DRUG AND TREATMENT Available at: BMC-B BMC-D BMC-N BMC-S Vital Signs Vital Signs Q4H (DEF)* Q2H Q1H Vital Signs Orthostatic Activity Activity Bedrest, for 12 hours then Up ad lib (DEF)* Bedrest, for 24 hours then Up ad lib Up Ad Lib Diet NPO No exceptions Comments: Notify Provider once Bedside Swallow Screen is passed for diet orders Nursing Orders Stroke Quality Measures Neuro Checks Q4H (DEF)* Q1H Q2H Cardiac Monitor Patient may leave floor without monitor Patient Education Stroke/TIA, document education daily in I-View and review at hand off on nursing communication Summary page that education has been done each day NIH Stroke Scale (NIHSS) On Admit, BID at shift change, before and after any intervention, PRN for any neurological decline, and at discharge. Call provider for any increase of 2 or more. Modified Rankin Scale On Admit and on Discharge Elevate Head of Bed 30 Degrees (DEF)* Head of Bed Flat Comments: Flat in Bed as tolerated for 24 hours, then HOB as desired. HOB 15 30 degrees IF at risk for airway obstruction, aspiration or increased ICP. Flat in Bed Flat in Bed as tolerated for 24 hours, then HOB as desired. HOB 15-30 degrees IF at risk for airway obstruction, aspiration or increased ICP Page 1 of 7
DRUG AND TREATMENT Bedside Swallow Screen Raise HOB to 90 degrees briefly to perform bedside swallow screen. If patient fails screen, keep NPO including po medications until cleared by SLP; for alternate medication routes. Blood Glucose Monitor POC Q6H, while NPO then QID AC and HS. If patient is non-diabetic, may discontinue in 24 hours IF no insulin given Physician has reviewed Inclusion/Exclusion Criteria Temperature Greater Than 38 degrees C (100 F) Other (See Special Instructions) Blood Glucose LESS Than 60 mg/dl OR GREATER Than 400 mg/dl Other (See Special Instructions) Any occurrence of Atrial Fibrillation and obtain 12 lead ECG stat Other (See Special Instructions) Deterioration of neurologic status Systolic Blood Pressure Greater Than 220 mmhg (DEF)* Systolic Blood Pressure Greater Than 180 mmhg Systolic Blood Pressure Greater Than Diastolic Blood Pressure Greater Than 120 mmhg (DEF)* Diastolic Blood Pressure Greater Than 105 mmhg Diastolic Blood Pressure Greater Than SCD Select a reason from the dropdown box for not providing Addiction Treatment (Alcohol,/Substance or Tobacco use)(note)* Reason Referral for Addictions Treatment Not Provided Medications insulin lispro (Humalog) unit inj SUBCUT Q6H Comments: Blood Glucose Administer 180-229: 2 units, 230-279: 4 units 280-329: 6 units, 330-379: 8 units, 380-429: 10 units, > 430: 12 units and notify physician GEN Hypoglycemia(SUB)* ***Reminder: Order GEN Hypoglycemia (SUB) on a separate form.*** Reason Alcohol/Substance Abuse Medication Not Prescribed Reason Tobacco Cessation Med Not Given MED Low Intensity Heparin(SUB)* ***Reminder: Order MED Low Intensity Heparin (SUB) on a separate form.*** Anticoagulants Page 2 of 7
DRUG AND TREATMENT ***NOTE*** Anticoagulants are NOT to be given within 24 hours of alteplase/t-pa administration ***NOTE*** Order the appropriate medications OR select a reason from the dropdown box for medication not being given Reason Anticoagulation Therapy Not Prescribed Discharge GEN Venous Thromboembolism Prophylaxis (VTE)(SUB)* ***Reminder: Order GEN Venous Thromboembolism Prophylaxis (VTE) (SUB) on a separate form.*** Reason Stroke VTE Prophylaxis Not Ordered Reason for Oral Factor Xa Inhibitor Antithrombotic ***NOTE*** Antithrombotics are NOT to be given within 24 hours of alteplase/t-pa administration ***NOTE*** Order the appropriate medications OR select a reason from the dropdown box for medication not being given Reason IV Thrombolytic Therapy Not Initiated Reason Antithrombotics Not Given by End Day 2 Reason Antithrombotic Therapy Not Prescribed Discharge Reason Aspirin Not Given on Arrival Reason Aspirin Not Prescribed at Discharge Reason Stroke VTE Prophylaxis Not Ordered aspirin 325 mg tab EC PO DAILY (DEF)* 324 mg tab chew NG TUBE DAILY Comments: Use 4 81mg tabs. 81 mg tab chew PO DAILY 300 mg supp PR DAILY, Clinical Instructions: Give IF patient did not pass Bedside Swallowing Screen and is NPO. Do NOT give if intracranial hemorrhage aspirin-dipyridamole (Aggrenox) 1 cap PO cap ER BID acetaminophen (Tylenol) 325 mg tab PO BID clopidogrel (Plavix) 75 mg tab PO DAILY (DEF)* 75 mg tab PO ONCE, STAT enoxaparin (Lovenox) Statins Reason Statin Not Prescribed at Discharge simvastatin (Zocor) 10 mg tab PO BEDTIME (DEF)* 20 mg tab PO BEDTIME 40 mg tab PO BEDTIME 80 mg tab PO BEDTIME Reason LDL-c Not Done Page 3 of 7
DRUG AND TREATMENT atorvastatin (Lipitor) 40 mg tab PO BEDTIME (DEF)* 20 mg tab PO BEDTIME rosuvastatin (Crestor) 20 mg tab PO BEDTIME PRN Medications Hold Medication Hold Next Dose Detail: Other (specify in Special Instructions), No sedatives or sleeping pills for 24 hours (DEF)* Hold Next Dose Detail: Other (specify in Special Instructions), No sedative or sleeping pills for 48 hours acetaminophen (Tylenol) 650 mg tab PO Q6H, PRN Other (see comment) (DEF)* Comments: PRN Pain Mild or Temperature GREATER than 100 degf. Give if GREATER Than 4 hours since last dose acetaminophen given. 650 mg supp PR Q6H, PRN Other (see comment) Comments: PRN Pain Mild or Temperature GREATER than 100 degf. Give if GREATER Than 4 hours since last dose acetaminophen given. 650 mg tab chew NG TUBE Q6H, PRN Other (see comment) Comments: PRN Pain Mild or Temperature GREATER than 100 degf. Give if GREATER Than 4 hours since last dose acetaminophen given. IV Solutions Normal Saline Bolus 10 ml/kg IVPB bag ONCE, Duration: 1 dose, Rate: 250 ml/hour Comments: Administer 1 dose and discontinue. Max Dose 1000 ml. 1 ml/kg/hour IVPB bag ONCE, Duration: 1 dose Comments: Administer 1 dose and discontinue. Max Dose 1000 ml. 1.5 ml/kg/hour IVPB bag ONCE, Duration: 1 dose Comments: Administer 1 dose and discontinue. Max Dose 1000 ml. NS IV bag 100 ml/hour (DEF)* IV bag 75 ml/hour IV bag 50 ml/hour Laboratory SUB Hypercoagulation Panel(SUB)* ***Reminder: Order SUB Hypercoagulation Panel (SUB) on a separate form.*** ESR Homocysteine Level ANA Screen w/reflex ANA COMR Serum B12 level Vitamin D Page 4 of 7
DRUG AND TREATMENT Hemoglobin A1C TSH Serum CRP Lipid Profile Early AM, ONCE Comments: Patient needs to be fasting Liver Profile Comments: If not already done CBC. T;N, Early AM, DAILY BMP T;N, Early AM, DAILY Urinalysis Routine, ONCE Urine Culture Routine, ONCE Toxicology Screen 12 - Urine Routine, ONCE Troponin Platelet Function Assay Expedite/ASAP, Blood, ONCE Platelet P2Y12 Monitoring Expedite/ASAP, Blood, ONCE Radiology ***NOTE*** IF Kidney function is within normal limits, no contrast allergy and able to have MRI CT Angio Head/Neck w/wo Contrast, If not already done MR Brain w/o Contrast ***NOTE*** If kidney function within normal limits, CONTRAST ALLERGY PRESENT and able to have MRI: MR Brain w/o Contrast MR Angio Head w/o Contrast MR Angio Neck w/ Contrast ***NOTE*** If kidney function within normal limits, no contrast allergy and UNABLE to have MRI: CT Angio Head/Neck w/wo Contrast, if not already done Page 5 of 7
DRUG AND TREATMENT +24 Hours CT Head w/o Contrast ***NOTE*** If ABNORMAL kidney function and able to have MRI: MR Brain w/o Contrast MR Angio Head w/o Contrast US Carotid Doppler Scan ***NOTE*** If ABNORMAL kidney function and UNABLE to have MRI: US Carotid Doppler Scan US Transcranial Doppler Scan +24 Hours CT Head w/o Contrast Respiratory Oxygen Therapy. Nasal Cannula, 2, if O2 Sat Less than 94% Comments: O2 at 2L per min. Titrate to maintain oxygen sats of at least 95%. Pulse Oximetry (Continuous) Special Instructions: See Order Comments Comments: Q8H sensor site must be inspected; IF circulatory condition or skin integrity has changed, the sensor should be applied to a different site. Cardiology ECG Standard Routine, If not done in ED. ECG Standard Stat, 12 Lead ECG for any occurrence of atrial fibrillation Echo 2-D and M-Mode with Bubble Study Consults Neurology, Stroke patient (BMCD) Comments: Neurointensivist, Stroke Comments: Neuropsychology. Consult should not delay discharge (BMCD) Stroke Comments: Physical Medicine and Rehab Endovascular Neurosurgery, Stroke Page 6 of 7
DRUG AND TREATMENT Cardiology, Stroke Social Work Consult Routine, Discharge Planning, Physician, Stroke patient for Rehab disposition. (DEF)* Other - See Special Instructions, Assess for Discharge Needs Consult Physical Therapy Consult Occupational Therapy Consult Speech Therapy Dietitian Consult Other - See Special Instructions, For diet and education Consult Diabetes-Adult Consult Palliative Care, Adult Consult Hospice Consult Wound Care Consult Pharmacy Page 7 of 7