DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S NEURO Intracranial Hemorrhage (Factor VII) Condition/Status Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8) Place in Observation Patient Status: Outpatient- Refer for Observation Status, Level of Care: Intensive Care (8) Vital Signs Vital Signs Q1H Int (DEF)* Q15MINS Int Q4H Activity Activity Bedrest, Head of bead elevated 30 Degrees. (DEF)* Increase as tolerated Diet NPO No exceptions Diet Order Low Cholesterol Fat Controlled (DEF)* Diabetic/ADA without HS Snack, 1800 kcal Diabetic/ADA with HS Snack, 1800 kcal Nursing Orders Quality Measures STK Notify Provider Vital Signs/Urine Output Temperature > 100.4 deg. F, HR > 100, HR < 60, SBP > 135, SBP < 110, DBP > 85, RR > 24, RR < 8, Urine Output < 240 Neuro Checks Q1H Int (DEF)* Q4H Bedside Swallow Screen - Code Stroke If patient not cleared for swallowing, insert short term NG tube Blood Glucose Monitor POC Q6H (DEF)* Comments: for non-diabetics while on alteplase protocol. 5XDAILY ACHS&0200 Comments: for diabetic patients Sequential Compression Device Bilateral knee high SCD Reason Stroke VTE Prophylaxis Not Ordered Page 1 of 8
DRUG AND TREATMENT Elastic Stockings Bilateral knee high TED's Reason Referral for Addictions Treatment Not Provided nicardipine (nicardipine 50 mg / NS 250 ml pre-mix) IV Start at 5 mg/hour Comments: Titrate by 2.5 mg/hr every 15 min to max dose of 15 mg/hr. Maintain goal blood pressure of /. clevidipine (Cleviprex) 50 ml IV bag Rate: 1 mg/hour Comments: initial rate 1 mg/hr titrated to BP response; double every 90 seconds to 10 min; as BP goal is reached, rate increase should be less and time length between rate changes should increase; max rate 32 mg/hr; labetalol 10 mg inj IV PUSH Q10MINS Int, PRN (DEF)* Comments: Maintain goal blood pressure of /. Give over 2 minutes. 20 mg inj IV PUSH Q10MINS Int, PRN Comments: Maintain goal blood pressure of /. Give over 2 minutes. labetalol 500mg/100mL IV Set (IVS)* Trandate 500 mg/100 ml IV drip (undiluted) IV bottle Titrate as Ordered Comments: Maintain goal blood pressure of /. Start at 2 mg/min and titrate by 1 mg/min to a maximum dose of 6 mg/min. HOLD FOR HEART RATE LESS THAN 60 bpm. evacuated container drip IV bottle pantoprazole (Protonix) 40 mg tab EC PO ACBRKF (DEF)* 40 mg inj IV PUSH DAILY fosphenytoin (Cerebyx) 20 mg/kg bag IVPB ONCE, NOW, Clinical Instructions: Ideal body weight. In 100 ml NS at a rate not to exceed 150 PE/min. 1 mg = 1 PE Comments: Ideal body weight. In 100 ml NS at a rate not to exceed 150 PE/min. +8 Hours fosphenytoin (Cerebyx) 150 PE inj IV PUSH Q8H (DEF)* Comments: Give IV slow push NOT to exceed 150 PE/minute. 100 PE inj IV PUSH Q8H Comments: Give IV slow push NOT to exceed 150 PE/minute. phenytoin (Dilantin) 300 mg cap PO BEDTIME (DEF)* 300 mg susp NG TUBE BEDTIME levetiracetam (Keppra) 1,000 mg iv IVPB Q12H Int, Duration: 2 dose, NOW (DEF)* 1,250 mg iv IVPB Q12H Int, Duration: 2 dose, NOW Page 2 of 8
DRUG AND TREATMENT 750 mg iv IVPB Q12H Int, Duration: 2 dose, NOW 500 mg iv IVPB Q12H Int, Duration: 2 dose, NOW 250 mg iv IVPB Q12H Int, Duration: 2 dose, NOW +30 Hours levetiracetam (Keppra) 1,000 mg iv IVPB Q12H (DEF)* 1,250 mg iv IVPB Q12H 750 mg iv IVPB Q12H 500 mg iv IVPB Q12H 250 mg iv IVPB Q12H 500 mg tab PO Q12H 1,250 mg tab PO Q12H 1,000 mg tab PO Q12H 750 mg tab PO Q12H 250 mg tab PO Q12H 500 mg soln NG TUBE Q12H 1,250 mg soln NG TUBE Q12H 1,000 mg soln NG TUBE Q12H 750 mg soln NG TUBE Q12H 250 mg soln NG TUBE Q12H magnesium sulfate (magnesium sulfate 2 gram (pre-mix bag)) 2 g premix IVPB ONCE Comments: Give over 2 hours acetaminophen (Tylenol) 650 mg tab PO Q4H, PRN Other (see comment) (DEF)* Comments: PRN pain mild OR temperature GREATER than 100.4 degrees Fahrenheit. 650 mg supp PR Q4H, PRN Other (see comment) Comments: PRN pain mild OR temperature GREATER than 100.4 degrees Fahrenheit. metoclopramide (Reglan) 10 mg tab PO Q8H, PRN Nausea/Vomiting (DEF)* 10 mg syrup DOBHOFF Q8H, PRN Nausea/Vomiting Comments: Or administer via NG tube. 10 mg inj IV PUSH Q8H, PRN Nausea/Vomiting ondansetron (Zofran ODT) 4 mg tab soluble PO Q8H, PRN Nausea/Vomiting (DEF)* Page 3 of 8
DRUG AND TREATMENT Comments: Do not remove from pouch until immediately before use. Place on top of tongue and allow to dissolve 5 seconds. Swallow with saliva. 4 mg tab soluble DOBHOFF Q8H, PRN Nausea/Vomiting Comments: Or administer via NG tube. ondansetron (Zofran) 4 mg inj IV PUSH Q8H, PRN Nausea/Vomiting droperidol (Inapsine) 0.625 mg inj IV PUSH Q6H, PRN Nausea/Vomiting docusate (Colace) 100 mg cap PO BID (DEF)* 100 mg liquid NG TUBE BID magnesium hydroxide (Milk of Magnesia) 30 ml PO susp Q6H, PRN Constipation (DEF)* 30 ml NG TUBE susp Q6H, PRN Constipation bisacodyl (Dulcolax) 10 mg supp PR DAILY, PRN Constipation (DEF)* 10 mg tab EC PO DAILY, PRN Constipation 10 mg supp PR DAILY 10 mg tab EC PO DAILY IV Solutions Sodium Chloride 0.9% (Normal Saline Bolus) 10 ml/kg IVPB bag ONCE, Clinical Instructions: BOLUS Comments: Administer over 1 hour. BOLUS Sodium Chloride 0.9% (NS) IV bag 100 ml/hour Factor VII (Novo 7) ***(NOTE)***ABSOLUTE CONTRAINDICATIONS TO NOVO 7 USE: Allergies to mouse, hamster or bovine protein ***(NOTE)***RELATIVE CONTRAINDICATIONS TO NOVO 7 USE: Active thrombotic event (including DVT, PE, MI) or known thrombophilia ***(NOTE)***Option 1: For patients with thrombocytopenia, uremia, hemodialysis, liver disease, alcohol use, Clopidogrel (Plavix), Prasugrel (Effient) or Aspirin use within the last 10 days SUB Factor VII (Novo 7) Option #1 (SUB)* 30 mcg/kg inj IV PUSH ONCE, STAT correspond with available package size desmopressin (DDAVP) 0.3 mcg/kg bag IVPB ONCE, STAT Comments: Place in NS 50 ml and administer over 15 minutes STAT x 1 dose Laboratory Platelet Pheresis Order Page 4 of 8
DRUG AND TREATMENT STAT, Transfusion Priority STAT, Platelet Pheresis, 2 unit(s) Comments: NOVO Seven Regimen ***(NOTE)***Option 2: For patients on Warfarin (Coumadin) SUB Factor VII (Novo 7) Option #2 (SUB)* Condition/Status ***(NOTE)*** For patients on warfarin (Coumadin) Nursing Orders Communication Order Draw INR 1 hour, 6 hours and 12 hours post administration of Factor VII (Novo 7) 30 mcg/hour inj IV PUSH ONCE, STAT, Clinical Instructions: Over 1 to 3 minutes STAT x 1 dose. Pharmacy NOVO 7 may be rounded to correspond with available package size. correspond with available package size. phytonadione (Aquamephyton) 10 mg iv IVPB ONCE, STAT Comments: Place in 50 ml of NS and Administer over 15 minutes. Laboratory Frozen Plasma Order STAT, Transfusion Priority STAT, Frozen Plasma, 2 unit(s) Comments: Give 2 units FFP for every 0.5 INR above 1 ***(NOTE)***Option 3: For patient with thrombocytopenia, uremia, hemodialysis, liver disease, alcohol use, clopidogrel (PLAVIX), Aspirin, or Prasugrel (Effient) AND Warfarin (COUMADIN) use within the last 10 days. SUB Factor VII (Novo 7) Option #3 (SUB)* Condition/Status ***(NOTE)*** Option 3: For patient with thrombocytopenia, uremia, hemodialysis, liver disease, alcohol use, clopidogrel (PLAVIX), aspirin, or prasugrel (Effient) AND warfarin (COUMADIN) use within the last 10 days. Nursing Orders Communication Order Draw INR 1hour, 6 hours and 12 hours post administration of Factor VII (Novo 7) 30 mcg/kg inj IV PUSH ONCE correspond with available package size. desmopressin (DDAVP) 0.3 mcg/kg bag IVPB ONCE, STAT Comments: Administer over 15 minutes. phytonadione (Aquamephyton) 10 mg iv IVPB ONCE, STAT Comments: Place in 50 ml of NS and Administer over 15 minutes. Page 5 of 8
DRUG AND TREATMENT Laboratory Platelet Pheresis Order STAT, Transfusion Priority STAT, Platelet Pheresis, 2 unit(s) Comments: Administer 2 units apheresis platelets STAT Frozen Plasma Order STAT, Transfusion Priority STAT, Frozen Plasma, 2 unit(s) Comments: Give 2 units FFP for every 0.5 INR above 1 ***(NOTE)***Option 4: For patient on Heparin Sodium (HEPARIN) or Enoxaparin (LOVENOX) within the LAST 4 HOURS. SUB Factor VII (Novo 7) Option #4 (SUB)* Condition/Status ***(NOTE)*** Option 4: For patient on Heparin Sodium (HEPARIN) or Enoxaprin (LOVENOX) within the LAST 4 HOURS. ***(NOTE)*** FOR USE IN PATIENTS THAT HAVE RECEIVED HEPARIN OR LOVENOX WITHIN THE LAST 3 HOURS OR LOVENOX IN THE LAST 12 HOURS. ***(NOTE)*** MAXIMUM PROTAMINE DOSE = 50mg 30 mcg/kg inj IV PUSH ONCE, STAT correspond with available package size. ***(NOTE)*** For Heparin Reversal: protamine mg inj IV PUSH ONCE, STAT Comments: Protamine sulfate (PROTOMINE) for Heparin Reversal Time Since Heparin Stopped Protomine per 100 units/heparin LESS than 1 hour Use 1mg per 100 units heparin administered 1 to 3 hours Use 0.5mg per 100 units heparin administered GREATER than 3 hours No protamine required ***(NOTE)*** For Lovenox Reversal: protamine mg inj IV PUSH ONCE, STAT Comments: Protomine Sulfate (PROTOMINE) for Lovenox reversal Time Since Lovenox last Administered Protamine per 1mg/Lovenox administered 0 to 8 hours 1mg protomine per 1 mg/lovenox 8 to 12 hours 0.5 mg protomine per 1 mg/lovenox GREATER than 12 hours No protamine required Page 6 of 8
DRUG AND TREATMENT Consults Consult Pharmacy Stat, Kinetics Dosing, Protamine Dosing ***(NOTE)***Option 5: For patients not meeting any of the above categories OR on fondaparinux (ARIXTRA) OR on dabigatran etexilate (PRADAXA) SUB Factor VII (Novo 7) Option #5(SUB)* ***(NOTE)*** Option 5: For patients not meeting any of the above categories OR on fondaparinux (ARIXTRA) OR on dabigatran etexilate (PRADAXA). 30 mcg/kg inj IV PUSH ONCE, STAT correspond with available package size. Laboratory PT INR STAT, Blood, ONCE Comments: If not done in the ED PTT STAT, Blood, ONCE Comments: If not done in ED +24 Hours PT INR Early AM, Blood, DAILY PTT Early AM, Blood, DAILY Prealbumin Serum Expedite/ASAP, Blood, ONCE Vitamin B12 Level Expedite/ASAP, Blood, ONCE Homocysteine Level Expedite/ASAP, Blood, ONCE ESR Early AM, Blood, ONCE Comments: If not completed in ED Lipid Profile Early AM, Blood, ONCE Chem 12 Early AM, Blood, DAILY CBC with Differential. Early AM, Blood, DAILY Fibrinogen Level Routine, Blood, ONCE D Dimer Routine, Blood, ONCE Page 7 of 8
DRUG AND TREATMENT Cardiac Enzymes Creatine Kinase Total Blood Creatine Kinase MB Blood Troponin Blood Radiology XP Chest Routine, Pending Discharge - No, ONCE, If not done in ED. MR Brain for TIA TIA, Stat, Pending Discharge - No, ONCE MRI Stroke(SUB)* ***Reminder: Order MRI Stroke(SUB) on a separate form*** MRI Brain Pending Discharge - No, With contrast. Comments: To include gradient echo axial. MRI Brain Pending Discharge - No, Without contrast. Comments: To include gradient echo axial. MRA Head Pending Discharge - No, Without contrast. MRA Neck Pending Discharge - No, With contrast. MRI Brain Angiogram Cerebral Bil Routine, Pending Discharge - No, ONCE Consults Consult Physician Neurology, Code Stroke Consult Physician Pulmonary, Ventilator Management Consult Physician Cardiology Consult Speech Therapy Code Stroke Consult Occupational Therapy Code Stroke Consult Physical Therapy Code Stroke Social Work Consult Other - See Special Instructions, Rehab Disposition (DEF)* Other - See Special Instructions, Assess for Discharge Needs Consult Dietitian Page 8 of 8