CHN2706 Hemorrhagic Stroke Admission Orders.pdf - Carondelet

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USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
HEMORRHAGIC STROKE ADMISSION ORDERS
Physician Signature: Date Signed: Time Signed:
STAT/NOW
(Check Box to Left)
* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission Orders
PATIENT STATUS: Inpatient Observation Outpatient (check if applicable)
1. Admit to: Neuro ICU Neuro Step-down Neuro Med/Surg Telemetry Monitoring ICU CSM
Admission to CSJ Neurology unit approved with verbal order per Dr. ____________________
Admitting Physician: __________________________
Admitting Neurointensivist (CSJ): ________________________________
Notify Dr. ____________________________ (PCP) of admission
Neurology Consultation, Dr. _________________________
NeuroIntensivist (CSJ only), Dr. _________________________
Pulmonary, Dr. _________________________________
2. Diagnosis: Hemorrhagic Stroke
3. Code Status: Full DNR Other: ______________________________
4. Condition: Critical Stable Other: __________________________
5. Old chart(s) to Nursing Unit
6. Document Height and Weight now
Height _________ (cm)
Weight _________(kg)
7. Vital Signs:
Every 1 hour Every 2 hours Every 4 hours Other____________
Neuro Checks
Every 1 hour Every 2 hours Every 4 hours Other: __________
8. Glasgow Coma Scale upon admission
NIH Stroke Scale (See NIH Stroke Scale Form) upon admission and discharge (CSM)
NIH Stroke Scale (See NIH Stroke Scale Form) upon admission, at discharge and every 12 hour (CSJ)
9. Nursing:
Notify physician for neurological changes or Temperature greater than ___________
SAH precautions: no loud noises, minimal external stimulation, no IM injections, restricted visitation
Foley Catheter
Cooling blanket for Temperature greater than 101.5 degrees F or ____________
Input/Output every 8 hours Aspiration Precautions Seizure Precautions
Pulse Oximetry every 4 hours Continuous Pulse Oximetry with documentation every 8 hours
Continuous telemetry monitoring with cardiac strips every 8 hours Daily Weight and record
Arterial line Other: ______________________________________________________
• For ICU patients: oral care with Chlorhexidine Gluconate 0.12% every 12 hours
10. Activity:
Bed rest
Head of Bed up 30 degrees, advance as tolerated
Out of Bed with assistance every ____________
Out of Bed ad lib
Other: _____________________________
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13
CHN2706 Expires – 03/2016
Page 1 of 5
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

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USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
HEMORRHAGIC STROKE ADMISSION ORDERS
Physician Signature: Date Signed: Time Signed:
STAT/NOW
(Check Box to Left)
11. Diet: Complete Dysphagia Screen prior to ANY oral intake
NPO
STRICT NPO until dysphagia screen completed and documented by RN. If abnormal, NPO and consult speech
therapy
When dysphagia screen completed and cleared, then:
Regular 2 gram Sodium ________ Cal ADA Diet Low Cholesterol Pureed Soft Mechanical
No Caffeine (INCLUDES NO DECAF COFFEE) Other: _____________________________
12. Patient Teaching For:
TIA, Stroke and Secondary Stroke Risk Prevention
CHF (Also, identify chart as CHF Patient and add Blue Progress Notes)
Diabetes Warfarin (Coumadin) Seizures Asthma
13. IV Fluid:
0.9% Sodium Chloride (NS) IV at _________ mL/hour Saline Lock
Other: ____________________________ at mL/hour with ______mEq Potassium Chloride/Liter
14. Glycemic Control:
Choose one:
Finger stick blood glucose every ______ hours
Finger stick blood glucose before meals and at bedtime
Finger stick – other: _______________________________________________
Use insulin sliding scale to cover:
Meals only
All fingersticks
Other: ______________________________________________
Prescribe one:
Insulin Aspart (NovoLOG) Sliding Scale Protocol – Mild
Insulin Aspart (NovoLOG) Sliding Scale Protocol – Moderate
Insulin Aspart (NovoLOG) Sliding Scale Protocol - Aggressive
15. VTE prophylaxis:
Risk assessment for VTE prophylaxis already completed
Relative or Absolute Contraindications to Anticoagulant and/or Mechanical Prophylaxis (check all that apply)
If contraindications present re-assess in 3-5 days
Active Bleeding
Within 24 hours of neuraxial anesthesia/analgesia
Risk of Bleeding (including but not limited to
History of heparin-induced thrombocytopenia (HIT)
coagulopathy, recent intracranial or intraocular
(unfractionated heparin and enoxaparin contraindicated)
surgery, hemorrhagic stroke or traumatic head injury
Clinically significant thrombocytopenia
Other: _________________________________
Physician Orders: See assessment tool on last page
Sequential Compression Devices to bilateral lower extremities (caution in peripheral arterial insufficiency)
Enoxaparin (LOVENOX) 40 mg subcutaneous daily
Enoxaparin (LOVENOX) 30 mg subcutaneous twice daily
Enoxaparin (LOVENOX) 30 mg subcutaneous daily (renal insufficiency CrCL less than 30 mL/min, not on dialysis)
Fondaparinux (ARIXTRA) 2.5 mg subcutaneous daily (HIT patients only; contraindicated if weight less than 50 kg
or CrCl less than 30 mL/minute
Other: ______________________________________________________
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13
CHN2706 Expires – 03/2016
Page 2 of 5
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

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USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
HEMORRHAGIC STROKE ADMISSION ORDERS
Physician Signature: Date Signed: Time Signed:
STAT/NOW
(Check Box to Left)
16. Medications:
Pravastatin (PRAVACHOL) ________ mg PO every evening
Laxatives
Milk of Magnesia Concentrate 10 mL PO daily PRN mild constipation
Bisacodyl (DULCOLAX) 10 mg PR daily PRN severe constipation
Sodium Phosphate (FLEETS) enema PR daily PRN severe constipation
Anxiety:
Lorazepam (ATIVAN) 0.5 mg IV/PO every 6 hours PRN anxiety
Dyspepsia:
Famotidine (PEPCID) 20 mg IV/PO every 12 hours Stress Ulcer Prophylaxis
Famotidine (PEPCID) 20 mg IV/PO once daily (if CrCl less than 50 mL/minute) Stress Ulcer Prophylaxis
Aluminum Hydroxide/Magnesium Hydroxide/Simethicone 30 mL PO 4 times daily PRN dyspepsia
Calcium Carbonate (TUMS) 500 mg 2 tabs PO every 4 hours PRN heartburn
Pain:
Morphine 2 mg ______ mg IV every 1 hour PRN severe pain
OXYcodone/Acetaminophen 5mg/325 mg (PERCOCET) 2 tablets PO every 4 hours PRN moderate pain
Acetaminophen (TYLENOL) 650 mg PO every 4 hours PRN for pain
Acetaminophen not to exceed
Acetaminophen (TYLENOL) 650 mg suppository PR every 4 hours PRN for pain 4 grams per 24 hours
Nausea:
Ondansetron (ZOFRAN) 4mg IV every 6 hours PRN nausea/vomiting
Promethazine (PHENERGAN) 12.5 mg PO/IV every 4 hours PRN nausea/vomiting
Other: _____________________________________________________________________________
Other Medications:
Fosphenytoin 15 mg/kg IV load _______ mg now STAT, then _________ mg IV every 8 hours starting at _______
Nimodipine 60 mg PO/NGT every 4 hours
Keppra (LEVETIRACETAM) 500 mg PO every 12 hours
17. Oxygen at ________ liters/minute via Nasal Cannula Face Mask
18. **ICU ONLY**
Blood Pressure Medications:
If systolic B/P is greater than180 mmHg or ____________, MAP greater than 130, or __________, give:
Labetalol 10 mg IV slow push over 2 minutes, then
Repeat Labetalol 20 mg IV slow push every 10 minutes PRN up to 300 mg
OR
After first dose start Labetalol IV drip at 2 mg/minute and titrate in increments of 0.5 mg every 2 minutes
(max rate 8 mg/minute) to maintain systolic B/P less than _________ mmHg
OR
Start NiCARdipine (CARDENE) IV drip at 5mg/hour and titrate in increments of 2.5 mg/hour every 5 minutes
(max rate 15 mg/hour) to maintain a systolic BP less than _________ mmHg
OR
Enalaprilat (VASOTEC) 0.625 mg 1.25 mg 2.5 mg IV slow push every 6 hours PRN. to maintain
systolic BP less than __________ mmHg
Esmolol 250 micrograms/kg loading dose IV, then 50 microgram/kg/minute maintenance infusion
If SBP or MAP uncontrolled, Notify Physician
Other:____________
19. For treatment of coagulopathy:
Physician to complete Emergency Management of the Coagulopathic ICH Patient Order
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13
CHN2706 Expires – 03/2016
Page 3 of 5
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

P
H
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S
I
C
I
A
N
‘
S
USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
HEMORRHAGIC STROKE ADMISSION ORDERS
STAT/NOW
(Check Box to Left)
20. Labs:
CBC with diff
Basic Metabolic Panel
UA Urine Culture Urine Pregnancy
Toxicology Screen
PT/INR and PTT
HgbA 1 C
Fasting lipid panel/LDL (Direct)
Other: ___________________
21. Skin Care:
If Braden Scale 18 or less, Consult Skin Care Team and initiate protocol
• Aloe Vesta every 4 hours to coccyx, heels, elbows and any other bony prominences
• Turn patient every 2 hours
• Elevate heels off bed
Lateral rotational therapy mattress replacement or bed
22. Diagnostic tests:
MRI brain CT head in AM __________ 2D Echocardiogram
MRA brain and neck CTA Brain and neck Carotid Doppler
ECG Chest X-Ray PA and lateral Other: _________________________________
23. Evaluate and Treat:
Physical Therapy Occupational Therapy Speech Therapy Social Worker Nutrition/Dietary
Rehab/Psychology Other: __________________________________
24. Physiatry Consultation, Dr. _______________________________________
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Physician Signature: Date Signed: Time Signed:
Physician Printed Name / License # / Telephone #:
PATIENT IDENTIFICATION
MEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13
CHN2706 Expires – 03/2016
Page 4 of 5
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

USE BALL POINT PEN – PRESS FIRMLY
CARONDELET HEALTH NETWORK
HOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERS
HEMORRHAGIC STROKE ADMISSION ORDERS
STAT/NOW
(Check Box to Left)
VTE Risk Assessment
Risk Assessment (Use the highest applicable risk category) Risk Level Suggested Prophylaxis Options
By Condition: Very High Enoxaparin 40 mg subq daily OR
• Total hip replacement 10 days of Enoxaparin 30 mg subq twice daily
• Hip fracture
prophylaxis is
suggested Enoxaparin 40 mg subq daily
• Total knee replacement Enoxaparin 30 mg subq twice daily
By High Risk Group:
Very High Enoxaparin 30 mg subq twice daily
• History of VTE
• Thrombophilia
• Immobility, paresis
By Risk Factor Assessment:*
• Surgery – general (high risk)
• Surgery – intracranial
neurosurgery, spinal,
gynecologic, urologic
(moderate risk)
• Age greater than 40 years
• Heart failure
• Inflammatory bowel disease
• Ischemic CVA with
paresis/plegia
• Nephrotic syndrome
• Obesity (BMI of 30 kg/m 2 or
greater)
• Sepsis/pneumonia
• Central line
• Severe respiratory distress
• Spinal cord injury within 1 month
• Trauma (major or lower
extremity)
• Pelvic fracture
• Estrogen/SERM** within 2
weeks
• Malignancy or cancer therapy
• Mechanical ventilation
• Pregnancy or post-partum
period
• Acute MI
• History of spinal cord injury
• Smoking
• Varicose veins
*List of risk factors is not all-inclusive
**SERM= selective estrogen receptor modulator
High
(3 or more risk
factors)
Moderate
(1 or 2 risk
factors)
Low
(0-1 risk factors)
Enoxaparin 40 mg subq daily
± mechanical prophylaxis
OR
Heparin 5000 units subq every 8 hour
± mechanical prophylaxis
Heparin 5000 units subq every 8 hour
OR
Mechanical prophylaxis
Early ambulation
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Copy 05.17.12 Page 5 of 5
UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED