ISCHEMIC STROKE/TIA PLAN

Transcription

1 ISCHEMIC STROKE/TIA PLAN PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status Code Status: Full Code Code Status: DNR - Do Not Resuscitate Code Status: DNI - Do Not Intubate Code Status: DNR/DNI - Do Not Resuscitate or Intubate Code Status: Partial Resuscitative Effort Patient Care Vital Signs Per Unit Standards, Every 15 min x 2 hrs; then every 30 min x 6 hrs; then every 1 hr x 16 hrs Perform Neurological Checks q4h See Special Instructions Daily Weight Nursing Swallowing Screen Perform prior to PO intake. If pt fails swallow screening order Swallow Evaluation by Speech Language Pathology. Patient Activity Bedrest, Bed Position: HOB Greater Than or Equal to 30 degrees Assist as Needed, Bed Position: HOB Greater Than or Equal to 30 degrees Up to Bedside Commode Only, Bed Position: HOB Greater Than or Equal to 30 degrees Seizure Precautions Strict Intake and Output Per Unit Standards Continuous Telemetry (Intermediate Care) Intermittent Telemetry Communication Notify Nurse (DO NOT USE FOR MEDS) Complete a Stroke Scale at onset of symptoms, at discharge, and with any change in neuro status. Notify Provider of VS Parameters (Notify Provider if VS) Temp Greater Than 101, RR Greater Than 24, RR Less Than 10, SpO2 Less Than 90, SBP Greater Than 220, SBP Less Than 120, DBP Greater Than 120, DBP Less Than 60, HR Greater Than 120, HR Less Than 50 Notify Provider (Misc) Reason: Deterioration of neurological status, problems swallowing, or signs of bleeding. Dietary Please choose only ONE diet type below. NPO Diet NPO, until after swallow/dysphagia screening performed. Page: 1 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

2 ISCHEMIC STROKE/TIA PLAN PHYSICIAN S DETAILS Oral Diet Clear Liquid Diet Full Liquid Diet Regular Diet AHA Diet ADA Diet 1800 Calories, AHA 1600 Calories, AHA 1800 Calories 1600 Calories IV Solutions NS IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, ml/hr NS + 20 meq KCl/L IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr IV, ml/hr NS + 40 meq KCl/L IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr IV, 200 ml/hr IV, ml/hr Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. Antithrombotics Must be given within 48 hours of arrival per Core Measures. If not given, choose the Contraindications Order below and Complete Contraindications Antithrombotic Allergy Anticoagulant already prescribed History of GI bleed Positive Occult Blood in Stool Risk of bleeding Other (specify below in other reason) aspirin FOR STROKE, 325 mg, PO, tab, Daily This medication must be given immediately for AMI or STROKE if not given in ER. FOR STROKE, 81 mg, chewed, tab chew, Daily This medication must be given immediately for AMI or STROKE. FOR STROKE, 300 mg, rectally, supp, Daily This medication must be given immediately for AMI or STROKE. aspirin-dipyridamole 1 cap, PO, cap, BID Do Not crush or chew. clopidogrel 75 mg, PO, tab, Daily Page: 2 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

3 ISCHEMIC STROKE/TIA PLAN PHYSICIAN S DETAILS warfarin 1 mg, PO, tab, QPM 2 mg, PO, tab, QPM 2.5 mg, PO, tab, QPM 3 mg, PO, tab, QPM 4 mg, PO, tab, QPM 5 mg, PO, tab, QPM 6 mg, PO, tab, QPM 7.5 mg, PO, tab, QPM 10 mg, PO, tab, QPM rivaroxaban 20 mg, PO, tab, In PM apixaban 5 mg, PO, tab, BID heparin 25,000 units/250 ml D5W Per protocol 25,000 units, Every Bag Blood Pressure Management labetalol 10 mg, IVPush, inj, q10min, PRN other As needed for blood pressure management mg, IVPush, inj, PRN other As needed for blood pressure management nicardipine 25 mg/250 ml NS IV Final concentration = 0.1 mg/ml (100 mcg/ml). Usual Dose Range is 5-15 mg/hr. Notify physician if administered dose (rate) is greater than the usual dose range. Start at rate: mg/hr enalapril 1.25 mg, IVPush, inj, q6h, PRN hypertension 1.25 mg, IVPush, inj, q4h, PRN hypertension mg, IVPush, inj, q6h, PRN hypertension mg, IVPush, inj, q4h, PRN hypertension hydralazine 10 mg, IVPush, inj, q6h, PRN hypertension 10 mg, IVPush, inj, q4h, PRN hypertension mg, IVPush, inj, q6h, PRN hypertension mg, IVPush, inj, q4h, PRN hypertension labetalol 100 mg/100 ml NS Start at rate: mg/min IV nitroprusside 50 mg/250 ml D5W IV Final Concentration = 0.2 mg/ml (200 mcg/ml). Usual Dose Range is mcg/kg/min. Protect from Light. Notify physician if administered dose (rate) is greater than the usual dose range. Start at rate: mcg/kg/min Statins Page: 3 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

4 ISCHEMIC STROKE/TIA PLAN PHYSICIAN S DETAILS Contraindications Statins Hypersensitivity Intolerance(myopathy, myalgia, myositis) Liver disease or elevated transaminases Pregnancy or breastfeeding Other simvastatin 5 mg, PO, tab, Nightly 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly atorvastatin 10 mg, PO, tab, Nightly 20 mg, PO, tab, Nightly 40 mg, PO, tab, Nightly 80 mg, PO, tab, Nightly Laboratory CBC with Differential Next Day in AM Prothrombin Time with INR Next Day in AM PTT Next Day in AM Lipid with Calculated LDL Next Day in AM, Comment: FASTING Comprehensive Metabolic Panel Next Day in AM Phenytoin Level Total (Dilantin Level) Next Day in AM Homocysteine Total Next Day in AM ***Perform pregnancy test if patient is premenopausal female.*** Beta HCG Serum Qualitative STAT Diagnostic Tests Echo Transthoracic (TTE) with contrast i (Echo Transthoracic (TTE) with contrast if needed) EKG-12 Lead VL Carotid Doppler (Vascular Lab) DX Chest PA & Lateral CT Head w/o Other (specify below), Ischemic Stroke/TIA Evaluation CT Head w/ Modified Barium Swallow Respiratory Page: 4 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

5 ISCHEMIC STROKE/TIA PLAN PHYSICIAN S DETAILS Respiratory Care Plan Protocol Arterial Blood Gas Physical Medicine and Rehab Consult Speech Therapy for Eval & Treat Swallow Evaluation & Treatment, Eval for Ischemic Stroke/TIA Consult PT Mobility for Eval & Treat Eval for Ischemic Stroke/TIA Consult Occ Therapy for Eval & Treat Eval for Ischemic Stroke/TIA Consults/Referrals Consult MD Service: Neurology, Reason: Ischemic Stroke/TIA Eval Consult Dietician for Other Nutrition Ne (Consult Dietician for Other Nutrition Needs) Eval for Ischemic Stroke/TIA...Additional Orders Page: 5 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

6 VTE PROPHYLAXIS PLAN PHYSICIAN S DETAILS Patient Care VTE Guidelines See Reference Text for Guidelines ***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated*** Contraindications VTE Patient low risk for VTE Patient is ambulatory Patient Refusal Family/Caregiver Refusal Cont IV heparin day of/after admission Anticoag therapy not warfarin for Afib Warfarin prior to admit; on hold r/t INR Risk of Bleeding Thrombocytopenia Active Bleeding Alteplase Administered w/in 24 hrs IV Heparin w/in 24 hrs of Surgery Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE) Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h*** enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 40 mg, subcut, syringe, q12h heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, Daily ***If you order RIVAROXABAN for your patient, please indicate the reason below*** Page: 6 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

7 VTE PROPHYLAXIS PLAN PHYSICIAN S DETAILS Reason for Oral Factor Xa Inhibitor Reason: Atrial fibrillation Reason: Persistent atrial fibrillation Reason: Paroxysmal atrial fibrillation Reason: Atrial flutter Reason: Hx Afib/flutter - NA w/in 8wks post CABG Reason: Partial hip arthroplasty Reason: Total hip arthroplasty Reason: Total hip replacement Reason: Total knee arthroplasty Reason: Total knee replacement rivaroxaban 10 mg, PO, tab, In PM warfarin 5 mg, PO, tab, QPM aspirin 81 mg, PO, tab, Daily 325 mg, PO, tab, Daily Page: 7 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

8 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS Patient Care Accucheck Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h Sliding Scale Insulin Protocol Follow SSI Reference Text Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. insulin regular (Low Dose Insulin Sliding Scale) 0-10 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, q6h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, q4h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... TO Read Back Scanned Powerchart Scanned PharmScan Page: 8 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

9 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS 0-10 units, subcut, inj, q2h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, TID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, BID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale units; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Page: 9 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

10 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS insulin regular (Moderate Dose Insulin Sliding Scale) 0-12 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, q6h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, q4h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, q2h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale roiutine. Call physician Continued on next page... TO Read Back Scanned Powerchart Scanned. PharmScan Page: 10 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

11 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS 0-12 units, subcut, inj, TID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician units, subcut, inj, BID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. insulin regular (High Dose Insulin Sliding Scale) 0-14 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters High Dose Insulin Sliding Scale units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q6h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and acchcheck every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... TO Read Back Scanned Powerchart Scanned Pharmscan Order Take By Signature: Page: 11 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

12 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS 0-14 units, subcut, inj, q4h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q2h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, TID, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, BID, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician Continued on next page... TO Read Back Scanned Powerchart Scanned PharmScan. Page: 12 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

13 SLIDING SCALE INSULIN PROTOCOL PLAN PHYSICIAN S DETAILS insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels - see parameters Blood glucose is less than ; Initiate hypoglycemic protocol and Call physician; units; units subq; units subq; units subq; units subq; units subq; units subq; Greater than units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG less than, then resume normal accucheck and sliding scale routine. Call physician HYPOglycemia Protocol HYPOglycemia Protocol If BS is less than 70 mg/dl, and patient SYMPTOMATIC, give 6 oz. of juice PO (if applicable) and/or follow HYPOglycemia Protocol meds. glucose (D50) 25 g, IVP, syringe, as needed, PRN glucose levels - see parameters Patient unable to swallow / NPO WITH IV access. Dextrose 50% 50 ml IV. Recheck BG in minutes. Repeat treatment until blood glucose greater than 100 mg/dl. If not NPO provide additional snack once able to swallow. glucose 15 g, PO, gel, as needed, PRN glucose levels - see parameters glucagon 1 mg, IM, inj, as needed, PRN glucose levels - see parameters Patient UNABLE to swallow / NPO WITHOUT IV access. Administer Glucagon 1 mg IM or SubQ. Contact physician for further orders. Establish IV access with saline lock. Recheck BG every 15 to 20 minutes. Use aspiration precautions as glucagon may cause nausea and vomiting. Page: 13 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

14 DISCOMFORT MED PLAN PHYSICIAN S DETAILS Patient Care Perform Bladder Scan Scan PRN, If more than 250, Then: Call MD, Perform as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hrs post Foley removal and patient has not voided. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. phenol-menthol topical (phenol-menthol 2.9%-0.12% (Cepastat) lozenge) 1 lozenge, PO, q4h, PRN sore throat Do not exceed 6 lozenges in 24 hours dextromethorphan-guaifenesin (dextromethorphan-guaifenesin 20 mg-200 mg/10 ml oral liquid) 10 ml, PO, q4h, PRN cough dexamethasone-diphenhydramin-nystatin-ns (Fred s Brew) 15 ml, swish & spit, q2h, PRN mucositis While awake lidocaine topical (Lidocaine Viscous 2% mucous membrane solution) 15 ml, swish & spit, q4h, PRN mucositis While awake Analgesics acetaminophen 1,000 mg, PO, tab, q4h, PRN pain-mild, Pain Scale 1-3 ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** 500 mg, PO, tab, q4h, PRN pain-mild, Pain Scale 1-3 ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** acetaminophen 650 mg, rectally, supp, q4h, PRN pain-mild, Pain Scale 1-3 ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****If acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** *****IF acetaminophen ineffective/contraindicated, USE ibuprofen if ordered:***** ibuprofen 400 mg, PO, tab, q6h, PRN pain-mild, Pain Scale 1-3 ***Do not exceed 3,200 mg of ibuprofen from all sources in 24 hours*** Give with food. Use if acetaminophen is ineffective or contraindicated. HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 2 tab, PO, tab, q4h, PRN pain-moderate, Pain Scale 4-7 ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** 1 tab, PO, tab, q4h, PRN pain-moderate, Pain Scale 4-7 ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** Continued on next page... Page: 14 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

15 DISCOMFORT MED PLAN PHYSICIAN S DETAILS *****IF HYDROcodone-acetaminophen ineffective/contraindicated or NPO, USE ketorolac if ordered***** ketorolac 30 mg, IVPush, inj, q6h, PRN pain-moderate, x 48 hr, Pain Scale 4-7 ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen (Lortab) ineffective or contraindicated. 15 mg, IVPush, inj, q6h, PRN pain-moderate, x 48 hr, Pain Scale 4-7 ***May give IM if no IV access*** Use if HYDROcodone-acetaminophen (Lortab) ineffective or contraindicated. morphine 4 mg, IVPush, inj, q4h, PRN pain-severe, Pain Scale 8-10 ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** 2 mg, IVPush, inj, q4h, PRN pain-severe, Pain Scale 8-10 ***Slow IV Push*** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered***** *****IF morphine is ineffective/contraindicated, USE HYDROmorphone if ordered.***** HYDROmorphone 1 mg, IVPush, inj, q4h, PRN pain-severe, Pain Scale 8-10 ***Slow IV Push*** Use if morphine ineffective or contraindicated. Antiemetics promethazine 25 mg, PO, tab, q4h, PRN nausea/vomiting *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered***** *****IF promethazine is ineffective/contraindicated or patient is NPO, USE ondansetron if ordered.***** ondansetron 4 mg, IVPush, soln, q8h, PRN nausea/vomiting Use if promethazine ineffective or contraindicated. Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl if ordered***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** Page: 15 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

16 DISCOMFORT MED PLAN PHYSICIAN S DETAILS *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** sodium biphosphate-sodium phosphate (Fleet Enema) 1 ea, rectally, enema, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema if ordered***** loperamide 4 mg, PO, cap, ONE TIME, PRN diarrhea Initial dose after first loose stool 4 mg, PO, liq, ONE TIME, PRN diarrhea Initial dose after first loose stool loperamide 2 mg, PO, cap, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day 2 mg, PO, liq, as needed, PRN diarrhea 2 mg after each loose stool, up to 16 mg per day Antacids Al hydroxide-mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 ml oral suspension) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. simethicone 160 mg, PO, tab chew, q4h, PRN gas 80 mg, PO, tab chew, q4h, PRN gas Sedatives ALPRAZolam 0.25 mg, PO, tab, TID, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** LORazepam 1 mg, IVPush, inj, q6h, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** 0.5 mg, IVPush, inj, q6h, PRN anxiety *****IF ALPRAZolam is ineffective/contraindicated or patient is NPO, USE LORazepam if ordered***** zolpidem 5 mg, PO, tab, Nightly, PRN insomnia may repeat x1 in one hour if ineffective Antihistamines diphenhydramine 25 mg, PO, cap, q4h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine inj if ordered***** Page: 16 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14

17 DISCOMFORT MED PLAN PHYSICIAN S DETAILS *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine injection if ordered***** diphenhydramine 25 mg, IVPush, inj, q4h, PRN itching *****IF diphenhydramine PO is ineffective or patient is NPO, USE diphenhydramine injection if ordered***** Anti-pyretics acetaminophen 1,000 mg, PO, tab, q4h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetminophen is ineffective/contraindicated, USE ibuprofen if ordered***** 500 mg, PO, tab, q4h, PRN fever ***Do not exceed 4,000 mg of acetaminophen from all sources in 24 hours*** *****IF acetminophen is ineffective/contraindicated, USE ibuprofen if ordered***** *****IF acetminophen is ineffective/contraindicated, USE ibuprofen if ordered***** ibuprofen 400 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. 200 mg, PO, tab, q4h, PRN fever Do not exceed 3,200 mg in 24 hours. Give with food. Use if acetaminophen is ineffective or contraindicated. Anorectal Preparations witch hazel-glycerin topical (witch hazel-glycerin 50% topical pad) 1 app, topical, pad, As Needed, PRN hemorrhoid care Wipe affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** phenylephrine topical (phenylephrine 0.25%-3% rectal ointment) 1 app, rectally, oint, q6h, PRN hemorrhoid care Apply to affected area *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** *****IF witch hazel-glycerin or phenylephrine ointment ineffective/contraindicated, USE hydrocortisone-pramoxine foam if ordered***** hydrocortisone-pramoxine topical (hydrocortisone-pramoxine 1%-1% rectal foam) 1 app, rectally, foam, q8h, PRN hemorrhoid care apply to affected area Page: 17 of 17 Ischemic Stroke/TIA Plan Version: 5 Effective on: 08/27/14