ISCHEMIC STROKE / TIA ORDERS 1 of 6

Transcription

1 ISCHEMIC STROKE / TIA 1 of 6 Actual Estimated Admit to (bed type): Med-Surg Telemetry Critical Care - NICU Critical Care - MICU Attending: Diagnosis: Weight kg Actual Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Resident/Pager: Condition: Time to Presentation from Symptom Onset: 0-3 hours 3-6 hours greater than 6 hours If patient presents within 8 hours, candi for intervention: Yes No, Reason: Stroke Severity Not enough Imaging Findings Patient has received IV alteplase (tpa) Vital signs and neuro checks every 15 minutes x 2 hours, then every 30 minutes x 6 hours, then every hour x 16 hours Immediately call neurologist for: vomiting, headache, change in mental status, diffi culty breathing, nausea, seizure, and/or signs of bleeding blood pressure greater than 180/100 mmhg NO placement of indwelling urinary catheter or enteral feeding tube for 7 hours after alteplase NO anticoagulants or antiplatelets for 24 hours after alteplase Non-contrast head computerized tomography (CT), 24 hours after alteplase ( ) Check, circle and/or fill in all orders to be implemented as appropriate. NURSING 1. ADVANCE DIRECTIVES (supporting documentation in chart): Full Support Do Not Resuscitate (DNR)/Medical Orders for Life-Sustaining Treatment (MOLST) Health Care Proxy 2. NEUROCHECKS: every 4 hours every hour(s) National Institute of Health Stroke Scale (NIHSS) Day 1 and Day 7 or day of discharge 3. VITAL SIGNS: every 4 hours every hour(s) every hour(s) x hour(s), then every hour(s) x hour(s) 4. BLOOD PRESSURE: If parameters greater than / or less than / mmhg notify House Officer BLOOD PRESSURE CONTROL EMERGENCY ROOM/ INTENSIVE CARE UNIT/ STEPDOWN UNIT ONLY Labetalol (Normodyne) mg (range 5-20 mg) intravenous (IV) push every minutes as needed for Systolic Blood Pressure mmhg Hold for heart rate less than 50 beats per minute Cardene (nicardipine) Drip (IV): 20 mg/200 ml 0.9% Sodium Chloride 40 mg/200 ml 0.9% Sodium Chloride Start at 5 mg/hour, titrate to keep Systolic Blood Pressure mmhg Norepinephrine (Levophed) 32 mcg/ml at 5 mcg/min, titrate to MAP of 65 mmhg 5. HEART RATE: If parameters greater than or less than beats per minute notify House Officer 6. TELEMETRY: 48 hours May be discontinued for tests/transport May not be discontinued for tests/transport 7. TEMPERATURE: Notify House Officer if temperature is greater than 37.8 C Obtain blood cultures x 2, urine culture, urinalysis with microscopic exam and sputum culture for temperature greater than 38.6 C 8. OXYGEN: Oxygen liters per minute Nasal Cannula Venti Mask Non-rebreather mask Discontinue oxygen if pulse oximetry is greater than 94% on room air 9. INTAKE AND OUTPUT: every hour every 2 hours every 4 hours every 8 hours insert indwelling urinary (foley) catheter to gravity (should be renewed/reordered every 24 hours) Reason for insertion of indwelling urinary (foley) catheter: Strict I&O Hemodynamic monitoring Vasopressor / Inotropic therapy Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 ISCHEMIC STROKE / TIA 2 of 6 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 10. FALL PRECAUTIONS: per routine (refer to fall risk assessment) 11. BLOOD GLUCOSE: Refer to Adult Subcutaneous Insulin Orders KH01169 ACTIVITY: Bedrest for 24 hours only, with head of bed at: Out of bed with assistance after 24 hours Out of bed to chair Ambulate Out of bed ad lib DYSPHAGIA: Nothing by mouth including medications until swallow screen complete and documented Aspiration Precautions Suction as needed Insert gastric decompression tube Insert gastric feeding tube DIET: Nothing by mouth Nothing by mouth after midnight for testing Consistency: Pureed Mechanical soft Regular Thickened liquids Liquid Type: Cardiac Diet (Heart Healthy) Diabetic American Diabetic Association Feeds: Continuous (type): at ml/hour Intermittent (type): volume ; every hours at ml/hour Dietician consult Reason for consult Enteral feeding tube flush ml every hours INTRAVENOUS (IV) FLUIDS: 0.9% Normal Saline at Intermittent infusion device ml/hour indication hydration LABS: Complete Blood Count Complete Blood Count with differential Comprehensive Metabolic Panel Basic Metabolic Panel Troponin I cardiac (stat) every 8 hours X 3 Urinalysis with microscopic exam Magnesium Level Phosphate Level Calcium Level High Sensitivity C-Reaction Protein (hscrp) Antinuclear Antibody Test (ANA) Erythrocyte Sedimentation Rate (ESR) Prothrombin Time/ International Normalized Ratio (PT/INR) Activated Partial Thromboplastin Time (aptt) Glycosylated Hemoglobin (Hb A1c ) Fasting Lipid Panel Hypercoagulable Stroke/TIA Studies (Young Stroke): Protein C Activity Protein S Total and Free Aq Antithrombin III Level Activated Protein C Resistance Cardiolipin Antibodies Quant Lupus Anticoagulant Coagulation Factor VII Activity Level (Factor VII Level) Coagulation Factor VIII Activity Level (Factor VIII Level) Beta 2 Glycoprotein Ab IgGAM The Hypercoagulable Panel may be completed as an outpatient AM Labs (daily X 3 days): CBC CBC with differential Basic Metabolic Panel Comprehensive Metabolic Panel PT - Prothrombin with INR APTT - Acct. Partial Thromboplastin Time Lipid Panel (daily X 1 test) Initials Place STAT barcode sticker within this box only on form copy being scanned

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5 ISCHEMIC STROKE / TIA 3 of 6 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. DIAGNOSTICS: Chest X-ray (indication): Portable Anteroposterior & Lateral Electrocardiogram Carotid Doppler Complete (UB Neurosurgery) Transcranial Doppler Complete (UB Neurosurgery) 2-Dimensional Echocardiogram (2D Echo) Echo Complete with Bubble Study (up to age 75 years) Echo Complete (age greater than 75 years) CT head / brain without contrast CT Stroke Study CT Perfusion head / brain CT Angiogram Head/Neck MRI brain without contrast MRI brain with and without contrast MRI brain DWI / FLAIR MRA head / neck with and without contrast DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (risk assessment on back) REQUIRED to ( ) check all that apply: Unfractionated Heparin 5000 units subcutaneous every 8 hours Below the knee intermittent Pneumatic Compression Device (PCD) Pneumatic Compression Device (PCD): Foot Pump Below the knee graduated compression stocking Other Orders: DVT Prophylaxis not indicated (reason): DVT Prophylaxis contraindicated: NEW MEDICATIONS: Antiplatelet Therapy: Aspirin (select one): 81 mg enteric coated formulation by mouth daily 81 mg chewable formulation down feeding tube daily 325 mg regular release down feeding tube daily 650 mg regular release down feeding tube daily 300 mg rectal suppository daily if unable to give by mouth 600 mg rectal suppository daily if unable to give by mouth Clopidogrel (Plavix) 75 mg by mouth daily Clopidogrel (Plavix) loading dose (if not given in ED): 600 mg 300 mg Anticoagulant Therapy: Warfarin (Coumadin) mg by mouth at bed (indication): Statin: Atorvastatin (Lipitor) by mouth daily (select one): 10 mg 20 mg 40 mg 80 mg indication dyslipidemia Pravastatin (Pravachol) by mouth daily (select one): 20 mg 40 mg 80 mg indication dyslipidemia Initials Place STAT barcode sticker within this box only on form copy being scanned

6 ISCHEMIC STROKE / TIA 4 of 6 RISK FACTORS DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture years 1 Patient confined to bed greater than 72 hours Recent uninterrupted travel greater than 4 hours 2 1 Multiple Trauma 5 Laparoscopic/Pelvic Surgery 2 Major Surgery greater than 45 minute duration 2 PRE-EXISTING/CURRENT MEDICAL CONDITIONS points points Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1 Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1 Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1 Cancer 2 Severe Dehydration 1 Central Venous Catheter greater than 1 week (excludes Renal Nephrotic syndrome 1 2 Access) Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Inflammatory Bowel Disease 1 Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1 Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1 *Examples of Hypercoagulation State: Protein C or S deficiency Antithrombin III deficiency Lupus Anticoagulant Homocystinemia LOW RISK (Score of 1 or less) No prophylaxis Ambulate MODERATE TO HIGH RISK* (Score of 2-4) Heparin 5000 units subcutaneous every 8 hours -OR- Pneumatic Compression Device (PCD) HIGHEST RISK/MULTI MODAL* (Score of 5 or higher) Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) *Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations. ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS Neurosurgery Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) Orthopaedic Surgery See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders Trauma/ Spinal Cord Injury Enoxaparin 30 mg subcutaneous every 12 hours -AND- Pneumatic Compression Device (PCD) Consider platelet monitoring for prolonged anticoagulation Coronary Artery Bypass Surgery Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30 mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 ml/minute) Bariatric Surgery Enoxaparin 40 mg subcutaneous every 12 hours High Risk Bleeding (any population History of with moderate Heparin-induced to high venous Thrombocytopenia thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) Fondaparinux 2.5 mg subcutaneous daily (Contraindicated if Creatinine Clearance [CrCl] less than 30 ml/minute) References: Modified From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

7 ISCHEMIC STROKE / TIA 5 of 6 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. Other Medications: Famotidine (Pepcid) 20 mg every 12 hours for gastrointestinal prophylaxis: by mouth IV Docusate Sodium (Colace) 100 mg by mouth twice a day for constipation Bisacodyl (Dulcolax) 10 mg 1 suppository per rectum daily as needed for constipation Acetaminophen (Tylenol) 650 mg by mouth every 4 hours as needed for (indication): Additional Medications dose route interval indication Refer to Powerchart Medication History a. b. c. d. e. f. g. REFERRALS: Physical Therapy Evaluation & Treatment Occupational Therapy Evaluation & Treatment Swallow Therapy Evaluation & Treatment Speech Therapy Evaluation & Treatment Physiatry Evaluation Patient Management Services CONSULTS: NEUROLOGY Neuroendovascular Cardiology IMMUNIZATIONS: Per New York State Department of Health (NYS DOH) Mandatory Immunization Program and Kaleida Policy CL.6, administer vaccine(s) if patient meets criteria. Pneumococcal Vaccine 0.5 ml intramuscular x 1 for prophylaxis If contraindicated please ( ) check one of the NYS DOH acceptable contraindications below: Allergy to pneumococcal vaccine Previously immunized Date: Influenza Vaccine 0.5 ml intramuscular x 1 for prophylaxis (September 1 - April 1) If contraindicated please ( ) check one of the NYS DOH acceptable contraindications below: Allergy to influenza vaccine Vaccinated this flu season Date: ADDITIONAL : NURSING TORB From: Date: Time: Signature: NOTED BY RN Date: Time: Signature: PROVIDER Date: Time: Print Name/Stamp: Signature: TORB = Telephone Orders Read Back Place STAT barcode sticker within this box only on form copy being scanned

8 ISCHEMIC STROKE / TIA 6 of 6 NEW YORK STATE DEPARTMENT OF HEALTH LAW SECTION , CHAPTER 443: Every in-patient must be assessed for pneumococcal and influenza vaccine need Appropriate vaccines must be administered Standing Physician Order for all in-patients, signed by Dr. Margaret Paroski, EVP CMO Additional physician order is not required CRITERIA INDICATIONS for BOTH PNEUMOVAX and INFLUENZA: Age 65 or greater Age greater than 18 with chronic illnesses such as diabetes, asthma, emphysema, pneumonia, congestive heart failure, coronary artery disease, chronic renal failure, immunosuppression If previous vaccination unknown, and criteria met, revaccinate NO VACCINATION INDICATED if patient is between 18 and 65 years old, without chronic illness CONTRAINDICATIONS: PNEUMOVAX (must be administered year round) Received pneumococcal vaccine at age 65 or greater. If unknown, revaccinate Received pneumococcal vaccine at age 65 or less, wait 5 years to revaccinate. If unknown, revaccinate. Previous severe reaction to pneumococcal vaccine (urticaria, laryngeal edema, anaphylaxis) INFLUENZA (Flu season is September 1 - April 1, as vaccine available from pharmacy) Received vaccine earlier THIS flu season. If unknown, revaccinate History of allergic reaction to eggs or contact lens solution (Thimerosal - preservative in solution) Previous severe reaction to influenza vaccine (urticaria, laryngeal edema, anaphylaxis) CONSENTS: PNEUMOVAX (must be administered year round) Patient read Vaccine Information Sheet (KH01159) Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. Patient refused and reason stated INFLUENZA (Flu season is September 1 - April 1, as vaccine available from pharmacy) Patient read Vaccine Information Sheet (KH01160) Patient consented - patient/ health care proxy signed Vaccine Information Sheet. Form scanned to pharmacy for vaccine dispensing. Patient refused and reason stated