CHN2706 Hemorrhagic Stroke Admission Orders.pdf - Carondelet

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSHEMORRHAGIC STROKE ADMISSION ORDERSPhysician Signature: Date Signed: Time Signed:STAT/NOW(Check Box to Left)* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission OrdersPATIENT STATUS: Inpatient Observation Outpatient (check if applicable)1. Admit to: Neuro ICU Neuro Step-down Neuro Med/Surg Telemetry Monitoring ICU CSMAdmission to CSJ Neurology unit approved with verbal order per Dr. ____________________Admitting Physician: __________________________Admitting Neurointensivist (CSJ): ________________________________Notify Dr. ____________________________ (PCP) of admissionNeurology Consultation, Dr. _________________________NeuroIntensivist (CSJ only), Dr. _________________________Pulmonary, Dr. _________________________________2. Diagnosis: Hemorrhagic Stroke3. Code Status: Full DNR Other: ______________________________4. Condition: Critical Stable Other: __________________________5. Old chart(s) to Nursing Unit6. Document Height and Weight nowHeight _________ (cm)Weight _________(kg)7. Vital Signs:Every 1 hour Every 2 hours Every 4 hours Other____________Neuro ChecksEvery 1 hour Every 2 hours Every 4 hours Other: __________8. Glasgow Coma Scale upon admissionNIH 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 visitationFoley CatheterCooling blanket for Temperature greater than 101.5 degrees F or ____________Input/Output every 8 hours Aspiration Precautions Seizure PrecautionsPulse Oximetry every 4 hours Continuous Pulse Oximetry with documentation every 8 hoursContinuous telemetry monitoring with cardiac strips every 8 hours Daily Weight and recordArterial line Other: ______________________________________________________• For ICU patients: oral care with Chlorhexidine Gluconate 0.12% every 12 hours10. Activity:Bed restHead of Bed up 30 degrees, advance as toleratedOut of Bed with assistance every ____________Out of Bed ad libOther: _____________________________Physician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13CHN2706 Expires – 03/2016Page 1 of 5UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSHEMORRHAGIC STROKE ADMISSION ORDERSPhysician Signature: Date Signed: Time Signed:STAT/NOW(Check Box to Left)11. Diet: Complete Dysphagia Screen prior to ANY oral intakeNPOSTRICT NPO until dysphagia screen completed and documented by RN. If abnormal, NPO and consult speechtherapyWhen dysphagia screen completed and cleared, then:Regular 2 gram Sodium ________ Cal ADA Diet Low Cholesterol Pureed Soft MechanicalNo Caffeine (INCLUDES NO DECAF COFFEE) Other: _____________________________12. Patient Teaching For:TIA, Stroke and Secondary Stroke Risk PreventionCHF (Also, identify chart as CHF Patient and add Blue Progress Notes)Diabetes Warfarin (Coumadin) Seizures Asthma13. IV Fluid:0.9% Sodium Chloride (NS) IV at _________ mL/hour Saline LockOther: ____________________________ at mL/hour with ______mEq Potassium Chloride/Liter14. Glycemic Control:Choose one:Finger stick blood glucose every ______ hoursFinger stick blood glucose before meals and at bedtimeFinger stick – other: _______________________________________________Use insulin sliding scale to cover:Meals onlyAll fingersticksOther: ______________________________________________Prescribe one:Insulin Aspart (NovoLOG) Sliding Scale Protocol – MildInsulin Aspart (NovoLOG) Sliding Scale Protocol – ModerateInsulin Aspart (NovoLOG) Sliding Scale Protocol - Aggressive15. VTE prophylaxis:Risk assessment for VTE prophylaxis already completedRelative or Absolute Contraindications to Anticoagulant and/or Mechanical Prophylaxis (check all that apply)If contraindications present re-assess in 3-5 daysActive BleedingWithin 24 hours of neuraxial anesthesia/analgesiaRisk of Bleeding (including but not limited toHistory of heparin-induced thrombocytopenia (HIT)coagulopathy, recent intracranial or intraocular(unfractionated heparin and enoxaparin contraindicated)surgery, hemorrhagic stroke or traumatic head injuryClinically significant thrombocytopeniaOther: _________________________________Physician Orders: See assessment tool on last pageSequential Compression Devices to bilateral lower extremities (caution in peripheral arterial insufficiency)Enoxaparin (LOVENOX) 40 mg subcutaneous dailyEnoxaparin (LOVENOX) 30 mg subcutaneous twice dailyEnoxaparin (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 kgor CrCl less than 30 mL/minuteOther: ______________________________________________________Physician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13CHN2706 Expires – 03/2016Page 2 of 5UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSHEMORRHAGIC STROKE ADMISSION ORDERSPhysician Signature: Date Signed: Time Signed:STAT/NOW(Check Box to Left)16. Medications:Pravastatin (PRAVACHOL) ________ mg PO every eveningLaxativesMilk of Magnesia Concentrate 10 mL PO daily PRN mild constipationBisacodyl (DULCOLAX) 10 mg PR daily PRN severe constipationSodium Phosphate (FLEETS) enema PR daily PRN severe constipationAnxiety:Lorazepam (ATIVAN) 0.5 mg IV/PO every 6 hours PRN anxietyDyspepsia:Famotidine (PEPCID) 20 mg IV/PO every 12 hours Stress Ulcer ProphylaxisFamotidine (PEPCID) 20 mg IV/PO once daily (if CrCl less than 50 mL/minute) Stress Ulcer ProphylaxisAluminum Hydroxide/Magnesium Hydroxide/Simethicone 30 mL PO 4 times daily PRN dyspepsiaCalcium Carbonate (TUMS) 500 mg 2 tabs PO every 4 hours PRN heartburnPain:Morphine 2 mg ______ mg IV every 1 hour PRN severe painOXYcodone/Acetaminophen 5mg/325 mg (PERCOCET) 2 tablets PO every 4 hours PRN moderate painAcetaminophen (TYLENOL) 650 mg PO every 4 hours PRN for painAcetaminophen not to exceedAcetaminophen (TYLENOL) 650 mg suppository PR every 4 hours PRN for pain 4 grams per 24 hoursNausea:Ondansetron (ZOFRAN) 4mg IV every 6 hours PRN nausea/vomitingPromethazine (PHENERGAN) 12.5 mg PO/IV every 4 hours PRN nausea/vomitingOther: _____________________________________________________________________________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 hoursKeppra (LEVETIRACETAM) 500 mg PO every 12 hours17. Oxygen at ________ liters/minute via Nasal Cannula Face Mask18. **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, thenRepeat Labetalol 20 mg IV slow push every 10 minutes PRN up to 300 mgORAfter 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 _________ mmHgORStart 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 _________ mmHgOREnalaprilat (VASOTEC) 0.625 mg 1.25 mg 2.5 mg IV slow push every 6 hours PRN. to maintainsystolic BP less than __________ mmHgEsmolol 250 micrograms/kg loading dose IV, then 50 microgram/kg/minute maintenance infusionIf SBP or MAP uncontrolled, Notify PhysicianOther:____________19. For treatment of coagulopathy:Physician to complete Emergency Management of the Coagulopathic ICH Patient OrderPhysician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13CHN2706 Expires – 03/2016Page 3 of 5UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

PHYSICIAN‘SUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSHEMORRHAGIC STROKE ADMISSION ORDERSSTAT/NOW(Check Box to Left)20. Labs:CBC with diffBasic Metabolic PanelUA Urine Culture Urine PregnancyToxicology ScreenPT/INR and PTTHgbA 1 CFasting 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 bedLateral rotational therapy mattress replacement or bed22. Diagnostic tests:MRI brain CT head in AM __________ 2D EchocardiogramMRA brain and neck CTA Brain and neck Carotid DopplerECG Chest X-Ray PA and lateral Other: _________________________________23. Evaluate and Treat:Physical Therapy Occupational Therapy Speech Therapy Social Worker Nutrition/DietaryRehab/Psychology Other: __________________________________24. Physiatry Consultation, Dr. _______________________________________ORDERPhysician Signature: Date Signed: Time Signed:Physician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSJ – 03/28/13 CSM – 03/28/13 CHC – 5/23/13CHN2706 Expires – 03/2016Page 4 of 5UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED