOR TO IMAGING AS NEEDED FOR AGITATION
MAY REPEAT X___________
 STATIN:_________________________________________________________________________
(CONSIDER FOR LDL GREATER THAN OR EQUAL TO 100mg/dL; FOR DIABETICS LDL GREATER THAN 70mg/dL)
 ACE INHIBITOR: ___________________________________________
 THIAZIDE DIURETIC: ________________________________________
 LAXATIVE:__________________________________________________
 ONDANSETRON (ZOFRAN®) 4MG IV EVERY 6 HOURS AS NEEDED FOR NAUSEA
 ESOMEPRAZOLE (NEXIUM®) 40mg IV DAILY
 FAMOTIDINE (PEPCID®) 20mg IV EVERY 12 HOURS
 ACETAMINOPHEN (TYLENOL®) 1000mg PO or 650mg PR, IF UNABLE TO TAKE PO, EVERY 6 HOURS AS NEEDED FOR
TEMPERATURE GREATER THAN 99.6F OR HEADACHE: NOT TO EXCEED 4 GRAMS DAILY
 ACETAMINOPHEN (TYLENOL®) 650mg PO or PR, IF UNABLE TO TAKE PO, EVERY 4 HOURS AS NEEDED FOR
TEMPERATURE GREATER THAN 99.6F OR HEADACHE: NOT TO EXCEED 4 GRAMS DAILY
 OTHER MEDICATION:___________________________________________
 OTHER MEDICATION:___________________________________________
 OTHER MEDICATION:___________________________________________
 OTHER MEDICATION:___________________________________________
MD SIGNATURE: ____________________________________________
DATE &TIME: __________________________
NURSE SIGNATURE: _______________________________________
DATE & TIME: ___________________________
 VERBAL ORDER READ BACK AND VERIFY X 1
Admission Orders for Intracerebral
Hemorrhagic Stroke (ICH)
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BLOOD PRESSURE MANAGEMENT (FOR ICU PATIENTS):
Systolic Blood Pressure greater
than 180 mm Hg
OR
 Target B/P 160/90
OR
 B/P Parameters:__________
Initial Mean Arterial Blood
Pressure greater than or equal to
130 mm Hg
OR
 B/P Parameters:__________
1. Notify MD IMMEDIATELY
2. Give labetalol (e.g., Trandate) 10mg IV over 1-2 minutes.
3. May repeat labetalol 10mg IV every 10 minutes, or follow by an infusion
of 2 to 8 mg/min.
MAXIMUM IV LABETALOL DAILY DOSE IS 300mg.
4. If non-responsive or if labetalol is contraindicated, initiate nicardipine
(e.g., Cardene) IV infusion therapy at 5mg/hr; if inadequate response,
titrate infusion rate up by 2.5mg/hr every 5 minutes. (Maximum infusion
rate is 15 mg/hr.)
5. Initiate continuous B/P monitoring every 15 minutes and titrate.
HOLD FOR ACUTE ASTHMA OR CHF EXACERBATION OR FOR
HEART RATE LESS THAN 50 OR FOR RHYTHM OF 2nd OR 3rd DEGREE
HEART BLOCK
1. Notify Attending MD immediately
2. Initiate nicardipine (e.g., Cardene) IV infusion therapy at 5mg/hr; if
inadequate response, titrate infusion rate up by 2.5mg/hr every 5 minutes.
Maximum infusion rate is 15mg/hr.
3. Titrate for MAP of 110 mm Hg
4. Continuous B/P Monitoring every 15 minutes
BLOOD GLUCOSE MANAGEMENT: Blood Glucose Target should be less than 140 mg/dL.
 NOTIFY MD FOR ADMISSION BLOOD GLUCOSE GREATER THAN 140 mg/dL AND CHECK BLOOD GLUCOSE
EVERY 4 HOURS X 24 HOURS; CONSULT ENDOCRINE: DATE & TIME DONE:______________________________
 BLOOD GLUCOSE LESS THAN140 mg/dL AND PATIENT IS NPO OR ON CONTINUOUS TUBE FEEDINGS:
BLOOD CAPILLARY GLUCOSE CHECKS EVERY 4 HOURS X 48 HOURS FOR NON-DIABETICS AND CONTINUE FOR
DIABETIC PATIENTS
 BLOOD GLUCOSE LESS THAN 140 mg/dL AND THE PATIENT IS TAKING A DIET:
BLOOD CAPILLARY BLOOD GLUCOSE CHECKS BEFORE EVERY MEAL AND @ HS x 48 HOURS FOR NON-DIABETICS
AND CONTINUE FOR DIABETIC PATIENTS
 NOTIFY MD FOR BLOOD GLUCOSE GREATER THAN 140 mg/dL ON TWO (2) CONSECUTIVE CHECKS FOR SSI
COVERAGE
 NOVOLOG SSI COVERAGE:____________________________________________________________
MD SIGNATURE: ____________________________________________
DATE &TIME: __________________________
NURSE SIGNATURE: _______________________________________
DATE & TIME: ___________________________
 VERBAL ORDER READ BACK AND VERIFY X 1
Admission Orders for Intracerebral
Hemorrhagic Stroke (ICH)
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