*GBHPO* GBHPO 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) Page 1 of 5 03/2011 TELEPHONE ORDERS READ BACK AND VERIFY X 2 *GBHPO* GBHPO 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) Page 2 of 5 03/2011 TELEPHONE ORDERS READ BACK AND VERIFY X 2 *GBHPO* GBHPO 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) Page 3 of 5 03/2011 *GBHPO* GBHPO 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) Page 4 of 5 03/2011 TELEPHONE ORDERS READ BACK AND VERIFY X 2 *GBHPO* GBHPO 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) Page 5 of 5 03/2011 TELEPHONE ORDERS READ BACK AND VERIFY X 2